BASICS
DESCRIPTION
- Health care " “associated infections (HAIs)
- Infection must not have been present or incubating on admission to a health care facility.
- CDC categories:
- Catheter-associated urinary tract infection (CAUTI)
- Surgical site infection (SSI)
- Ventilator-associated pneumonia (VAP)
- Central line " “associated bloodstream infection (CLABSI)
- Clostridium difficile infection (C. diff, C. difficile, CDAD, CDI)
- The National Healthcare Safety Network (NHSN) at www.cdc.gov/nhsn monitors emerging HAI pathogens and their mechanisms of resistance to promote current prevention strategies.
- Medicare and Medicaid will not pay for the treatment of certain HAI including CAUTIs, CLABSIs, and SSIs.
EPIDEMIOLOGY
- General
- 13/1,000 patient-days in the ICU (1)
- 7/1,000 patient-days in high-risk nurseries
- 2.6/1,000 patient-days in nurseries (1)
- Estimated cost of HAIs is $20 billion per year (2).
- Infection specific
- CAUTI
- Hospital stay increased by 1 to 3 days.
- Cost up to $600/infection
- VAP
- Hospital stay increased by 6 days.
- Cost up to $5,000/infection
- CLABSI
- Hospital stay increased by 7 to 20 days.
- Cost up to $56,000/infection
- SSI
- Hospital stay increased by 7.3 days.
- Cost >$3,000/infection
- May not be apparent until 1 month after surgery
- C. difficile infection (see topic "Clostridium difficile Infection " ¯)
Incidence
- 1 out of 25 inpatients in the United States has at least one HAI (3).
- 722,000 HAIs in U.S. acute care hospitals in 2011 (3)
- UTI: 13% of HAIs (3)
- Pneumonia: 22% of HAIs (3)
- Bloodstream infection: 10% of HAIs (3)
- SSI: 22% of HAIs (3)
- 107,000 C. difficile cases in 2011(4)[A]
- Infections caused by gram-negative rods resistant to almost all antibiotics are increasing. Up to 70% of nosocomial infections are resistant to at least one previously active antimicrobial.
ETIOLOGY AND PATHOPHYSIOLOGY
- Endogenous spread: Patient host flora causes invasive disease (most common).
- Exogenous spread: Flora acquired from within health care facility.
- Causative organisms
- UTI: Escherichia coli, Klebsiella spp., Serratia spp., Enterobacter, Pseudomonas aeruginosa, Enterococcus spp., Candida albicans (3)
- Pneumonia: aerobic gram-negative bacilli, Staphylococcus aureus, P. aeruginosa, Streptococcus spp. (3)
- Bloodstream infection: Staphylococcus spp., Candida spp., Enterococcus spp., gram-negative bacilli (3)
- SSI: S. aureus, gram-negative bacilli, Enterococcus spp., Streptococcus spp., Enterobacter spp., Bacteroides spp. (3)
RISK FACTORS
- Extremes of age
- Invasive surgical procedures (abdominal surgeries, orthopedic surgeries, urogynecologic surgeries, neurosurgery)
- Use of indwelling medical devices.
- Chronic disease (including diabetes, renal failure, and malignancy)
- Immunodeficiency
- Malnutrition
- Medications (recent antibiotics, proton pump inhibitors, and sedatives)
- Colonization with pathogenic strains of flora
- Breakdown of mucosal/cutaneous barriers, including trauma and battle wounds
- Anesthesia
- Lack of attention to detail with universal precautions
GENERAL PREVENTION
- Prevention should target both patient-specific and facility-related risk factors.
- Hand hygiene " ”thoroughly wash hands (5)[C]
- On entering and leaving any patient room (5)
- After contact with blood, excretions, body fluids, wound dressings, nonintact skin, mucous membranes (5)
- Before using and after removing gloves (gloves are permeable to bacteria)
- When moving hands from contaminated to clean body site (5)
- Alcohol-based products are satisfactory when hands are not visibly soiled (5).
- Soap and water should be used when surfaces are visibly soiled or when contact with spores is anticipated.
- Antibiotic stewardship " ”appropriate selection of antimicrobial therapy includes the following:
- Judicious use of antibiotics to reduce the emergence of multidrug-resistant organisms and the occurrence of C. difficile infection (2).
- Use of narrow-spectrum early-generation antibiotics when possible.
- Taking an antibiotic "time out " ¯ at 72 hours to review the patient 's clinical status and culture results, and eliminate ( "streamline " ¯) any redundant or unnecessary antibiotics
- Use shorter courses of antibiotics when appropriate.
- Hospital-based surveillance programs and antibiograms
- Infection control programs with specially trained employees (5)[C]
- Employee education on HAIs (5)[C]
- Disinfection of hospital rooms with hydrogen peroxide vapor or UV irradiation in addition to standard cleaning reduces environmental contamination and the risk of infection with multidrug-resistant organisms.
- Minimize invasive procedures.
- Caregiver stethoscope cleaning
- Stethoscope bacterial contamination is common. Regular cleaning with alcohol-based preparations reduces bacterial load. Evidence is lacking to confirm whether stethoscope contamination causes nosocomial infections.
- Isolation of known pathogen carriers (5)[A]
- Contact precautions
- Institute for known pathogens spread by direct contact including methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus (VRE), C. difficile, extended-spectrum ˇ ²-lactamase " “producing gram-negative rods, and carbapenemase-producing gram-negative rods.
- Glove when entering room (5)[B]
- Gown if clothing will touch patient or environment (5)[B]
- Droplet precautions
- Infectious particles measure >5 ˇ ¼m.
- Institute for pathogens shed via talking, coughing, sneezing, mucosal shedding, airway suctioning, and bronchoscopy. These include Neisseria meningitidis, influenza, Haemophilus influenzae, Corynebacterium diphtheriae, and Bordetella pertussis.
- Mask when entering room (5)[B]
- Airborne precautions
- Infectious particles measure <5 ˇ ¼m.
- Institute for pathogens shed via coughing including tuberculosis, varicella-zoster virus, and measles.
- Fit-tested National Institute of Occupational Safety and Health (NIOSH) " “approved ≥ N-95 respirator on entering room (5)[B]
- Infection-specific measures
- CAUTI
- Employee education on urinary catheters (indications, placement, maintenance)
- Sterile catheter placement technique (6)[C]
- Closed urine collection system (6)[C]
- Use catheter only for necessary duration and remove as early as possible (6)[B].
- Use of nurse-driven protocols for guideline-driven catheter removal.
- Do not confuse catheter-associated asymptomatic bacteriuria with CAUTI.
- Do not screen for bacteriuria by routinely performing a urine culture when the catheter is withdrawn.
- VAP
- Intubate only when clinically necessary (7)[C]
- Perform oral decontamination with oral chlorhexidine (8)[A].
- Avoid nasotracheal intubation (7)[B].
- Inline suctioning (7)[C]
- Elevate head to 30 to 45 degrees (7)[C].
- CLABSI
- Educate staff about appropriate use of IV catheters (indications, placement, maintenance) (9)[A].
- Place catheters using sterile technique (including chlorhexidine prep and maximal barrier precautions) (9)[A].
- Use order "bundles " ¯ to improve adherence to catheter insertion guidelines.
- Remove catheter promptly when no longer clinically indicated (9)[A].
- Hand hygiene in addition to glove use (9)[A]
- Regularly monitor catheter site (9)[A].
- With introduction of these measures, CLASBI rates fell 46% between 2008 and 2011 (10)[A].
- SSI
- Proper surgical hand hygiene (2)[B]
- Prophylactic antibiotic therapy when indicated (2)[A]; eliminate underlying infections before surgery if possible (2)[A].
- Remove hair with electric clippers/depilatory agent prior to incision (2)[B].
- Poor postoperative blood sugar control increases risk of infection.
- C. difficile infection
- Gloves combined with hand hygiene with soap and water (spores are resistant to alcohol-based products) (2)
- Restrict use of fluoroquinolones, cephalosporins, and clindamycin when possible (2).
- C. difficile is associated with the use of proton pump inhibitors: H2 blockers is preferred for acid suppression (11)[A].
- Probiotics may reduce nonspecific antibiotic-associated diarrhea; the effectiveness of probiotics for prevention of C. difficile is unclear (11).
- Bloodstream infections
- Use of chlorhexidine-impregnated washcloths to bathe ICU patients reduces bloodstream infections by 28% (12)[B].
- Routine surveillance for systemic inflammatory response syndrome (SIRS) using established criteria
DIAGNOSIS
Consistent with nature of infection ‚
HISTORY
- Exposure to health care facility
- Recent surgery/open wounds
- History of invasive procedure
- Urinary catheter placement
- Indwelling vascular catheter
- Recent intubation/mechanical ventilation
- History of past infections (MRSA, VRE, etc.)
PHYSICAL EXAM
Consistent with nature of infection; site-specific exam for infections of skin, catheter sites, wounds, signs of sepsis, or pneumonia ‚
DIFFERENTIAL DIAGNOSIS
- Community-acquired infection
- Sepsis/SIRS
- Other causes of infectious diarrhea
DIAGNOSTIC TESTS & INTERPRETATION
Specific to condition ‚
- CBC, blood culture
- Wound culture
- Urine culture
- Chest x-ray
- Stool culture
Test Interpretation
Consistent with underlying infection ‚
TREATMENT
GENERAL MEASURES
- Treat with appropriate antibiotics.
- Order bundles improve adherence to sepsis guidelines and improves survival.
- UTI: Remove urinary catheters.
- CLABSI: Remove IV catheter.
- C. difficile: Stop all antibiotics not being used to treat C. difficile infection.
MEDICATION
First Line
- Targeted antimicrobial therapy
- Several agents have been recently approved for the treatment of antibiotic-resistant infections and should be considered for second-line therapy.
- Daptomycin, telavancin, dalbavancin, ceftaroline, oritavancin, tedizolid, ceftolozane-tazobactam, and ceftazidime-avibactam
ISSUES FOR REFERRAL
- Failure to respond to initial therapy
- Some emerging resistant gram-negative infections are resistant to nearly all antibiotics and require expert consultation for management.
SURGERY/OTHER PROCEDURES
- Screening for nasal carriage and isolation reduce the nosocomial spread of MRSA.
- Treating proven nasal carriers of Staphylococcus or MRSA with mupirocin prevents S. aureus nosocomial infections after surgery, as long as the prevalence of mupirocin resistance is low (13)[B].
INPATIENT CONSIDERATIONS
IV Fluids
As needed for hemodynamic support ‚
Nursing
- Hand washing should be performed on entering and exiting the patient room even when there is no direct contact with the patient.
- Isolation precautions as indicated
Discharge Criteria
When infection has resolved or patient is stable and not an infectious risk ‚
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Risk for recurrence is generally low in immunocompetent patients. Manage underlying comorbidities (risk factors). ‚
PROGNOSIS
- 99,000 deaths in 2002 in the United States (1)
- Bloodstream infection mortality: 27%
- Pneumonia mortality: 33 " “50%
- SSI mortality: 11%
COMPLICATIONS
Related to specific nature of infection ‚
REFERENCES
11 Klevens ‚ RM, Edwards ‚ JR, Richards ‚ CLJr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160 " “166.22 Yokoe ‚ DS, Mermel ‚ LA, Anderson ‚ DJ, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S12 " “S21.33 Magill ‚ SS, Edwards ‚ JR, Bamberg ‚ W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198 " “1208.44 Lessa ‚ FC, Mu ‚ Y, Bamberg ‚ WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825 " “834.55 Siegel ‚ JD, Rhinehart ‚ E, Jackson ‚ M, et al. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10)(Suppl 2):S65 " “S164.66 Hooton ‚ TM, Bradley ‚ SF, Cardenas ‚ DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625 " “663.77 Tablan ‚ OC, Anderson ‚ LJ, Besser ‚ R, et al. Guidelines for preventing health-care associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1 " “36.88 Chan ‚ EY, Ruest ‚ A, Meade ‚ MO, et al. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ. 2007;334(7599):889.99 O ' Grady ‚ NP, Alexander ‚ M, Burns ‚ LA, et al. 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. www.cdc.gov/hicpac/BSI/01-BSI-guidelines-2011.html. Accessed 2011.1010 Centers for Disease Control and Prevention. 2013 National and State Healthcare-Associated Infections Progress Report. www.cdc.gov/hai/progress-report/index.html.1111 Surawicz ‚ CM, Brandt ‚ LJ, Binion ‚ DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478 " “498.1212 Climo ‚ MW, Yokoe ‚ DS, Warren ‚ DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533 " “542.1313 van Rijen ‚ M, Bonten ‚ M, Wenzel ‚ R, et al. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;(4):CD006216.
CODES
ICD10
- T83.51XA Infect/inflm reaction due to indwell urinary catheter, init
- T81.4XXA Infection following a procedure, initial encounter
- J95.851 Ventilator associated pneumonia
- T82.7XXA Infect/inflm react d/t oth cardi/vasc dev/implnt/grft, init
- N39.0 Urinary tract infection, site not specified
ICD9
- 996.64 Infection and inflammatory reaction due to indwelling urinary catheter
- 998.59 Other postoperative infection
- 997.31 Ventilator associated pneumonia
- 999.31 Other and unspecified infection due to central venous catheter
- 599.0 Urinary tract infection, site not specified
SNOMED
- 19168005 Nosocomial infectious disease (disorder)
- 371061003 infection of bladder catheter (disorder)
- 33910007 Postoperative infection (disorder)
- 425464007 Nosocomial pneumonia (disorder)
- 68566005 urinary tract infectious disease (disorder)
- 431193003 Infection of bloodstream (disorder)
CLINICAL PEARLS
- Nosocomial infections increase mortality, length of hospital stay, and cost of hospitalization.
- Preventive efforts should address patient-specific and facility-related risk factors.
- Proper hand hygiene, using an alcohol-based hand product or soap and water should be carried out before and after each patient encounter, even when gloves are used. Alcohol-based hand rubs are not effective for killing spores formed by C. difficile. Hand washing with soap and water is preferred in this situation.
- Adherence to contact, droplet, or airborne precautions reduces the spread of infection.
- The risk of developing a resistant nosocomial infection can be reduced by antibiotic streamlining, use of narrow-spectrum antibiotics, and frequent patient reevaluation to ensure the necessity of continuing antibiotics.