Hospital acquired infections Flashcards
Other name for hospital acquired infection
Nosocomial acquired infections
What is a nosocompial acquired infection
Not present or incubating at time of admission
Break in time in sterile technique, getting from the hospital
Hospital acquired infection frequency
1 in 31 hospital patients (CDC)
Sources of HAI and frequency (6)
Central line associated sepsis
Urinary catheter associated UTI (12.9%)
Surgical site infections (21.8%)
Hospital-acquired pneumonia (21.8%)
Ventilator-associated pneumonia
Clostridium difficile infections (12.1%)
Risk factors for HAI (8)
Patient’s immune status
Infection control practices
Prevalence of certain pathogens in community
Older age
Longer hospital stays
Multiple chronic illnesses
Mechanical ventilatory support
Critical care unit stays
How are HACI transmitted
Direct contact with healthcare workers
Contaminated environments
Extraluminal migration
What is extraluminal migration
Normal skin flora -> catheters and can go down the catheters to the blood stream
Coag neg staphylococci (skin flora)
Symptoms suggestive of pre-existing infection (10)
Subjective fever
Chills
Night sweats
Altered mental status
Productive cough
Shortness of breath
Rebound tenderness
Suprapubic pain
Dysuria
CVA tenderness
Vital signs suggesting infection
Hypotension, tachypnea, low saturations, tachycardia
Lines that can contribute to infection (5)
Central line
Foley catheter
Insulin pump
Endotracheal tube
Intravenous lines
Labs suggesting infection
Lactic acid
Prothrombin time
BUN/Creatinine
Elevated WBC
Hypo/hyperglycemia
Cultures
SSI typically occur within ______ days of surgery
30
_________nosocomial infections in surgical patients
38%
coming in with no infection and developing infection from the hospital process
________ spent yearly due to prolonged recovery/hospitalization
$3.5 to $8 billion spent yearly due to prolonged recovery/hospitalization
What are the three types of SSI
Superficial incisional
Deep incisional
Organ or space
infection just in the area of the incision
Superficial incisional infection
infection beneath the incision area in muscle and tissues surrounding muscles
Deep incisional infection
infection that is any area other than skin and muscle…includes organs or space between organs.
Organ or space infection
Signs of SSI (7)
Redness
Delayed healing
Fever
Pain
Warmth
Swelling
Drainage of pus (abscess)
Types of common bacteria
Staphylococcus
Streptococcus
Pseudomonas
wound with not inflamed or contaminated; don’t involve internal organ
clean wound
Types of wounds (4)
clean
clean-contaminated
contaminated
Dirty
wound with no evidence of infection; do involve internal organ
clean- contaminated wound
deeper wound and has a potential because of increased opening
wound involves internal organ with spillage of contents from the organ
contaminated wound
appendicitis that ruptures, bowel or ulcer that ruptured.
wound known infection at time of surgery
dirty wound
RISK for SSI (4)
types of wound
surgery lasting > 2hrs (more likely to break technique)
Comorbidites
Elderly Emergency or abdominal surgery
Comorbidieites for risk of SSI (5)
Overweight, cancer, smoking, immunocompromised, diabetes
Whats the chance of SSI being preventable?
Maybe ½ of SSI’s are preventable!!!
1A grading categories
strongly recommended; moderate-to high quality of evidence
1 B grading categories
strong recommendation; low quality evidence
1 C grading category
strong recommendation required by state/federal regulation
II grading category
weak recommendation
Parenteral antibiotics and SSIs
- administer only when indicated (1B)
- timed so that agent is established in tissue upon incision (1B)
Non-parenteral antibiotics and SSIs
No recommendations for antibiotic irrigation
No recommendation for soaking prosthetic devices in antibiotic solution
Should not apply antibiotic ointments to incisions (1B)
Glycemic control and SSIs
Perioperative control (1A)
Glucose targets < 200 mg/dL (1A)
No recommendation for tighter control
No recommendation for A1C target
Normothermia and infection
Maintain perioperative normothermia (1A)
No recommendation for strategies to maintain normothermia
Oxygenation (Increased FiO2) and SSIs
Patients with normal pulmonary function, GETA intraoperative and immediately after extubation (1A) FIO1s in. 80%
No recommendation for increased FiO2 in patients;
Only intraoperatively with GETA
Neuraxial anesthesia
Postoperatively by mask or nasal cannula
No trials r/t percentage/duration/delivery method
Antiseptic prophylaxis and SSIs
Shower or bathe with soap or antiseptic pm before (IB)
Intraoperative skin preparation with alcohol-based antiseptic (1A)
Consider intraoperative iodine irrigation in deep tissues (II)
Where is iodine irrigation in deep tissues not beneficial
No benefit intra-peritoneally
No benefit with iodine imbedded adhesive drapes
No benefit soaking prosthetic devices
Blood transfusion and SSIs
Do not withhold necessary transfusion from surgical patient as a means to prevent SSI (I B)
Systemic immunosuppressive therapy and SSis
Uncertain benefits/harm with systemic corticosteroids on risk of SSI in joint arthroplasty
Infection most common indication for revision TKA
Uncertain benefit/harm with intra-articular corticosteroids preoperatively in planned joint arthroplasty
Goal for preoperative prophylaxis
Adequate bactericidal concentration in serum and tissues when incision is made…
MIC: Minimum inhibitory concentration
6 general principles of antibiotic prophylaxis
- should be active against common surgical wound pathogens
- proven efficacy in clinical trials
- must achieve MIC
- shortest possible course effective….ideally 1 dose
- newer antibiotics reserved for resistant infections
- if everything equal: oldest, cheapest…
Antibiotic timing
Initiated within 1 hr of incision (30 minutes even better)
Unless vancomycin or fluoroquinolone: initiated within 2 hrs
Completely infused prior to tourniquet use
May hold antibiotics for cultures
Redosing for antibiotic
Usually given after 2 half-lives or with excessive blood loss
May be re-dosed following cardiopulmonary bypass
Required for prolonged procedures
Drug dependent; usually 2-4 hours while in OR
Common surgical antibiotics (5)
Beta lactams;
-Penicillins
-Cephalosporins
-Carbapenems
Vancomycin
Aminoglycosides (gentamycin)
Fluoroquinolones (cipro)
Metronidazole (flagyl)
Penicillins-Beta Lactams MOA
Inhibit bacterial cell wall synthesis
Penicillins-Beta Lactam is the DOC for……
DOC for streptococci, meningococci, pneumococci
Mostly gram +
Skin infections, catheter infections, URI’s
Resistance to Penicillins-Beta Lactams is due to……..
Resistance d/t Beta-lactamase enzyme
Reside on outer surface of cytoplasmic membrane
Examples of Penicillins-Beta Lactams
Penicillin G
Methicillin
Nafcillin
Amoxicillin
Adverse reactions with Penicillins-Beta Lactams
Hypersensitivity
-History of reaction unreliable
-Skin rashes to anaphylaxis (0.05%)
GI upset (large doses)
Vaginal candidiasis
Cephalosporins-Beta lactams MOA
More stable against Beta lactamases;
Broader spectrum
Beta-lactam rings bind to Penicillin-binding protein and inhibit the normal activity of the protein (can’t synthesize a bacterial cell wall)
Resistance to Cephalosporins-Beta lactams
Resistance occurs by protein altering its structure
Cephalosporins-Beta lactams is DOC for……
DOC for;
Surgical prophylaxis
Can be used with PCN allergy except anaphylaxis
Generation 1 cephalosporins
Cefazolin- Ancef, Kefzol
Does not penetrate BBB
Most gram + (staph and streptococci)
Cellulitis, abscesses, URI, UTI
Most common surgical prophylaxis
Generation 2 Cephalosporins
Cefuroxime- Ceftin, Zinacef
Better gram – coverage
H-influenzae pneumonia, UTI, otitis media
Cefoxitin- Mefoxin
Cefotetan- Cefotan
Generation 3 cephalosporins
Cefotaxime- Claforan
Some cross BBB
Better gram – than before; treats resistance
Meningitis
Ceftriaxone- Rocephin; Gonorrhea
Ceftazidime- Fortaz
Generation 4 cephalosporins
Cefepime- Maxipime
Most resistant to hydrolysis by lactamases
Usually reserved for multi-resistant organisms
Penetrates BBB well
Adverse reactions with Cephalosporins-Beta lactams
Hypersensitivity
Uncommon
Rashes, fever, nephritis, anaphylaxis
Potential production deficit of Vitamin K
Common cause of colitis (3rd generation)
Cross reaction approx. 1%
Increased likelihood of rx IF PCN anaphylaxis
For true anaphylaxis, use vancomycin or clindamycin
Carbapenem-Beta lactam MOA
Good activity against gram – rods (P aeruginosa) and Enterobacter
Can inhibit the beta-lactamase enzyme
Possess the broadest spectrum of activity
Bind to penicillin-binding protein…
Carbapenem-Beta lactam used for_____
Last line agents
Intra-abdominal, resistant UTI’s, pneumonia
Carbapenem-Beta lactam most penetrate ______
BBB
Examples of Carbapenem-Beta lactam
Ertapenem (Invanz)
Meropenem (Merrem)
Imipenem (Primaxin)
Adverse reactions to Carbapenem-Beta lactam
N/V
Diarrhea
Rashes
Injection site reactions;
IM formulations contain lidocaine…LA allergies?
Decrease valproic acid (Depakote) up to 90%(sz hx don’t give carbopenem to them)
Cross sensitivity to PCN < 1%
Vancomycin MOA
Inhibits cell wall synthesis
Active against gram + bacteria (too large to penetrate gram – wall)
Only works if bacterial is actively dividing
Is very slow
Vancomycin most valuble against_______
Most valuable against blood-stream infection and endocarditis
Caused by MRSA
Adverse reactions with vancomycin
Frequent
Phlebitis at injection site
Chills, fever
Nephrotoxicity
“red man” syndrome
Aminoglycosides MOA
Inhibit ribosomal proteins and cause mRNA to misread
Amionoglycosides are useful in
Significant post antibiotic effect
Synergistic with Beta-lactams or vancomycin
Especially useful in enterococcal endocarditis
Examples of aminoglycosides
Gentamycin
Adverse reactions for aminoglycosides
Ototoxicity
Nephrotoxicity, In elderly, For more than 5 days, In renal insufficiency, With higher doses, Concurrent with loop diuretics
Curare-like affect
Fluoroquinolone MOA
Inhibits bacterial DNA protein synthesis
Fluoroquinolone Used for
Excellent with gram – organisms
UTI, bacterial diarrhea, bone/joint infections
Examples of Fluoroquinolone
Examples:
Ciprofloxacin (Cipro)
Levofloxacin (Levaquin)
Adverse reactions for Fluoroquinolone
N/V/D
Prolongation of QT interval
Cartilage damage/tendon rupture
Renal insufficiency
Concurrent steroid use
Advanced age
Metronidazole MOA
Antiprotozoal /Anaerobic antibacterial
Forms toxic byproducts that cause unstable DNA molecules
Metronidazole is indicated for
Indicated for:
Intra-abdominal infections
Vaginitis
C-diff
present as superinfections
Metronidazole other name
(Flagyl)
Adverse reactions for Metronidazole
Nausea
Peripheral neuropathy In prolonged use
Disulfiram-like effect With alcohol
Flushing, dizziness, HA, chest/abd pain
Hangover
