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CSI > Case 3 - Hospital Acquired Infections > Flashcards

Case 3 - Hospital Acquired Infections Flashcards

1
Q

What are HAIs?

A

Hospital acquired infections

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2
Q

Where do HAIs occur?

A

Infections that patients get while receiving treatment for medical or surgical conditions

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3
Q

What are the 5 main types of care settings in that HAIs occur?

A
  1. Acute care hospitals
  2. Ambulatory surgical centers
  3. Dialysis facilities
  4. Outpatient care (e.g., physicians’ offices and health care clinics)
  5. Long-term care facilities (e.g., nursing homes and rehabilitation facilities)
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4
Q

What are the common types of HAIs?

A
  1. Catheter-associated urinary tract infections
  2. Surgical site infections
  3. Bloodstream infections
  4. Pneumonia
  5. Clostridium difficile
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5
Q

Risk factors for HAIs can be grouped into which 3 general categories?

A
  1. Medical procedures and antibiotic use
  2. Organisational factors
  3. Patient characteristics
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6
Q

What is a reservoir of an infectious agent?

A

The habitat in which the infectious agent normally grows

The reservoir is not necessarily the host from which an agent is transferred to a new host

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7
Q

What are the 3 types of reservoirs and their definitions?

A

Human - transmitted person to person
Animal - called zoonosis when infections are passed from animals to humans
Environmental - plants, soil, water all act as reservoirs

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8
Q

What is the portal of exit?

A

The path by which the pathogen leaves its host

Usually from the site the infection is localised

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9
Q

What are the 2 modes of transmission and explain them?

A

Direct - via direct contact / droplet spread

Indirect - airborne, vehicleborne (things / materials) or vectorborne (e.g. mosquitoes)

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10
Q

What is the portal of entry?

A

The manner in which a pathogen enters a susceptible host

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11
Q

What is a host?

A

An individual susceptible to the pathogen

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12
Q

What is the chain of infection?

A

The infectious agent leaves its reservoir or host through the portal of exit, and via a mode of transmission, enters through the appropriate portal of entry to infect a susceptible host

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13
Q

How can knowledge on the chain of infection help improve public health?

A

Interventions are directed at:
Controlling or eliminating agent at source of transmission
Protecting portals of entry
Increasing host’s defenses

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14
Q

What does the patient’s profile tell us about him?

A

His hobby is bell ringing
He loves to socialise at his local wine club
He takes statins for his high cholestrol
He is an ex-smoker, gave it up 10 years ago
He has a dog and he likes walking his dog
He has been married for 22 years

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15
Q

Why was the patient initally admitted to hospital?

A

He was eligible for a hip replacement surgery

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16
Q

Why is the patient still in the hospital?

A

There were some complications that gave him abdominal discomfort and the inability to pass urine, leading to the implant of a urinary catheter

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17
Q

What does the patient have currently and what is the likely cause?

A

Infection spread from UTI into blood
Most likely due to the insertion of the catheter, which disrupts gut bacteria, often pushing the e.g. E. coli in the gut from the GI to the urinary tract

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18
Q

How does the patient feel in the video when talking to the doctor?

A

Tired from lack of sleep due to his fever
Frustrated the anti-inflammatory does not seem to be working (been an hour since it was administered)
Confused - why does he have an infection if he is a hospital? Considers it a safe environment

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19
Q

What does the doctor tell the patient during the video?

A

The anti-inflammatory drugs should be helping him with his fever
His fever is due to an UTI
Infection has spread to the blood / bacteria has gotten into the blood
Giving him IV antibiotics

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20
Q

What impact on the NHS do HAIs have?

A 
Strained resources 
Increased cost 
Lack of efficiency 
Desensitisation to HAIs as an issue 
Reduces the good reputation of the NHS
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22
Q

What is the impact of HAIs on the hospital?

A

Reduced bed availability (bed blocking) - knock on effect, so next patient cannot undergo scheduled surgery if there is no bed available, and especially in A&E, patients spend hours on chairs / trolleys
Isolation wards filled
Longer hospital stays

22
Q

What is the impact of HAIs on hospital staff?

A

Stressed
Demotivated
Increased workload
Overworked = clouded judgement; maybe focus more on the infection than what they came in for?
Focused on discharging patients - discharge too early resulting in them perhaps coming back with a larger issue
Increased risk of infection to staff

23
Q

What is the impact of HAIs on the patients?

A

Frustration
Pain
Stress - work, family, commitments etc. Not just from the hospital
Worry
Increased hospital stay
Confusion - came in for one thing and now being treated for another
Lessened trust in the healthcare system - may not come back to the hospital

24
Q

How can the hospital staff regain / increase the patient’s trust in the healthcare system?

A

Apologise, take responsibility, have the same person explain the situation (consistency)

25
Q

What is the impact of HAIs on the friends and families of the patient?

A 
Disruptive
Frustrating
Worried
Stressed
If the patient is a carer for someone at home, the people at home may also get injured / need to find somewhere to be temporarily cared for
26
Q

What impact do HAIs have on visitors to the patient?

A

Fear of getting an infection

Perhaps a burden? i.e. take time out of their day to go visit the patient in hospital

28
Q

What are the 2 modes of spread?

A

Direct - touch / droplets

Indirect - air borne

29
Q

What are the mechanisms of spread of infection in hospitals?

A

Invasive, portal of entry - IVs, Catheters
Open wounds - need to disinfect well
Surgical site - e.g. not changing dressings often enough
Overcrowding - close proximity
One staff working with multiple patients
Proper hand washing techniques - staff, visitors and even patients themselves
Spread between medical equipment - trolleys

30
Q

What are the five moments of hand hygiene and link it back to the patient?

A
  1. Before touching the patient - wash hands before e.g. examining patient / surgical site
  2. Before clean / aseptic procedure - wash hands, new clean gloves, gown and sterile environment (clean trolley and equipment) e.g. to insert catheter
  3. After body fluid exposure risk - wash hands after exposure to fluids e.g. blood samples, inserting the catheter (urine)
  4. After touching a patient - wash hands just before seeing the next patient
  5. After touching patient‘s surroundings - wash hands and clean / disinfect their surrounding e.g. after cleaning up the bed, trolleys, etc. (all the things involved in the patient’s care)
31
Q

What is WCC and how does it show in the patient?

A

White cell count
Raised from 9.4 to 15.3
Indicates inflammation / infection

32
Q

What is CRP and how does it look for the patient?

A

Protein (C reactive protein) released during inflammation - measures amount of inflammation
Increased from 19 to 148, above normal range, pointing to inflammation and is a sign of infection

33
Q

What is meant by sensitivities?

A

Which antibiotic is the bacteria sensitive to (so which Ab would work to fight the infection well)

34
Q

What is RR and how does it look for the patient?

A

Respiratory rate
Normal is between 12-15
The patient has 17, which is a little high - first sign of septic shock (due to infection)

36
Q

What are sats and how does it look for the patient?

A

Saturation = 98%
Normal
But the doctor hasn’t written whether it’s on air or with respiratory support (e.g. 2 litres of O2?)

37
Q

What is BP and how does it look for the patient?

A

Blood pressure, 132/89
Normal
Not going into septic shock yet

37
Q

What is HR and how does it look for the patient?

A

Heart rate, 101

Slightly tackycardic

37
Q

What is the symptom ‘sleeping poorly’ a sign of?

A

Sepsis - life-threatening disease caused by the body’s response to an infection, inflammation across the body caused by the release of the that are part of the immune response

39
Q

What is septic shock?

A

Serious condition that occurs when a body-wide infection leads to dangerously low blood pressure

40
Q

What is the likely course of symptoms of septic shock?

A

First, higher respiratory rate
Afterwards, an increase in heart rate
Lastly, blood pressure drops

41
Q

Why were the antibiotics delivered intravenously?

A

Faster delivery, and infection spreading to the blood
Not localised - systemic effect (effect occuring in tissues distant from where the drug is being administered)
Need a systemic, hardcore Ab that works well
First the doctor chose an Ab on what would work well on a typical UTI
But later will check sensitivities to monitor / change Ab

41
Q

What is MCS and how is it measured?

A

Microscopy culture sensitivity - collects the pathogen, grows it on a petridish, applies different types of Abs to it. The effective Abs / the Abs the pathogen is sensitive to is shown by a zone of inhibition
CSU = catheter specific urine sample
MSU = midstream specimen of urine sample

41
Q

What did they find the bacteria in the UTI to be and which antibiotics are they sensitive to?

A

E. coli
Coamoxiclav - has the amoxicillin and also has clarisonic acid that is an inhibitor of beta lactamase
Gentamicin
Ciprofloxacin

Resistant to amoxicillin

43
Q

What are common mechanisms of resistance to antibiotics?

A
  1. Enzymes that metabolise the Ab e.g. beta lactamase
  2. If the Ab is a competitive inhibitor, increase the no. of substrate to outcompete the inhibitor
  3. Change the permeability of the membrane so the drug / Ab cannot diffuse in efficiently - therefore, decreased accumulation and so insufficient to be effective
  4. Altered target sites (process of natural selection) - Ab cannot enter
  5. Reflux pumps - Ab enters the bacteria, but is pumped out - prevents drug from reaching its target / accumulating in high enough concentrations to cause an effect
  6. Change the metabolism pathway from the current pathway that is being inhibited by the drug, to an alternative one
45
Q

What are some systems / processes for effective antimicrobial medicine use?

A

Not prescribe Abs straight away or if it is likely the infection is viral / looks viral
Take Abs exacly as prescribed - finish the course to ensure even the slightly resistant bacteria are killed

46
Q

What is the sequence of events from the admission for the elective hip replacement to his diarrhoea?

A

Hip replacement surgery - requires catheter
Urine retention (because the bladder becomes insensitive to the need to urinate as the catheter allows them to urinate whenever without thinking about it) - catheterised again
E. Coli UTI due to lack of sterile catherisation, catheter left in too long etc.
IV Abs started (co-amoxiclav) = broad spectrum Abs - more susceptible to C. Difficile infection as it kills the good gut bacteria
Less competition activates genes in C. diff so it becomes toxinogenic - produces different proteins

47
Q

What is the sequence of events from the admission for the elective hip replacement to his diarrhoea?

A

Hip replacement surgery - requires catheter
Urine retention (because the bladder becomes insensitive to the need to urinate as the catheter allows them to urinate whenever without thinking about it) - catheterised again
E. Coli UTI due to lack of sterile catherisation, catheter left in too long etc.
IV Abs started (co-amoxiclav) = broad spectrum Abs - more susceptible to C. Difficile infection as it kills the good gut bacteria
Less competition activates genes in C. diff so it becomes toxinogenic

49
Q

How is the process of natural selection increased?

A

Excessive use of Abs

Not finishing a course of Abs

49
Q

What is the sequence of events from the admission for the elective hip replacement to his diarrhoea?

A

Hip replacement surgery - requires catheter
Urine retention (because the bladder becomes insensitive to the need to urinate as the catheter allows them to urinate whenever without thinking about it) - catheterised again
E. Coli UTI due to lack of sterile catherisation, catheter left in too long etc.
IV broad spectrum Abs started - more susceptible to C. Difficile infection as the other ‘good bacteria’ in the gut is killed
C. Difficile is now a toxicogenic form, causing diarrhoea in the patient
The patient will be given a different antibiotic to treat the diarrhoea

49
Q

Why does IV Abs increase the risk of a C. Difficile infection?

A

C. Difficile exists on gut bacteria - non toxinogenic
Broad spectrum Ab kills off some other good gut bacteria - activates C. difficile to become toxinogenic as there is lack of competition - allows C. difficile to grow as genes activated (due to imbalance in gut bacteria)

50
Q

What is candour and why was candour introduced?

A

Candour is honesty, owning up to mistakes
Before in the NHS, mistakes were tried to cover up - mistakes were not apologised for, it was more likely to lead to patient dissatisfaction and patient complaints
Now : Mistakes must be documented, then the patient must be told and apologised to

51
Q

What is the mechanism of Ab resistance to penicillin?

A

Penicillin is a beta lactam Ab, therefore has a beta lactam ring in its structure, and is vital to interrupt the enzymes that crosslink the peptidoglycan in the cell walls
Some bacteria have developed the enzyme beta lactamase to break down the beta lactam structure in penicillin so it is no longer the right shape for its function
The cell wall is successfully manufactured by the bacteria, so does not die

CSI (10 decks)

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