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CIC Exam > SSIs and VAP > Flashcards

SSIs and VAP Flashcards

1
Q

What are some examples of the impact of SSIs?

A

-risk for readmission
-prolonged admission
-reoperation
-ICU admission
-another surgery
-doubles mortality
-cost

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2
Q

What is the most common HAI?

A

SSI (25% of all HAIs)

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3
Q

What are four clinical variables in the pathogenesis of SSIs?

A
  1. Inoculum of bacteria: wound contamination. Each species has a quantitative threshold.
  2. Virulence of bacteria: the more virulent the microorganism the less contamination required.
  3. adjuvant effects in the microenvironment
  4. impaired host defenses
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4
Q

what are the 4 classes of SSIs?

A
  1. clean
    II. clean contaminated
    III. contaminated
    IV. infected (dirty)
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5
Q

Define a clean SSI

A

An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered

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6
Q

Define a clean contaminated SSI

A

respiratory, urinary, GI or genital tracts were entered under controlled conditions and without unusual contamination. A minor break in surgical aseptic technique would fit into this class.

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7
Q

Define a contaminated SSI

A

open, fresh, accidental wounds

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8
Q

Define an infected SSI

A

Old traumatic wounds with retained devitalized tissue and those that involve an existing clinical infection or perforated viscera

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9
Q

What are the 3 definitions of an SSI?

A

-superficial
-deep
-organ/space

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10
Q

Define a superficial incisional SSI

A

Infections within 30 days of a NSHN procedure.

Infections that involve only the skin or subcutaneous tissue of the incision.

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11
Q

define a deep incisional SSI

A

infection within 30-90 days after procedure
Infections that involve deep soft tissue (e.g., fascial and muscle layers).

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12
Q

define an organ/space SSI

A

infection occurs within 90 days
Infections that involve any part of the anatomy (e.g., organs, spaces) other than the incision

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13
Q

What are some SSI prevention methods?

A

-pre op antiseptic scrubs at the surgical site and total body showers and baths to diminish potential pathogen presence
-skin antiseptic as skin prep in the OR (chlorohenixidne vs iodine)
-sterile drapes and sterile barriers
-mechanical hair clippers just prior to surgery
-HVAC/air handling (OR suites at positive pressure, a minimum of 20 air exchanges per hour with 4 being fresh air, air introduced at the ceiling and exhausted near the floor, HEPA in place)
-restrict OR traffic
-nasal carriage decolonization

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14
Q

how is surgical hand antisepsis performed to prevent SSI?

A

-remove rings, watches, and bracelets first
-remove debris under nails using a nail cleaner under water
-use antimicrobial soap or ABHR with persistent activity
-follow manufacturer time (usually 2-6 mins). longer scrubs are not necessary.
-before applying ABHR, prewash hands and forearms with a non antimicrobial soap and dry compeltely
-after ABHR application, allow it to thoroughly dry before donning sterile gloves

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15
Q

What are some characteristics of the antibiotics used to prevent SSIs?

A

-give 60 mins before incision is made (except vancomycin or fluoriquiolones-window is 120 minutes)
-antibiotic should be consistent with recommendations
-antibiotics should be discontinued 24 hours after procedure (except coronary artery bypass grafting which is 48 hours)

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16
Q

what are some benefits of SSI prevention-negative pressure would therapy

A

Macrostrain:
-draws wound edges together
-removes infectious material
-reduces edema
-promotes perfusion

Microstrain:
-micro tissue deformation
-stimulates cellular activity -

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17
Q

describe SSI prevention-pressure irrigation

A

-disrupts fibrin film and removes bacterial contaminants hidden within fibrin
-used on high risk or grossly contaminated wound

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18
Q

What is one argument against pressure irrigation?

A

high pressure may drive bacteria deeper into tissues and damage tissues

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19
Q

what are some SSI prevention methods-enhancement of host

A

-normothermia-maintain body temp above 36.5
-hyperglycemia
-decolonize nasal MRSA pre-operation

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20
Q

what are the foundational principles in the management of SSIs?

A

-open and drain the incision (evacuate manually with local irrigation and suction)
-debride fibrous debris and necrotic tissue
-remove foreign bodies
-implement antimicrobial therapy as needed
-Manage the open wound (NPWT, moist dressings)

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21
Q

What is a sign that a wound needs further opening?

A

sinus tract infection

22
Q

Describe the clinical diagnosis of VAP

A

clinical filtrates: new x ray infiltrate
AND two of:
-fever
-purulent sputum
-leukocytosis or leukopenia
-increased oxygen needs

70% sensitivity, 75% specificity with autopsy

23
Q

What are the 4 classes of pneumonia?

A
  1. community acquired (CAP): occurs in a patient admitted to hospital from the community
  2. Healthcare associated (HCAP): occurs in patients with any of the following epi characteristics:
    -hospitalized for 2 or more days within 90 days of the current infection
    -resident in a nursing home or LTC facility
    -received recent intravenous or IV therapy, chemo, or wound care within 30 days of the current infection
    -attended a hospital or hemodialysis clinic (at risk for hospital colonization similar to hospitalized patients)
    3: Hospital acquired pneumonia (HAP): pneumonia developing >48 hours after hospital admission
  3. VAP: patients who have been intubated and received mechanical ventilation for at least 48 hours
24
Q

what is the 2nd most common HAI?

A

VAP

25
Q

why is VAP important?

A

-2nd most common HAI
-2nd most expensive HAI
-longer admission to ICU/hospital (increase 7 days for ICU)
-increase ventilator time (4-30 days)
-leading cause of death among HAIs
-mortality of ventilated patients who develop VAP is 46% compared to 32% in those ventilated without VAP
-adds an estimated cost of 40k to each hospital admission
-difficult diagnosis and comorbidities often lead to unnecessary courses of antibiotics

26
Q

what is the VAP surveillance definition

A

NHSN
-CXR findings: new or progressive infiltrate, consolidation or cavitation (1 or 2)

AND

one of: fever >38; WBC <4000 or >12000; or altered mental status

AND

at least two of: sputum change, worsening cough or dyspenea/auscultative changes; worsening gas exchange

27
Q

what are some benefits of NHSN voluntary VAP reporting?

A

-less reliance on chest x-ray
-potential for cases to be automatically generated electronically
-inclusive of non-infectious complications
-LTC and inpatient facilities can participate
-simplified, non-infectious critiera

28
Q

What are 3 definitions associated with ventilator associated events (VAEs)

A
  1. ventilator associated conditions
  2. infected related ventilator associated complication
  3. possible and probable VAP
29
Q

_____% of patients will be colonized with hospital flora within ___ hours of admission

A

75%; 48 hours

30
Q

describe the pathogenesis of VAP

A

-aspiration of oral/gastric contents
-lumen of ETT
-direction inoculation by devices
-inhalation of aerosolized agents (i.e., influenza)
-microaspiration of oropharyngeal secretions
-intubation faciliates adpiration
-virulence
-microbial load
-host factors

31
Q

aspiration can be

A

chronic: accumulation of pooled secretions
Acute events: during intubation, cuff deflation

32
Q

describe lumenal contamination

A

acute events: tube condensate leak, instillation across tube.

chronically: development of biofilm in lumen

33
Q

what are some patient factors for VAP development?

A

-smoking
-pre existing lung disease
-malnourished (esp. protein malnourished)
-immunocompromise
-colonzation of mouth or pharynx with one or more virulent organisms

34
Q

what are some peri-intubation factors?

A

emergent intubation: increases risk of aspiration

nasotracheal intubation: increases risk of sinitis, contamination of ETT

sedatives may be immunocomprimsiing

35
Q

what are some post intubation factors?

A

poor care of ventilator circuit
poor oral care
ongoing antimicrobials
flat head of bed
introduction of more virulent organisms to patient
complications: DVT, stress ulcers

36
Q

what are some causative agents of VAP?

A

-VAP usually >1 organism
-patients flora: oral/enteric
-introduced organisms: environmental/MDRO

37
Q

What are some VAP preventative measures?

A

-prevent endotracheal intubation
-prevent aspiration
-prevent contamination of vent circuit
-prevent person to person transmission
-programmatic measures

38
Q

how do you prevent intubation?

A

-consider other ventilation options (non-invasive)
-discontinue early-sedation vacation. spontaneous breathing trails. No strong evidence of benefit.
-tracheostomy: reduces laropharyngeal trauama, duration (data not shown to reduce VAP)

39
Q

How do you prevent aspiration?

A

-elevate head of bed to 45 degrees (3-fold decrease in VAP)
-avoid over distended stomach
-continuous subglottic suctioning
-keep cuff properly inflated (20cm H20)
-intubate via mouth rather than nose
-mouth care/decontamination (mouth rinses, removal of excess fluid, antisepsis, CHG rinses -limited evidence)
-antacid use (reduce damage from aspiration)

40
Q

How do you prevent contamination of a vent circuit

A

-avoid unecessary circuit break (ventilator circuit units should not be changed routinely. change when soiled or malfunctioning).
-drain condensate in tubing
-only sterile water in humidified vents
-high efficacy bacterial filters are to be used on the expiratory arms on the vnetilator circuit and should not be placed between the inspiratory arm of the humidifier and patient.

41
Q

how do you prevent VAP person to person spread

A

-hand hygiene before and after contact with patient
-gloves when handling respirtory secretions
-no sick visitors or healthcare workers present

42
Q

What are some programmatic (administrative) measures for VAP?

A

-education
-surveillance (NHSN)
-bundled interventions

43
Q

what are some examples of bundled interventions?

A

-collection of best evidence and practices believed to work as a whole (3-5 interventions)

-subject to evaluation as a unit. May be subject to a factorial study.

44
Q

what are the expected effects of a bundle?

A

-not an immediate result
-achieve process benchmarks then clinical benchmarks

45
Q

What is an example of a VAP bundle?

A

-elevate head of bed
-daily sedation vacation
-use orotrachel, not nasotrachel intubation
-use ETT with port for continous subglottic suctioning

46
Q

What are some categories for SSI prevention?

A

-parental antimicrobail prophylaxis (only when indicated)
-non parental antimicrobial prophylazis (don’t apply ointments and powders to prevent SSIs)
-glycemic control (blood glucose less than 200 mg/Dl in diabaetic and non diabetic patients).
-normotermia
-oxygenation: administer an increased fraction of inspired oxygen during surgery and after extubation in the immediate postoperative period. To optimize tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement.
-environemnt of care
-antiseptic prophylaxis (baths before)
-blood transfusions (do not withhold to prevent an SSI)

47
Q

describe NPWT

A

placing a polyester foam over the wound and covering the foam and the adjacent skin with a transparent plastic adhesive drape. A suction device applies negative pressure, actively removing inflammatory fluids and presumably microbes from the surface of the wound.

48
Q

what are the most effective surgical hand antisepsis products?

A

The most effective products contain idophors or chlorhexidine gluconate (CHG) at 2% or 4% strength

49
Q

what should selection criteria for hand antisepsis be?

A

effectiveness and low-irritancy potential, not cost

50
Q

what are challenges of IPAC with dialysis?

A

-services are often outsourced
-patients have conditions that make infection presentation difficult to spot

51
Q

what are some strategies for preventing dialysis infections?

A

-HH
-PPE
-hazard assessment (employers conduct assessments to determine what PPE is necessary).
-skin cleaning and disinfection (alcohol-based chlorhexidine (>0.5%) solution should be used as skin antiseptic for central line insertion and during dressing changes; and an antibiotic or povidone-iodine ointment should be applied to catheter exit sites during dressing changes)
-environmental cleaning (with 1:100 dilution of household bleach)
-dialysis station maintenance
-scrub the hub (Catheter hubs must be scrubbed with an appropriate antiseptic after the cap is removed and before accessing the catheter—and this should be done whenever the catheter is accessed or disconnected)
-water management (test monthly)
-occ health
-staff education
-patient education
-patient screening and vaccination
-catheter reduction (remove or do permanent access)

52
Q
A

CIC Exam (9 decks)

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