Nosocomial Infection

A NOSOCOMIAL INFECTION A NOSOCOMIAL INFECTION is:is:

Also known as healthcare – acquired infectionAlso known as healthcare – acquired infection Traditionally referred as hospital – acquired Traditionally referred as hospital – acquired

infectionsinfections Infections that develop during hospitalizationInfections that develop during hospitalization One of the leading causes of death and One of the leading causes of death and

increased morbidity for hospitalized patientsincreased morbidity for hospitalized patients Of which are mostly caused by drug – resistant Of which are mostly caused by drug – resistant

strains of bacteriastrains of bacteria

INFECTION RELATED TO IV INFECTION RELATED TO IV THERAPY DEVICESTHERAPY DEVICES

Local InfectionLocal Infection Invasion and multiplication of microorganisms in Invasion and multiplication of microorganisms in

body tissues which may be clinically unapparent body tissues which may be clinically unapparent or result in local cellular injury due to competitive or result in local cellular injury due to competitive metabolism toxins, intracellular replication or metabolism toxins, intracellular replication or antigen antibody responseantigen antibody response

Systemic InfectionSystemic Infection A systemic disease caused by pathogenic A systemic disease caused by pathogenic

organisms or their toxins in the bloodstreamorganisms or their toxins in the bloodstream

DefinitionsDefinitions Catheter Colonization:Catheter Colonization: The isolation of 15 The isolation of 15

colony forming units (CFUs) of any colony forming units (CFUs) of any microorganism by semiquantitative culture microorganism by semiquantitative culture (roll-plate method) or 10(roll-plate method) or 103 3 CFUs by quantitative CFUs by quantitative culture (sonication technique), from a catheter culture (sonication technique), from a catheter tip or subcutaneous segment in the absence tip or subcutaneous segment in the absence of simultaneous clinical symptoms.of simultaneous clinical symptoms.

Local catheter-related infection:Local catheter-related infection: Exit site Infection:Exit site Infection: purulent drainage from the purulent drainage from the

catheter exit site, or erythema, tenderness, and catheter exit site, or erythema, tenderness, and swelling within 2cm of the catheter exit site.swelling within 2cm of the catheter exit site.

Port-pocket infection:Port-pocket infection: erythema and necrosis of erythema and necrosis of the skin over reservoir of totally implantable the skin over reservoir of totally implantable device, or purulent exudates in the subcutaneous device, or purulent exudates in the subcutaneous pocket containing the reservoir.pocket containing the reservoir.

Tunnel infection:Tunnel infection: erythema, tenderness, and erythema, tenderness, and indurations of the tissues overlying the catheter indurations of the tissues overlying the catheter and more than 2cm from the exit site. and more than 2cm from the exit site.

DefinitionsDefinitions Systemic Catheter infection: Systemic Catheter infection: isolation of the same isolation of the same

microorganisms from catheter culture and from the microorganisms from catheter culture and from the blood of a patient with accompanying clinical blood of a patient with accompanying clinical symptoms of a BSI and no other apparent source of symptoms of a BSI and no other apparent source of infection.infection.

Catheter-related bloodstream infectionCatheter-related bloodstream infection is the isolation is the isolation of the same microbe from blood cultures that is of the same microbe from blood cultures that is known to be significantly colonizing the catheter of a known to be significantly colonizing the catheter of a patientpatient

Primary BSIPrimary BSI is one that arises without apparent local is one that arises without apparent local infection elsewhere due to the same microbe.infection elsewhere due to the same microbe.

Common catheters used for venous and arterial accessCommon catheters used for venous and arterial access

CATHETER TYPECATHETER TYPE ENTRY SITEENTRY SITE LENGTHLENGTH COMMENTSCOMMENTS

Peripheral venous Peripheral venous catheters (short)catheters (short)

Peripheral arterial Peripheral arterial catheterscatheters

Midline cathetersMidline catheters

Usually inserted in Usually inserted in veins of forearm or veins of forearm or handhand

Usually inserted in Usually inserted in radial artery; can be radial artery; can be placed in femoral, placed in femoral, axillary, brachial, axillary, brachial, posterior tibial arteriesposterior tibial arteries

Inserted via the Inserted via the antecubital fossa into antecubital fossa into the proximal basilic or the proximal basilic or cephalic veins; does cephalic veins; does not enter central veins, not enter central veins, peripheral cathetersperipheral catheters

<3 inches<3 inches

<3 inches<3 inches

3 – 8 inches3 – 8 inches

Phlebitis with prolonged Phlebitis with prolonged use; rarely associated use; rarely associated with BSIwith BSI

Low infection risk; rarely Low infection risk; rarely associated with BSIassociated with BSI

Reported with Reported with anaphylactoid reactions anaphylactoid reactions on elastommeric on elastommeric hydrogel catheter; lower hydrogel catheter; lower rates of phlebitis than rates of phlebitis than short peripheral short peripheral catheterscatheters



Nontunneled CVCNontunneled CVC Percutaneously Percutaneously inserted into central inserted into central veins ( subclavian, veins ( subclavian, internal jugular, or internal jugular, or femoral)femoral)

≥≥8 cm depending on 8 cm depending on the patient sizethe patient size

Account for majority Account for majority CRBSICRBSI

Pulmonary artery Pulmonary artery cathetercatheter

Peripherally inserted Peripherally inserted central venous central venous catheter (PICC)catheter (PICC)

Inserted through a Inserted through a TeflonTeflon®® introducer in introducer in a central a central vein( subclavian, vein( subclavian, internal jugular, or internal jugular, or femoral)femoral)

Inserted in basilic, Inserted in basilic, cephalic, or brachial cephalic, or brachial veins and enter the veins and enter the superior vena cavasuperior vena cava

≥≥30 cm depending 30 cm depending on the patient sizeon the patient size

≥≥20 cm depending 20 cm depending on patient sizeon patient size

Usually heparin Usually heparin bonded; similar rates bonded; similar rates of BSI as CVCs; of BSI as CVCs; subclavian site subclavian site preferred to reduce preferred to reduce infection riskinfection risk

Lower rate of Lower rate of infection than infection than nontunnelled CVCsnontunnelled CVCs



Tunneled central Tunneled central venous cathetervenous catheter

Implanted into Implanted into subclavian, internal subclavian, internal jugular, or femoral jugular, or femoral veinsveins


Cuff inhibits migration Cuff inhibits migration of organisms into the of organisms into the catheter tract; lower catheter tract; lower rate of infection than rate of infection than that of the nontunneled that of the nontunneled CVCCVC

Totally implantableTotally implantable

Umbilical cathetersUmbilical catheters

Tunnelled beneath the Tunnelled beneath the skin and have skin and have subcutaneous port subcutaneous port accessed with needle; accessed with needle; implanted in implanted in subclavian, internal subclavian, internal jugular veinjugular vein

Inserted into umbilical Inserted into umbilical vein or umbilical arteryvein or umbilical artery


≤≤6 cm depending on 6 cm depending on the patient sizethe patient size

Lowest rate of CRBSI; Lowest rate of CRBSI; improved patient self improved patient self image; no need for image; no need for local catheter site care; local catheter site care; surgery required for surgery required for catheter removalcatheter removal

Risk for CRBSI similar Risk for CRBSI similar with catheters placed in with catheters placed in umbilical vein vs arteryumbilical vein vs artery

Other Nosocomial InfectionOther Nosocomial Infection

Urinary tract infectionUrinary tract infection

Surgical site infectionSurgical site infection

Ventilator-associated pneumonia Ventilator-associated pneumonia

Intravascular device-related bloodstream infectionIntravascular device-related bloodstream infection

Clostridium difficile-Clostridium difficile- associated diarrhea associated diarrhea

CHAIN OF INFECTION CHAIN OF INFECTION CONTROLCONTROL

Infectious Agent

Reservoir

Portal of Exit

Susceptible host

Portal of Entry

Mode of Transmission

MODE OF TRANSMISSIONMODE OF TRANSMISSION It is the method of transfer by which It is the method of transfer by which

organism moves or is carried from one organism moves or is carried from one place to anotherplace to another

E.g. Hands of the health care worker may E.g. Hands of the health care worker may carry bacteria from one person to another.carry bacteria from one person to another.

How does catheter-related infection How does catheter-related infection occur? occur?

Infection of short-term catheters is Infection of short-term catheters is frequently been due to microbes from the frequently been due to microbes from the skin moving along the catheter surface skin moving along the catheter surface where the catheter enters the skin.where the catheter enters the skin.

Date and Time IV

was InsertedKARDEX

Risk FactorsRisk Factors Type of catheter usedType of catheter used

The number of lumen of the catheter hasThe number of lumen of the catheter has Total parenteral nutritionTotal parenteral nutrition Duration of catheterizationDuration of catheterization Catheter site insertionCatheter site insertion Expertise of the person insertingExpertise of the person inserting Management of catheter after insertionManagement of catheter after insertion Guidewire exchangeGuidewire exchange Use of dressingUse of dressing Use of triple antibiotic ointmentUse of triple antibiotic ointment

Common pathogens of BSICommon pathogens of BSI

Candida albicansCandida albicans Staphylococcus aureusStaphylococcus aureus Enterobacter cloaceaeEnterobacter cloaceae Staphylococcus epidermidisStaphylococcus epidermidis Pseudomonas aeruginosaPseudomonas aeruginosa Enterococcus fecalisEnterococcus fecalis

Breaking the Chain of Infection – Breaking the Chain of Infection – Levels of Aseptic ControlLevels of Aseptic Control

How Health Care Workers Break the Chain of InfectionHow Health Care Workers Break the Chain of Infection

LinkLink InterventionIntervention

Infectious or Causative Infectious or Causative AgentAgent

Accurate and rapid identification of microorganismsAccurate and rapid identification of microorganismsEarly recognition of sign and symptoms of infectionEarly recognition of sign and symptoms of infection

ReservoirsReservoirs Employee health examinations and screeningsEmployee health examinations and screeningsEnvironmental sanitationsEnvironmental sanitationsDisinfection / Sterilization of instrumentsDisinfection / Sterilization of instrumentsStandard Precautions, Medical Asepsis, Proper HygieneStandard Precautions, Medical Asepsis, Proper HygieneClean gowns, linens, towels, Clean wound dressingClean gowns, linens, towels, Clean wound dressing

Portal of ExitPortal of Exit Handwashing, use of PPE, proper waste disposal, standard Handwashing, use of PPE, proper waste disposal, standard precautionsprecautions

Method or Mode of Method or Mode of TransmissionTransmission

Handwashing, Standard Precautions, Safe food handling, Handwashing, Standard Precautions, Safe food handling, isolations, use of PPE, transmission based precautionsisolations, use of PPE, transmission based precautions

Portal of EntryPortal of Entry Aseptic technique, medical or surgical asepsis, wound / Aseptic technique, medical or surgical asepsis, wound / catheter care, proper disposal, maintain skin integrity, standard catheter care, proper disposal, maintain skin integrity, standard precautionsprecautions

Susceptible HostSusceptible Host Treatment of Disease, Recognition of clients at risk, Treatment of Disease, Recognition of clients at risk, immunization, exercise, proper nutritionimmunization, exercise, proper nutrition

PRINCIPLES OF PREVENTION PRINCIPLES OF PREVENTION OF INFECTIONOF INFECTION

Consider every person (patient of staff) infectiousConsider every person (patient of staff) infectious

Wash hands – the most practical procedure for Wash hands – the most practical procedure for preventing cross – contamination (person to person)preventing cross – contamination (person to person)

Wear gloves before touching anything wet – broken skin, Wear gloves before touching anything wet – broken skin, mucous membranes, blood or other body fluids mucous membranes, blood or other body fluids (secretions or excretions) or soiled instruments and other (secretions or excretions) or soiled instruments and other itemsitems

Use physical barriers (protective goggles, face masks Use physical barriers (protective goggles, face masks and aprons) if splashes and spills of any body fluids and aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated(secretions or excretions) are anticipated

Use safe work practices, such as not recapping Use safe work practices, such as not recapping or bending needles, safely passing sharp or bending needles, safely passing sharp instruments and properly disposing of medical instruments and properly disposing of medical wastewaste

Isolate patients only if secretions (airborne) or Isolate patients only if secretions (airborne) or excretions (urine and feces) cannot be excretions (urine and feces) cannot be containedcontained

Decontaminate process instruments and other Decontaminate process instruments and other items (decontaminate, clean, high – level items (decontaminate, clean, high – level disinfect or sterilize using Infection Prevention disinfect or sterilize using Infection Prevention PracticesPractices

PreventionPrevention Selection of a subclavian, basilic, or cephalic vein Selection of a subclavian, basilic, or cephalic vein

site rather than an internal jugular or femoral sitesite rather than an internal jugular or femoral site

Avoid use of TPN catheters for other infusion Avoid use of TPN catheters for other infusion purposespurposes

Use of special team for insertion and maintenance Use of special team for insertion and maintenance of catheterof catheter

Avoid the use of triple antibiotic ointment on central Avoid the use of triple antibiotic ointment on central venous cathetervenous catheter

REVIEW INFECTION RISK REVIEW INFECTION RISK FACTORS AND PRACTICESFACTORS AND PRACTICES

Infection is the presence and growth of a Infection is the presence and growth of a microorganisms that produces tissue deathmicroorganisms that produces tissue death

Wash your handsWash your hands Routinely clean and disinfect surfacesRoutinely clean and disinfect surfaces Handle and prepare food safelyHandle and prepare food safely Get immunizedGet immunized Us antibiotics appropriatelyUs antibiotics appropriately Keep pets healthyKeep pets healthy Avoid contact with wild animalsAvoid contact with wild animals

PRINCIPLES OF SAFE IV CARE / PRINCIPLES OF SAFE IV CARE / PRACTICESPRACTICES

Use aseptic technique to avoid contamination of sterile Use aseptic technique to avoid contamination of sterile injection equipmentinjection equipment

Do not administer medications from a syringe to multiple Do not administer medications from a syringe to multiple patients, even if the needle of cannula on the syringe is patients, even if the needle of cannula on the syringe is changedchanged

Use fluid infusion and administration sets for one patient Use fluid infusion and administration sets for one patient only and dispose after useonly and dispose after use

Use single – dose vials for parenteral medications Use single – dose vials for parenteral medications whenever possible.whenever possible.

Use proper personal protective equipment (PPE).Use proper personal protective equipment (PPE). Adhere to safety waste protocol according to institution’s Adhere to safety waste protocol according to institution’s

policy.policy.

VENIPUNCTURE TECHNIQUES VENIPUNCTURE TECHNIQUES USING VARIOUS CATHETERS USING VARIOUS CATHETERS

AND DEVICESAND DEVICES

The Use of Infusion Pumps

The use of needleless systemThe use of needleless system

Proper use of sharp containersProper use of sharp containers

Monitoring and AssessmentMonitoring and Assessment

The use of appropriate dressingThe use of appropriate dressing

Health Care Worker Education and TrainingHealth Care Worker Education and Training Surveillance for Catheter – Related InfectionSurveillance for Catheter – Related Infection HandwashingHandwashing Barriers Precautions During Catheter Insertion Barriers Precautions During Catheter Insertion

and Careand Care Catheter InsertionCatheter Insertion Catheter Site CareCatheter Site Care Selection and Replacement of Intravascular Selection and Replacement of Intravascular

DevicesDevices

General Recommendations For General Recommendations For Intravascular Device UseIntravascular Device Use

Health Care Worker Education and TrainingHealth Care Worker Education and Training Surveillance for Catheter – Related InfectionSurveillance for Catheter – Related Infection HandwashingHandwashing Barriers Precautions During Catheter Insertion Barriers Precautions During Catheter Insertion

and Careand Care Catheter InsertionCatheter Insertion Catheter Site CareCatheter Site Care Selection and Replacement of Intravascular Selection and Replacement of Intravascular

DevicesDevices

Replacement of Administration Sets and Replacement of Administration Sets and Intravenous FluidsIntravenous Fluids

Intravenous Injection PortsIntravenous Injection Ports Preparation and Quality Control of Intavenous Preparation and Quality Control of Intavenous

AdmixturesAdmixtures In – line FiltersIn – line Filters Intravenous Therapy PersonnelIntravenous Therapy Personnel Needleless Intravascular DevicesNeedleless Intravascular Devices Prophylactic antimicrobialsProphylactic antimicrobials

Preventing Catheter-Related Preventing Catheter-Related Bloodstream InfectionsBloodstream Infections

References:References: CCenters for enters for DDisease isease CControl and Prevention ontrol and Prevention

((CDCCDC), USA), USA HHealthcare ealthcare IInfection nfection CControl ontrol PPractices ractices AAdvisory dvisory

CCommittee (ommittee (HICPACHICPAC), USA), USA Hospital Epidemiology and Infection Control, Hospital Epidemiology and Infection Control,

Mayhall 3Mayhall 3rdrd ed. ed.

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Nosocomial Infection