MEDICAL & SURGICAL HEALTHCARE-

PATHOLOGY 1
ASSOCIATED INFECTIONS
HEALTHCARE-ASSOCIATED INFECTIONS
GENERALITIES

• HAI are infections that occur in hospitalized (or recently discharged patients) or in those who are treated in
healthcare facilities (asylums, social centers).
• Nosocomial is a term used to define the HAI that occur in a hospital setting.
• According to updates from the CDC (US Center for Disease Control and Prevention), every day, 3% of the
hospitalized patients are diagnosed with at least one HAI
• Types of HAI :
1. Pneumonia
2. Catheter-associated urinary tract infection
3. Central line-associated bloodstream infections
4. Surgical site infections (see Unit 16)
NOSOCOMIAL PNEUMONIA
NOSOCOMIAL PNEUMONIA
GENERAL NOTIONS

• Is the second most frequent among HAI and the most frequent type in the ICU
• Has the highest mortality among all HAI
• Subtypes :
a) hospital acquired pneumonia (no previous intubation and mechanical ventilation) - HAP
b) ventilator-associated pneumonia - VAP

• In both cases, the definition requires > 2 days of hospital stay or mechanical ventilation
• Aspiration of oropharyngeal secretions or downward leakage of secretions around the
endotracheal tube cuff are the primary routes of contamination of the lower airways
NOSOCOMIAL PNEUMONIA
DIAGNOSIS

• Diagnostic criteria:
1. New or progressive uni or bilateral lung infiltrate on chest X-ray/CT scan
2. A combination of clinical criteria : fever, purulent sputum, leukocytosis, hypoxemia

• Clinical diagnostic criteria specificity is low and a high index of suspicion is necessary,
especially in ICU patients
• Whenever possible, cultures (from blood and airway secretions) should be obtained in
order to increase the diagnostic yield and guide the antimicrobial therapy
NOSOCOMIAL PNEUMONIA
DIAGNOSIS

Protected specimen brush (PSB) and bronchoalveolar lavage (BAL)

are preferred invasive methods of obtaining lower respiratory secretion samples in intubated patients
NOSOCOMIAL PNEUMONIA
RISK FACTORS FOR MULTIDRUG RESISTANT PATHOGENS

• Antimicrobial therapy in the preceding 3 months

• Current hospitalization of > 5 days
• High frequency of antibiotic resistance in the community or in the specific hospital unit
• Immunosuppression
• Presence of risk factors for health care-associated pneumonia (hospitalization for > 2 d or
more in the preceding 90 d, residence in a nursing home, home wound care and home
infusion therapy, family member with multidrug-resistant pathogen, chronic dialysis)
NOSOCOMIAL PNEUMONIA
TREATMENT

• Timing :
 Early onset (< 5 days) : usually caused by antibiotic- • 3rd gen. cephalosporines (ceftriaxone) / quinolones / ertapenem
sensitive bacteria (methicillin-sensible S. aureus,
Streptococcus pneumoniae, H. influenzae)
• Antipseudomonal cephalosporines/carbapenems/beta-lactam
&beta-lactamase inhibitor
 Late onset (> 5 days) : multi-drug resistant agents
+
(methicillin-resistant S. aureus – MRSA, Pseudomonas
aeruginosa, Acinetobacter) : combinations Antipseudomonal quinolone/aminoglucosydes
+
Anti-MRSA (linezolid/vancomycin)
• Early initiation of antibiotics (in combination, to address
the most likely pathogens) and posterior adjustment once
cultures and drug sensitivity are available
NOSOCOMIAL PNEUMONIA
PREVENTION

• Avoid invasive ventilatory support whenever possible (most important factor); when unavoidable, reduce its
duration
• Orotracheal intubation preferred instead of nasotracheal
• Strategies to prevent VAP :
 Pharyngeal decontamination with topical clorhexidine
 Semi recumbent position (head up at 30-45º) to reduce the risk of digestive content ascension
 Use of tubes that provide a good airway seal
 Frequent aspiration of subglottic secretions
 Postpone enteral feeding at least 48 hours after intubation and favour postpyloric enteral feeding (reduces gastric secretion)
 Transfusion restriction
CATHETER-ASSOCIATED URINARY
TRACT INFECTION
CATHETER-ASSOCIATED URINARY TRACT INFECTION
GENERAL NOTIONS

• Most frequent HAI

• 75% of all cases of nosocomial urinary tract infection (UTI) are catheter-related
• Prolonged catheter use is the most important factor for developing a CAUTI
• Pathogen sources : patients GI tract and perineum – mainly Gram-negative bacteria
• Pathogenesis :
- bacteria adhere to the biofilm that coats the surface of the catheter and colonize the bladder in 1-3
days
- colonization of the collecting system due to improper handling
CATHETER-ASSOCIATED URINARY TRACT INFECTION
DIAGNOSIS

• In most cases, the presence of bacteria (bacteriuria) or Candida (candiduria) in the urine of a
catheterized patient represents colonization; its probability increases with the duration of
catheterization
Bacteriuria : > 105 colony-forming units (CFU) /ml urine in non-catheterized patients
> 100 CFU/ml in catheterized patients
• Bacteriuria is not equivalent to infection !!!
• Bacteriuria is universal in long-term catheterization and if asymptomatic SHOULD NOT be
treated
CATHETER-ASSOCIATED URINARY TRACT INFECTION
DIAGNOSIS

• Classical symptoms/signs of UTI : fever/chills, hypogastric/flank pain

• The combination of bacteriuria and fever is one of the most challenging (is the fever caused by
a urinary infection or is there another cause ?)
• Urine dipstick - widely used in the emergency department - can be misleading :
- Presence of pyuria (leukocyte esterase detection) is not specific for bacteriuria (occurs in
other inflammatory conditions of the genitourinary tract)
- Absence of nitrites only discards nitrites-producing bacteria (Enterobacteriaceae)
Most important diagnostic tools :
Adequate collection of urine sample for quick and direct microscopic analysis and Gram staining + cultures
CATHETER-ASSOCIATED URINARY TRACT INFECTION
TREATMENT

• Routine antimicrobial treatment of catheter-associated bacteriuria

is not recommended
• Antimicrobial treatment should be administered only in case of a
symptomatic CAUTI
• The catheter should be replaced before starting antimicrobial
therapy if the indwelling catheter has been in place for more than
1 week;
• Treatment should be initiated on an empirical basis with broad-
spectrum antibiotics based on local susceptibility patterns and later
adjusted according to the urine culture results.
CATHETER-ASSOCIATED URINARY TRACT INFECTION
PREVENTION

• Appropriate use of catheters :

 Only for appropriate indications and for the shortest time possible
 Avoid their use as a means to manage incontinence in institutionalized patients
 In patients with limited mobility, bladder dysfunction, neurologic impairment, etc., consider
alternatives to indwelling catheters (intermittent catheterization, urine condom catheters)

• Proper insertion techniques :

 Trained personnel, hand hygiene, aseptic technique, sterile material
 Consider using the smallest bore catheter
 Properly secure indwelling catheters to avoid traction and bladder/ uretral trauma
CATHETER-ASSOCIATED URINARY TRACT INFECTION
PREVENTION

• Proper techniques for catheter maintenance :

 Closed drainage system
 Maintain urine circuit patency
 Regular emptying with adequate hygienic measures
 Change the catheter whenever a breach in the closed system/aseptic technique is detected
 Do not use routinely antibiotics to prevent CR-UTI
CENTRAL LINE-ASSOCIATED
BLOODSTREAM INFECTIONS
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS
GENERALITIES

• Central venous catheters (CVC) : large-bore intravenous catheters used in critically-

ill, complex surgical and traumatic patients
• Utility : hemodynamic monitoring, fluid and antibiotic therapy, parenteral nutrition Lowest risk
of infection
• Prone to infection with the flora residing on the surrounding skin (external) or by
inadequate handling of catheter/hubs (less frequent through infusates or
hematogenous spread)
• Risk of infection varies with insertion site (see image)
• Common causative agents :
Highest risk
of infection
 S. aureus, Coagulase-negative staphylococci (eg. S. epidermidis)
 Candida spp.
 Gram-negative bacilli
CENTRAL
VENOUS
LINE
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS
DIAGNOSIS

• Local signs of infection at the catheter site (erythema, tenderness over the catheter,
purulent discharge) are usually absent but daily assessment of CVC is important in order
to detect them early
• Local/ systemic signs of sepsis (fever, hypotension, tachycardia) + positive blood cultures
: diagnosis of CVC-related infection
• Cardiac auscultation to detect any signs of possible endocarditis (murmurs)
• Catheter tip culture (whenever the catheter is removed) : high diagnostic value when the
isolated germ coincides with the one present in a positive blood culture
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS
TREATMENT

• CVC removal; in case the CVC infection is not clear its use must be avoided until the issue is clarified
• Empiric treatment with :
1. anti-staphylococcal antibiotics, active against MRSA (methicillin-resistant S. aureus) : vancomycin, linezolid
2. In case of severe sepsis/immunosupression : antifungal therapy (for Candida) and antibiotics active against Gram-
negative bacilli

• Assess for possible endocarditis in patients with diseased/prosthetic heart valves or in case of S. aureus
• Treatment duration :
 5-7 days in uncomplicated infections caused by coagulase-negative staphylococci
 10-14 days in case of positive blood culture
 4-6 weeks in case of septic thrombosis or infective endocarditis
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS
PREVENTION

• Sound indications for CVC placement

• Sterile insertion technique performed by trained personnel (surgical procedure)
• Avoid the femoral vein and use subclavian vein whenever possible
• Ultrasound guidance whenever possible to minimize number of attempts and possible mechanic
complication (pneumothorax, haemothorax, arterial/venous laceration)
• Use a CVC with the minimum number of ports
• Remove promptly when no longer essential
• Replace whenever adherence to aseptic technique cannot be ensured