HOSPITAL INFECTIONS

(HCAI)

HOSPITAL INFECTIONS

(HCAI)Meral SÖNMEZOĞLU, MD

Yeditepe University HospitalAssociate Professor of

Department of Infectious Diseases and Clinical Microbiology

Meral SÖNMEZOĞLU, MD

Yeditepe University HospitalAssociate Professor of

Department of Infectious Diseases and Clinical Microbiology

HCAI Definition• Health Care-associated

Infection (HCAI)– Also referred to as “nosocomial”

or “hospital” infection • “An infection occurring in a

patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the health-care facility but appearing after discharge, and also occupational infections among health-care workers of the facility”

HCAI

• The World Health Organization has reported that, at any given time, approximately 1.4 million people have an HAI;

• in developing countries, the risk can be up to 20 times greater than in developed countries.

• In addition, the emergence of HAIs caused by multidrug-resistant microorganisms is an increasing concern.

Healthcare-Associated Infections (HAIs)

1 out of 20 hospitalized patients affected

Associated with increased mortality Attributed costs: $26-33 billion annually HAIs occur in all types of facilities,

including:• Long-term care facilities• Dialysis facilities• Ambulatory surgical centers• Hospitals

Healthcare Safety

Healthcare-

associated Infections

Antimicrobial ResistanceAdverse Drug Events Transfusion/

Transplant Safety

Healthcare Preparedness

Outbreak Investigations

Surveillance

Prevention Recommendations

Intervention Implementation

Extramural Research

Laboratory Research and Support

Immunization Safety

Patient Safety within CDC’s Division of Healthcare Quality Promotion (DHQP)

HCAIs: emerging priorities

MRSA bacteraemias and C.difficile are the tip of the iceberg for HCAIs. What steps are we taking

to reduce all other HCAIs? What should we monitor to help drive this improvement?

MRSA

Clostridium difficile

Surgical site

infections

Urinary

catheter

UTIs

Ventilator-associated

pneumonia Enteral feeding tube

infections

Line

associated

sepsis

Dialysis related

infections

34 trusts reported zero

MRSA bacteraemias

between 11.2010 –

11.2011

Hospitals

Ambulatory Facilities

Long-term Care

Dialysis Facilities

Healthcare has moved beyond hospitals

Estimated rates of HCAI worldwide

– At any time, over 1.4 million people worldwide are suffering from infections acquired in health-care facilities

– In modern health-care facilities in the developed world: 5–10% of patients acquire one or more infections

– In developing countries the risk of HCAI is 2–20 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25%

– In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%

The impact of HCAI

• HCAI can cause:– more serious illness– prolongation of stay in a health-care

facility– long-term disability– excess deaths – high additional financial burden– high personal costs on patients and

their families

Outbreaks vs. Endemic Problems

Endemic problems represent the majority of HAIs

Device-associated infections• Catheter-associated urinary tract infections

(CAUTI)

• Central line-associated Blood stream infections (CLABSI)

• Ventilator-associated Pneumonia (VAP)

Procedure-associated infections• Surgical site infections (SSI)

Adherence problems• Antimicrobial stewardship, hand hygiene

Most frequent sites of infection and their risk factors

LOWER RESPIRATORY TRACT INFECTIONS

Mechanical ventilation

Aspiration

Nasogastric tube

Central nervous system depressants

Antibiotics and anti-acids

Prolonged health-care facilities stay

Malnutrition

Advanced age

Surgery

Immunodeficiency

13%

BLOOD INFECTIONS

Vascular catheter

Neonatal age

Critical care

Severe underlying disease

Neutropenia

Immunodeficiency

New invasive technologies

Lack of training and supervision

14%

SURGICAL SITE INFECTIONS

Inadequate antibiotic prophylaxis

Incorrect surgical skin preparation

Inappropriate wound care

Surgical intervention duration

Type of wound

Poor surgical asepsis

Diabetes

Nutritional state

Immunodeficiency

Lack of training and supervision

17%

URINARY TRACT INFECTIONS

Urinary catheter

Urinary invasive procedures

Advanced age

Severe underlying disease

Urolitiasis

Pregnancy

Diabetes

34%

Most common

sites of health care-

associated infection

and the risk factors

underlying the

occurrence of

infections

LACK OF HAND

HYGIENE

Patients Most Likely to Develop Nosocomial Infections

1. Elderly patients.2. Women in labor and delivery.3. Premature infants and newborns.4. Surgical and burn patients.5. Diabetic and cancer patients.6. Patients receiving treatment with steroids,

anticancer drugs, antilymphocyte serum, and radiation.

Nabeel Al-Mawajdeh RN.MCS

Patients Most Likely to Develop Nosocomial Infections (Cont’d)

7. Immunosupressed patients (I. e., patients whose immune systems are not functioning properly)

8. Patients who are paralyzed or are undergoing renal dialysis or catheterization; quite often, these patient’s normal defence mechanisms are not functioning properly)

Nabeel Al-Mawajdeh RN.MCS

Major Factors Contributing to Nosocomial Infections

1. An ever- increasing number of drug-resistant pathogens.

2. Lack of awareness of routine infection control measures.

3. Neglect of aseptic techniques and safety precautions.

4. Lengthy complicated surgeries.5. Overcrowding of hospitals.

Nabeel Al-Mawajdeh RN.MCS

Major Factors Contributing to Nosocomial Infections (Cont’d)

6. Shortage of hospital staff.7. An increased number of Immunosupressed

patients.8. The overuse and improper use of indwelling

medical devices.

Nabeel Al-Mawajdeh RN.MCS

SURGICAL SITE INFECTIONSSURGICAL SITE INFECTIONS

Surgical Site Infections (SSI)• First most common nosocomial

infection (%31)*• Most common nosocomial infection

among surgical patients (38%)– 2/3 incisional– 1/3 organs or spaces accessed during

surgery• 7.3 additional postoperative days at

cost of $3,152 in extra chargesMangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

* Infect Control Hospital Epidemiol 2012;33(3):283-91

Colonization vs Contamination – Definitions • Colonization

– Bacteria present in a wound with no signs or symptoms of systemic inflammation

– Usually less than 105 cfu/mL• Contamination

– Transient exposure of a wound to bacteria

– Varying concentrations of bacteria possible

– Time of exposure suggested to be < 6 hours

– SSI prophylaxis best strategy

SSI – Definitions

• Infection– Systemic and local signs of

inflammation– Bacterial counts ≥ 105 cfu/mL– Purulent versus nonpurulent– LOS effect– Economic effect

• Surgical wound infection is SSI

LOS=length of stay.

Superficial Incisional SSI

Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Subcutaneous tissue

Skin

Superficial incisional

SSI

Deep Incisional SSI

Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves the deep soft tissue (e.g., fascia and muscle layers)

Deep soft tissue (fascia &

muscle)

Deep incisional SSI

Superficial incisional SSI

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Organ/Space SSI

Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation

Deep incisional SSI

Superficial incisional SSI

Organ/space SSIOrgan/space

Mangram AJ et al. Infect Control Hosp Epidemiol.

1999;20:250-278.

SSI – Risk FactorsOperation Factors

• Duration of surgical scrub

• Maintain body temp• Skin antisepsis• Preoperative shaving• Duration of operation• Antimicrobial

prophylaxis• Operating room

ventilation• Inadequate sterilization

of instruments

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

•Foreign material at surgical site

•Surgical drains

•Surgical technique

–Poor hemostasis

–Failure to obliterate dead space

–Tissue trauma

SSI – Risk FactorsPatient Characteristics

• Age• Diabetes

– HbA1C and SSI– Glucose > 200 mg/dL

postoperative period (<48 hours)

• Nicotine use: delays primary wound healing

• Steroid use: controversial• Malnutrition: no

epidemiological association

• Obesity: 20% over ideal body weight

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

•Prolonged preoperative stay: surrogate of the severity

of illness and comorbid conditions

•Preoperative nares colonization with Staphylococcus

aureus:

significant association

•Perioperative transfusion: controversial

•Coexistent infections at a remote body site

•Altered immune response

SSI – Wound Classification

• Class 1 = Clean• Class 2 = Clean contaminated• Class 3 = Contaminated• Class 4 = Dirty infected

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Prophylactic

antibiotics indicated

Therapeutic antibiotics

SSI – Wound Classification

SSI – Risk Stratification NNIS Project

3 independent variables associated with SSI risk

– Contaminated or dirty/infected woundclassification

– ASA > 2– Length of operation > 75th

percentile of the specific operation being performed

NNIS=National Nosocomial Infections Surveillance.

NNIS. CDC. Am J Infect Control. 2001;29:404-421.

Principles of Antibiotic Prophylaxis

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Preop administration, serum levels adequate

throughout procedure with a drug active

against expected microorganisms.

High Serum Levels

1. Preop timing

2. IV route

3. Highest dose

of drug

During Procedure

1. Long half-life

2. Long procedure–redose

3. Large blood loss–redose

Duration

1. None after wound closed

2. 24 hours maximum

SCIP Performance Measures

Surgical infection prevention

• SSI rates• Appropriate prophylactic antibiotic chosen• Antibiotic given within 1 hour before incision• Discontinuation of antibiotic within 24 hours of surgery

• Glucose control• Proper hair removal• Normothermia in colorectal surgery patients

Downloaded from: Principles and Practice of Infectious Diseases

Infe

ctio

n R

ate

Process Indicators:

Duration of Antimicrobial Prophylaxis

Prophylactic antimicrobials should be discontinued within 24 hrs after the end of surgery

Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

Process Indicators:

Timing of First Antibiotic Dose

Infusion should begin within 60 minutes of the incision

Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

CATHETER ASSOCIATED UTI

(CAUTI)

CATHETER ASSOCIATED UTI

(CAUTI)

Importance

• Catheter-associated (CA) bacteriuria is the most common health care–associated infection worldwide and

• a result of the widespread use of urinary catheterization, much of which is inappropriate, in hospitals and longterm care facilities (LTCFs).

34

• The most effective way to reduce the incidence of CA-ASB and CA-UTI is to reduce the use of urinary catheterization by restricting its use to patients who have clear indications and by removing the catheter as soon as it is no longer needed

35

CAUTI• Patient has at least 2 of the

following signs or symptoms with no other recognized cause:

• fever (38.8C), • urgency, frequency, • dysuria, or suprapubic tenderness • and at least 1 of the following

CAUTI

• positive dipstick for leukocyte esterase and/ or nitrate

• pyuria (urine specimen with >10 white blood cell [WBC]/mm or >3 WBC/highpower field of unspun urine)

• organisms seen on Gram’s stain of unspun urine

• at least 2 urine cultures with repeated isolation of the same uropathogen (gram negative bacteria or Staphylococcus saprophyticus) with >10 colonies/mL in non voided specimen

38

39

HICPAC Guidelines

40

41

42

43

CAUTI• Catheter associated bacteriuria

increase every catheter day: • Day 1: 5%• Week 1: 25%• Month 1: 100%

Prevention• removing the catheter as soon as it is no

longer needed

Nosocomial Bloodstream InfectionsNosocomial Bloodstream Infections

Nosocomial Bloodstream Infections

• 12-25% attributable mortality• Risk for bloodstream infection:

BSI per 1,000 catheter/days

Subclavian or internal jugular CVC 5-7

Hickman/Broviac (cuffed, tunneled) 1

PICC 0.2 - 2.2

Risk Factors for Nosocomial BSIs

• Heavy skin colonization at the insertion site

• Internal jugular or femoral vein sites• Duration of placement• Contamination of the catheter hub

Prevention of Nosocomial BSIs

• Coated catheters– In meta-analysis C/SS catheter decreases BSI

(OR 0.56, CI95 0.37-0.84)– M/R catheter may be more effective than C/SS– Disadvantages: potential for development of

resistance; cost (M/R > C/SS > uncoated)• Use of heparin

– Flushes or SC injections decreases catheter thrombosis, catheter colonization & may decrease BSI

Epidemiology of CVC-BSIPathogen (%)

Coagulase-negative staphylococci 37 %

Gram-negative rods 14 %

Enterobacter species 5 %

Pseudomonas aeruginosa 4 %

Klebsiella pneumoniae 3 %

Escherichia coli 2 %

Staphylococcus aureus 13 %

Enterococcus 13 %

Candida species 8 %

Prevention of Nosocomial BSIs

• Limit duration of use of intravascular catheters– No advantage to changing catheters routinely

• Change CVCs to PICCs when possible• Maximal barrier precautions for insertion

– Sterile gloves, gown, mask, cap, full-size drape– Moderately strong supporting evidence

• Chlorhexidine prep for catheter insertion

Catheter Insertion Site

Risk of infection:• Central vein >>> Peripheral vein• Femoral >>> IJ > SubclavianSubclavian = preferred

Insertion

Components of IHI CR-BSI Prevention Bundle

1) Hand hygiene2) Maximal barrier precautions3) Chlorhexidine skin prep4) Optimal site selection5) Daily review of line necessity

Hospitals using NHSN are preventing bloodstream infections

Trends in bloodstream infections* by ICU type, NHSN hospitals, 1997-2007

Medical/Surgical--Major Teaching

Medical/Surgical--Non-Major Teaching

Burton DC, et al. Methicillin-Resistant

Staphylococcus aureus Central Line-Associated

Bloodstream Infections in US Intensive Care

Units, 1997-2007. JAMA. 2009;301(7):727-736.

0

1

2

3

4

5

6

7

8

9

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Medical

Pediatric

Surgical

Po

ole

d M

ean

An

nu

al C

LA

BS

I Ra

te p

er 1

,000

Ce

ntr

al L

ine

Day

s

Health-Care Associated (Nosocomial) Pneumonia

Health-Care Associated (Nosocomial) Pneumonia

Definition

Occurring at least 48 hours after admission and not incubating at the time of hospitalization

Introduction

• Nosocomial pneumonia is the 2nd most common hospital-acquired infections after UTI. Accounting for 31 % of all nosocomial infections

• Nosocomial pneumonia is the leading cause of death from hospital-acquired infections.

• The incidence of nosocomial pneumonia

is highest in ICU.

Introduction

• The incidence of nosocomial pneumonia in ventilated patients was 10-fold higher than non-ventilated patients

• The reported crude mortality for HAP is 30% to greater than 70%.

--- Medical Clinics of North America

Therapy of Nosocomial pneumonia 2001 vol.85 1583-94

Pathogenesis

--- The Prevention of Ventilator-Associated Pneumonia Vol.340 Feb 25, 1999 NEJM

Classification

• Early-onset nosocomial pneumonia: Occurs during the first 4 days Usually is due to S. pneumoniae, MSSA, H.

Influenza,

or anaerobes.• Late-onset nosocomial pneumonia: More than 4 days More commonly by G(-) organisms, esp. P.

aeruginosa, Acinetobacter, Enterobacteriaceae (klebsiella,

Enterobacter, Serratia) or MRSA.

Causative Agent

• Enteric G(-) bacilli are isolated most frequently particularly in patients with late-onset disease and in patients with serious underlying disease often already on broad-spectrum antibiotics.

• Prior use of broad-spectrum antibiotics and an immunocompromised state make resistant gram-negative organisms more likely.

Causative Agent

• P. aeruginosa and Acinetobacter are common causes of late-onset pneumonia, particularly in the ventilated patients.

Causative Agent• S. aureus is isolated in about 20~40%

of cases and is particularly common in :1. Ventilated patients after head trauma,

neurosurgery, and wound infection 2. In patients who had received prior antibiotics

or Prolonged care in ICU

• MRSA is seen more commonly in patients

Received corticosteroids Undergone mechanical ventilation >5 days Presented with chronic lung disease Had prior antibiotics therapy

Causative Agent

• Anaerobes are common in patients predisposed to aspiration

• VAP with anaerobes occurred more often with oropharyngeal intubation than nasopharyngeal intubation.

Causative Agent• Legionella pneumophilia occurs sporadically

but may be endemic in hospitals with contaminated water systems. The incidence is underestimated because the test to identify Legionella are not performed routinely.

• Because the incubation period of Legionella infection is 2 to 10 days. cases that occur more than 10 days after admission are considered to be nosocomial, and cases that develop between 4 and 10 days are considered as possible nosocomial.

• Patients who are immunocompromised, critically ill, or on steroids are at highest risk for infection.

Prevention of health care-associated infection

– Validated and standardized prevention strategies have been shown to reduce HCAI

– At least 50% of HCAI could be prevented

– Most solutions are simple and not resource-demanding and can be implemented in developed, as well as in transitional and developing countries

SENIC study: Study on the Efficacy of Nosocomial Infection Control

– >30% of HCAI are preventable

With infection

control

-31%-35%-35%

-27%-32%

Without

infection control

14%

9%

19%

26%

18%

LRTI SSI UTI BSI Total

Relative change in NI in a 5 year period (1970–1975)

0

10

20

30

-40

-30

-20

-10

%

Haley RW et al. Am J Epidemiol 1985

Hand transmission

– Hands are the most common vehicle to transmit health care-associated pathogens

– Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps

5 stages of hand transmission

Germs present on

patient skin

and immediate

environment

surfaces

Germ transfer

onto health-care

worker’s hands

Germs survive on

hands for several

minutes

Suboptimal or

omitted hand

cleansing results

in hands

remaining

contaminated

Contaminated

hands transmit

germs via direct

contact with

patient or

patient’s

immediate

environment

one two three four five

Bundles (sets of infection control

recommendations) to prevent infection

when inserting devices or performing

procedures.

Prevent Infection

Hand Hygiene,

Isolation,

Environmental

Cleaning, etc

Prevent Transmission

Adherence to infection control guidelines is incomplete

Many HAIs are preventable with current recommendations

Failure to use proven interventions is unacceptable

Only 30%-38% of U.S. hospitals are in full compliance

Just 40% of healthcare personnel adhere to hand hygiene

Insufficient infection control infrastructure in non-acute care settings has allowed major lapses in safe care

Why should you clean your hands?

– Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene

– Therefore hand hygiene concerns you!

– You must perform hand hygiene to:

– protect the patient against harmful germs carried on your hands or present on his/her own skin

– protect yourself and the health-care environment from harmful germs

The “My 5 Moments for Hand Hygiene” approach

• Adequate handwashing with water and soap requires 40–60 seconds

• Average time usually adopted by health-care workers: <10 seconds

• Alcohol-based handrubbing: 20–30 seconds

Time constraint = major obstacle for hand hygiene

National Standardized Infection Ratios (SIRs) and facility-specific percentiles using HAI data reported from all NHSN facilities reporting during 2010 by HAI and patient population:

Central Line-associated Bloodstream Infections (CLABSIs), Catheter-associated Urinary Tract Infections (CAUTIs), and Surgical Site Infections (SSIs)

2010

2010

2010

2010

2010

TUS 2012• Aşağıdakilerden hangisi temiz-

kontamine yaraya örnektir?A) KolesistektomiB) TiroidektomiC) İnguinal fıtık onarımıD) MastektomiE) Perfore apandisit varlığında apendektomi

TUS 2012• Aşağıdakilerden hangisi temiz-

kontamine yaraya örnektir?A) KolesistektomiB) TiroidektomiC) İnguinal fıtık onarımıD) MastektomiE) Perfore apandisit varlığında apendektomi

TUS 2012• Protez, greft gibi implantların

uygulandığı ameliyatlarda cerrahi alan enfeksiyonu tanısı koyabilmek için enfeksiyon en geç ne zaman ortaya çıkmalıdır?A) 1 ayB) 3 ayC) 6 ayD) 1 yılE) 2 yıl

TUS 2012• Protez, greft gibi implantların

uygulandığı ameliyatlarda cerrahi alan enfeksiyonu tanısı koyabilmek için enfeksiyon en geç ne zaman ortaya çıkmalıdır?A) 1 ayB) 3 ayC) 6 ayD) 1 yılE) 2 yıl

TUS 2010 Aşağıdaki ameliyat tiplerinin

hangisinde cerrahi alan enfeksiyonu en fazla görülür?

A) KolesistektomiB) TiroidektomiC) Memeden kitle eksizyonuD) Kolon rezeksiyonuE) İnguinal herni ameliyatı

TUS 2010 Aşağıdaki ameliyat tiplerinin

hangisinde cerrahi alan enfeksiyonu en fazla görülür?

A) KolesistektomiB) TiroidektomiC) Memeden kitle eksizyonuD) Kolon rezeksiyonuE) İnguinal herni ameliyatı