HOSPITAL INFECTIONS (HCAI)

1. HOSPITAL INFECTIONS(HCAI) Meral SÖNMEZOĞLU, MD Yeditepe UniversityHospital AssociateProfessor of Department of InfectiousDiseases andClinicalMicrobiology

2. 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”

3. HCAI • The World Health Organization has reported that, atany given time, approximately 1.4 million people have anHAI; • in developing countries, the risk can be up to 20 timesgreater than in developed countries. • In addition, the emergenceof HAIs caused by multidrug-resistant microorganisms is an increasingconcern.

4. 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

5. Patient Safety within CDC’s Division of Healthcare Quality Promotion (DHQP) Healthcare Safety Transfusion/Transplant Safety Healthcare-associated Infections Adverse Drug Events Antimicrobial Resistance Immunization Safety Healthcare Preparedness • Outbreak Investigations • Surveillance • Prevention Recommendations • Intervention Implementation • Extramural Research • Laboratory Research and Support

6. HCAIs: emerging priorities MRSAClostridiumdifficile 34 trusts reported zero MRSA bacteraemias between 11.2010 – 11.2011 Surgical site infections Urinary catheter UTIs Ventilator-associated pneumonia Line associated sepsis Enteral feeding tube infections Dialysis related infections 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?

7. Healthcare has movedbeyondhospitals

8. 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%

9. 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

10. 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

11. URINARY TRACT INFECTIONS Urinary catheter Urinary invasive procedures Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes 34% 13% 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 Most frequent sites of infection and their risk factors LACK OF HAND HYGIENE Most common sites of health care-associated infection and the risk factors underlying the occurrence of infections 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 BLOOD INFECTIONS Vascular catheter Neonatal age Critical careSevere underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision 17% 14%

12. Patients Most Likely to Develop Nosocomial Infections • Elderly patients. • Women in labor and delivery. • Premature infants and newborns. • Surgical and burn patients. • Diabetic and cancer patients. • Patients receiving treatment with steroids, anticancer drugs, antilymphocyte serum, and radiation. Nabeel Al-Mawajdeh RN.MCS

13. Patients Most Likely to Develop Nosocomial Infections (Cont’d) • Immunosupressed patients (I. e., patients whose immune systems are not functioning properly) • 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

14. Major Factors Contributing to Nosocomial Infections • An ever- increasing number of drug-resistant pathogens. • Lack of awareness of routine infection control measures. • Neglect of aseptic techniques and safety precautions. • Lengthy complicated surgeries. • Overcrowding of hospitals. Nabeel Al-Mawajdeh RN.MCS

15. Major Factors Contributing to Nosocomial Infections (Cont’d) • Shortage of hospital staff. • An increased number of Immunosupressed patients. • The overuse and improper use of indwelling medical devices. Nabeel Al-Mawajdeh RN.MCS

16. SURGICAL SITE INFECTIONS

17. Surgical Site Infections (SSI) • Firstmost 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 charges Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278. * InfectControlHospitalEpidemiol 2012;33(3):283-91

18. Colonization vs Contamination – Definitions • Colonization • Bacteria present in a wound with no signs or symptoms of systemic inflammation • Usually less than 105cfu/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

19. SSI – Definitions • Infection • Systemic and local signs of inflammation • Bacterial counts ≥ 105cfu/mL • Purulent versus nonpurulent • LOS effect • Economic effect • Surgical wound infection is SSI LOS=length of stay.

20. Skin Superficial incisional SSI Subcutaneous tissue 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.

21. Deep soft tissue (fascia & muscle) Deep 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) Superficial incisional SSI Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

22. Organ/space SSI Organ/space Superficial incisional SSI 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 Mangram AJ et al. Infect Control Hosp Epidemiol.1999;20:250-278.

23. Duration of surgical scrub Maintain body temp Skin antisepsis Preoperative shaving Duration of operation Antimicrobial prophylaxis Operating room ventilation Inadequate sterilization of instruments SSI – Risk FactorsOperation Factors • Foreign material at surgical site • Surgical drains • Surgical technique • Poor hemostasis • Failure to obliterate dead space • Tissue trauma Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

24. 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 – 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.

25. Prophylactic antibiotics indicated Therapeutic antibiotics 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.

26. SSI – Wound Classification

27. 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.

28. Preop administration, serum levels adequate throughout procedure with a drug active against expected microorganisms. • High Serum Levels • Preop timing • IV route • Highest dose of drug • During Procedure • Long half-life • Long procedure–redose • Large blood loss–redose • Duration • None after wound closed • 24 hours maximum Principles of Antibiotic Prophylaxis Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

29. SCIP Performance Measures

30. Infection Rate Downloaded from: Principles and Practice of Infectious Diseases

31. 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.

32. Process Indicators:Timing of First AntibioticDose Infusion should begin within 60 minutes of the incision Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

33. CATHETER ASSOCIATED UTI (CAUTI)

34. Importance • Catheter-associated (CA) bacteriuria is the most commonhealth care–associated infection worldwide and • a result of the widespread use of urinary catheterization,much of which is inappropriate, in hospitals and longtermcarefacilities (LTCFs).

35. The most effective way to reduce the incidence of CA-ASBand CA-UTI is to reduce the use of urinary catheterization byrestricting its use to patients who have clear indications andby removing the catheter as soon as it is no longer needed

36. 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

37. CAUTI • positive dipstick for leukocyte esterase and/ or nitrate • pyuria (urine specimen with >10 white blood cell [WBC]/mmor >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 (gramnegative bacteria or Staphylococcus saprophyticus) with >10colonies/mL in nonvoidedspecimen

39. HICPAC Guidelines

44. CAUTI • Catheterassociatedbacteriuriaincreaseeverycatheterday: • Day 1: 5% • Week 1: 25% • Month 1: 100%

45. Prevention • removing the catheter as soon as it is no longer needed

46. Nosocomial Bloodstream Infections

47. Nosocomial Bloodstream Infections • 12-25% attributable mortality • Risk for bloodstream infection:

48. 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

49. 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

50. Epidemiology of CVC-BSI