Course 9447

__________________________________________________________________ #9447 Nosocomial 01/31/10 CourSE #9447 15 CoNTACT HourS/CrEDITS Release Date: 02/01/07 expiRation Date: Infections
Nosocomial Infections
Faculty Lori L. Alexander, MTPW, ELS, is President of Editorial Rx, Inc., which provides medical writing and editing services on a wide variety of clinical topics and in a range of media. A medical writer and editor for nearly 25 years, Ms. Alexander has written for both professional and lay audiences, with a focus on continuing education materials, medical meeting coverage, peer-review articles and guidelines for healthcare professionals, and educational materials for patients. She is the Editor of the American Medical Writers Association (AMWA) Journal, providing oversight for all aspects of this quarterly peer-review journal that represents the largest association of medical communicators in the United States. Ms. Alexander earned a Masters degree in professional and technical writing, with a concentration in medical writing, at Northeastern University, Boston, has completed the AMWA core and advanced certificate programs, and is certified by the Board of Editors in the Life Sciences. Faculty Disclosure Contributing faculty, Lori L. Alexander, MTPW, ELS, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planners Jane Norman, RN, MSN, CNE, PhD John V. Jurica, MD, MPH Division Planner Disclosures The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Audience This course is designed for healthcare professionals who would benefit from enhanced knowledge of nosocomial infections, including physicians, physician assistants, nurses, surgical technologists and assistants, and others involved with the care of patients in hospitals, long-term care facilities, or other healthcare institutions. Accreditation CME Resource is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CME Resource is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. Designation of Credit CME Resource designates this educational activity for a maximum of 15 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. CME Resource designates this continuing education activity for 15 ANCC contact hours. CME Resource designates this continuing education activity for 18 hours for Alabama nurses. AACN Synergy CERP Category A. Individual State Nursing Accreditations In addition to states that accept ANCC, CME Resource is accredited as a provider of continuing education in nursing by: Alabama, ABNP0353 (valid through December 12, 2013); California, CEP9784; California BVNPT Provider #V10662; Florida Provider #50-2405; Iowa, #295; Kentucky, 7-0054, Kentucky Board of Nursing approval of an individual nursing continuing education provider does not constitute endorsement of program content; Texas, ANCC/Type I Provider.
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#9447 Nosocomial Infections __________________________________________________________________ Special Approval This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency. About the Sponsor The purpose of CME Resource is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of CME Resource not to accept commercial support. Course Objective The purpose of this course is to provide physicians, nurses, pharmacists, microbiologists, and other healthcare professionals with enhanced knowledge of nosocomial infections, particularly an understanding of evidence-based guidelines, in order to prevent the most serious and common nosocomial infections and utilize the appropriate treatment options. Learning Objectives Upon completion of this course, you should be able to: 1. Describe the effect of nosocomial infections on mortality, morbidity, and cost of healthcare, including the importance of surveillance and prevention. 2. Outline the pathogenesis of infection. 3. Identify the environmental, patient-related, and iatrogenic risk factors for nosocomial infection. 4. Define the necessary cleaning and disinfection processes for the healthcare environment, devices, and equipment. 5. Describe the impact of implanted devices and procedures on nosocomial infection. 6. Discuss the association between inappropriate antibiotic use and nosocomial infection. 7. List the most common types of nosocomial infections. 8. Identify the most common pathogens and risk factors associated with urinary tract infections, and outline the appropriate prevention measures, diagnosis, and treatment. 9. List the most common pathogens and causes of surgical site infections, and outline the appropriate prevention measures, diagnosis, and treatment. 10. Review the most common pathogens and risk factors associated with pneumonia, and outline the appropriate prevention measures, diagnosis, and treatment. 11. Outline the most common pathogens and risk factors associated with intravascular device-related bloodstream infections, and discuss the appropriate prevention measures, diagnosis, and treatment. 12. Identify the most common pathogens and risk factors associated with gastrointestinal tract infections, and outline the appropriate prevention measures, diagnosis, and treatment. 13. Define the essential elements of an institutions infection control program. 14. Describe ways to prevent antimicrobial resistance, including proper patient education for non-English proficient individuals. 15. Discuss the need for hospital preparedness for potential outbreaks.
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.
CME Resource January 15, 2010
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__________________________________________________________________ #9447 Nosocomial Infections
oVErVIEW
This course is structured to provide background information on the pathogenesis of infections, focusing on bacterial pathogens, as they are the primary cause of nosocomial infections. A brief overview of infection transmission in the healthcare setting is followed by a discussion of the primary sources of nosocomial infections related to the environment, patient factors, and iatrogenic factors. The core of the course is a comprehensive description of the five most common nosocomial infections: urinary tract infections, ventilator-associated pneumonia, surgical site infections, intravascular device-related infections, and Clostridium difficile-associated diarrhea. The overall incidences, related costs, causes, common pathogens, prevention, diagnosis and treatment are presented for each type of infection. An overview of infection control programs in the healthcare setting is provided, with attention given to the problems associated with emerging drug-resistant microorganisms and preparedness for outbreaks and epidemics. The discussion is limited to infections in adults, although many measures for prevention are applicable in all settings for all patient populations.
EPIDEMIoLoGY AND BACKGrouND

Nosocomial infection is one of the leading causes of death and increased morbidity for hospitalized patients [1]. Nosocomial infections have traditionally referred to infections that develop during hospitalization and so have also been known as hospital-acquired infections. As health care increasingly expands beyond hospitals into outpatient settings, nursing homes, long-term care facilities, and even home care settings, the more appropriate term has become healthcare-acquired infection. By any name, nosocomial infections affect more than 2 million patients each yearor about 5% to 10% of hospitalized patientsleading to approximately 90,000 deaths per year [2; 3]. In addition to the significant morbidity and mortality burdens, nosocomial infections are associated with higher healthcare costs, with an average cost of $14,000 to $38,000 per infection, adding more than $4.5 billion to the total national healthcare bill [2; 4; 6; 7; 8]. Within the realm of safety in the healthcare setting, nosocomial infections have the most substantial impact. A study was done to explore the costs associated with 18 Patient Safety Indicators established by the Agency for Healthcare Research and Quality (AHRQ). Postoperative sepsis, postoperative wound dehiscence, and infection due to medical care were the three indicators associated with the highest costs in terms of length of stay, charges, and mortality (Table 1) [5].
CoSTS oF NoSoCoMIAL INFECTIoNS Indicator Postoperative sepsis Postoperative wound dehiscence Infection due to medical care
were found.
Excess* Length of Stay 10.89 days 9.42 days 9.58 days
Excess* Charges $57,727 $40,323 $38,656
Excess* Mortality 21.96% 9.63% 4.31%
*Excess was determined by the difference for a case and a matching control or the mean for controls if multiple matching controls Source: [5] Table 1
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#9447 Nosocomial Infections __________________________________________________________________
As health care has evolved, lowering the rate of nosocomial infections has been a challenge for infection control programs. Advances in medical treatments have led to more patients with decreased immune function or chronic disease. The increase in these patients, coupled with a shift in health care to the outpatient setting, yields a hospital population that is both more susceptible to infection and more vulnerable once infected. The increased use of invasive devices and procedures has also contributed to higher rates of infection [1; 2; 3]. Of particular danger are the several resistant strains of bacteria that have developed through their natural course of adaptation and the overuse of antibiotics. Nearly 70% of nosocomial infections are caused by drugresistant strains of bacteria [3]. Evidence-based guidelines exist for the prevention and control of nosocomial infections, and the guidelines address a wide range of issues from architectural design of hospitals to hand hygiene. These guidelines have been established primarily by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), as well as infection-related organizations and other professional societies. Proper handwashing is the single most important preventive measure, yet compliance rates among healthcare workers have ranged from 16% to 81% [3; 9]. Heightened awareness of this guideline and others, as well as ways to promote adherence, are necessary. Reducing the risk of healthcare-associated infections is one of the National Patient Safety Goals developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [10]. Reflecting the expansion of nosocomial infections beyond the hospital, this goal is included in the JCAHO safety goals developed for a variety of settings in addition to hospitals, including ambulatory care/office-based surgery, long-term care, and assisted living settings.
Other organizations have launched grassroots efforts to reduce the frequency of nosocomial infections. The nonprofit Institute for Healthcare Improvement (IHI) established the 100,000 Lives Campaign as a challenge to save 100,000 patient lives through six healthcare interventions. Three of the interventions were related to nosocomial infections: preventing central line infections, preventing surgical site infections, and preventing ventilator-associated pneumonia [11]. The 18-month campaign, in which more than 3,000 hospitals participated, surpassed its goal by saving an estimated 122,300 lives, demonstrating the substantial effect that can result by lowering the frequency of these three types of nosocomial infections. The reporting of nosocomial infections is currently done on a voluntary basis through the National Nosocomial Infection Surveillance (NNIS) system, which is managed by the CDCs Division of Healthcare Quality. This database system was established in the early 1970s to monitor the incidence of nosocomial infections, the responsible pathogens, and the associated risk factors. Approximately 300 hospitals participate. The four objectives of the NNIS system are to [12]: Detect and monitor adverse events Assess risk and protective factors Evaluate preventive interventions Provide information to event reporters and stakeholders, and partner with them to implement effective prevention strategies
The NNIS system includes documentation of only nosocomial infections in three hospital areas: intensive care units, neonatal intensive care units, and burn units, as these are the areas with the highest rates of infection, as well as the patient populations at greatest risk [2].
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Many in the healthcare and policy arenas believe that voluntary reporting of nosocomial infections is not sufficient and have advocated for required reporting. Changes in the healthcare system have moved care and surgery to the outpatient setting and decreased the length of hospital stays. Coupled with an increasing number of patients living with chronic conditions and compromised immune systems, shorter hospital stays increase the potential for transmission of infection into the community, creating a major public health concern. The Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), and the Society for Healthcare Epidemiology of America (SHEA) have led an effort to establish uniform standards for surveillance of nosocomial infections and standardized systems for collecting and reporting. These standards are needed to ensure enhanced patient safety, to optimize healthcare outcomes, and to minimize the public health risk. As a result, several states have passed legislation requiring that nosocomial infections be reported to the state, and, in some cases, to the public. Legislation is pending in several other states [13]. Such legislation will have an impact on the cost of infection control programs; a study in Virginia indicated that mandated surveillance would require an additional 160 infection control personnel, at an annual cost of $11.5 million [14]. In light of these statistics, it is incumbent on physicians, nurses, pharmacists, microbiologists, and other healthcare professionals to enhance their knowledge of nosocomial infections, particularly an understanding of the guidelines for preventing the most serious and common nosocomial infections and the appropriate treatment options.
MICroBIAL PATHoGENESIS
A comprehensive description of the pathogenesis of infection is beyond the scope of this course. However, a broad overview of the pathogen-host interaction will aid in the understanding of how infection develops in the healthcare setting. A healthy human body has several defenses against infection: the skin and mucous membranes form natural barriers to infection, and immune responses (nonspecific and specific) are activated to resist microorganisms that are able to invade. The skin can effectively protect the body from most microorganisms unless there is physical disruption. For example, the human papillomavirus can invade the skin, and some parasites can penetrate intact skin, but bacteria and fungi cannot [15]. Other disrupters of the natural barrier are lesions or injury or, in the healthcare setting, invasive procedures or devices. In addition to breaks in the skin, other primary entry points for microorganisms are mucosal surfaces, such as the respiratory, gastrointestinal, and genitourinary tracts [16]. The membranes lining these tracts comprise a major internal barrier to microorganisms due to the antimicrobial properties of their secretions. The respiratory tract filters inhaled microorganisms, and mucociliary epithelium in the tracheobronchial tree moves it out of the lung. In the gastrointestinal tract, gastric acid, pancreatic enzymes, bile, and intestinal secretions destroy harmful microorganisms. Nonpathogenic bacteria (commensal bacteria) make up the normal flora in the gastrointestinal tract and act as protectants against invading pathogenic bacteria. Commensal bacteria are a source of infection only if they are transmitted to another part of the body or if they are altered by the use of antibiotics [1].
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Nosocomial infections are commonly caused by bacteria. Nosocomial infections can also be caused by viruses, fungi, and parasites, but these types of infection occur less frequently, especially those caused by parasites (e.g., scabies), and often do not carry the same risks of morbidity and mortality as bacterial infections. Viral nosocomial infections are more common in children than in adults and carry a high epidemic risk [2]. Fungal nosocomial infections frequently occur during prolonged treatment with antibiotics and in patients who have compromised immune systems [1]. The transmission of infection follows the cycle that has been described for all diseases, and humans are at the center of this cycle [1; 17]. In brief, a microorganism requires a reservoir (a human, soil, air, or water), or a host, in which to live. The microorganism also needs an environment that supports its survival once it exits the host, as well as a method of transmission. Inherent properties allow microorganisms to remain viable during transmission from a reservoir to a susceptible host, another essential factor for transmission of infection. The primary routes of transmission for infections are through the air, blood (or body fluid), contact (direct or indirect), fecal-oral route, food, animals, or insects. Once inside a host, microorganisms thrive because of adherent properties that allow them to survive against mechanisms in the body that act to flush them out. Bacteria adhere to cell surfaces through hair-like projections such as fibrillae, fimbriae or pili, as well as by proteins that serve as adhesions [16]. Fimbriae and pili are found on gram-negative bacteria, whereas the other types of adhesins are found with both gram-negative and gram-positive bacteria. Receptor molecules in the body act as ligands to bind the adhesins, enabling bacteria to colonize within the body. The virulence of the microorganism will determine whether only colonization occurs or if infection will develop. With colonization, there is no damage to local or distant tissues and no immune reaction; with infection, bacterial toxins that break down cells and intracellular matrices are released, causing damage to
local and distant tissues and prompting an immune response in the host. Bacteria continue to thrive within a host through strategies that enable them to acquire iron for nutrition and to defend against the immune response. These virulence factors enhance a microorganisms potential for infection by allowing microorganisms to interrupt or avoid phagocytosis or to live inside phagocytes [16]. A healthcare environment increases the risk of infection for two primary reasons. First, it is likely that normally sterile body sites will become exposed, allowing pathogens to cause infection through contact with mucous membranes, nonintact skin, and internal body areas [17]. Second, the likelihood of a susceptible host is high because of the vulnerable health status of patients. Especially in an era of decreased hospital stays and increased outpatient treatments, it is the sickest patients who are hospitalized, increasing the risk not only for infection to develop in these patients but also for their infection to be more severe and for it to be transmitted to others. Infection is transmitted in a healthcare environment primarily through exogenous and endogenous modes. Exogenous transmission is through patient-to-patient or staff-to-patient contact. Patients who do not have infection but have bacterial colonization can act as vectors of transmission. Staff members can also act as vectors because of colonization or contamination. Endogenous infection occurs within an individual patient through displacement of commensal microorganisms. In general, the spread of infectious disease is prevented by eliminating the conditions necessary for the microorganism to be transmitted from a reservoir to a susceptible host. This can be accomplished by: Destroying the microorganism Blocking the transmission Protecting individuals from becoming vectors of transmission Decreasing the susceptibility of potential hosts
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Antiseptic techniques and antibiotics will kill microorganisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove healthcare workers from the transmission cycle by protecting them from contact with microorganisms. Contact precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that patients and healthcare workers are immune or vaccinated can help decrease the availability of potential hosts.
SourCES oF NoSoCoMIAL INFECTIoNS

In general, the sources of nosocomial infections can be categorized as being related to environmental factors (air, water, architecture), patient-related factors (age, degree of illness/immune status, length of hospital stay), and iatrogenic factors (surgery and invasive procedures, devices and equipment, and antibiotic use). Taken together, these sources have a substantial impact on the increasing incidence of nosocomial infections, as WHO notes that the rate of nosocomial infections will continue to rise as a result of four factors [1]:
ENVIroNMENTAL SourCES oF PATHoGENS IN THE HEALTHCArE SETTING Source Air Bacteria Gram-positive cocci (originating from skin) Tuberculosis Gram-negative bacteria (Pseudomonas aeruginosa, Aeromonas hydrophilia, Burkholderia cepacia, Stenotrophomonas maltophilia, Serratia marcescens, Flavobacterium meningosepticum, Acinetobacter calcoaceticus, and Legionella pneumophila) Mycobacteria (Mycobacterium xenopi, Mycobacterium chelonae, or Mycobacterium avium-intracellularae) Salmonella species Staphylococcus aureus Clostridium perfringens Clostridium botulinum Bacilluscereus and other aerobic spore-forming bacilli Escherichia coli Campylobacter jejuni Yersinia enterocolitica Vibrio parahaemolyticus Vibrio cholerae Aeromonas hydrophilia Streptococcus species Listeria monocytogenes Viruses Varicella zoster (chickenpox) Influenza Molluscum contagiosum Human papillomavirus (bath water) Noroviruses Fungi Aspergillus
Water (tap and bath)
Aspergillus Exophiala jeanselmei
Food
Rotavirus Caliciviruses
Source: [1; 26; 187; 216]
Table 2
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Crowded hospital conditions Increasing number of people with compromised immune systems New microorganisms Increasing bacterial resistance ENVIroNMENTAL FACTorS Factors specifically related to the healthcare environment are not common causes of nosocomial infections (Table 2). However, consideration should be given to the prevention of infection with environmental pathogens, such as fungi (e.g., Aspergillus), bacteria (e.g., Legionella species), or viruses (e.g., varicella). In 2003, the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) revised the guideline related to environmental factors for infection [18]. The report provides clear recommendations for infection control measures according to several environment-related categories, including air (normal ventilation and filtration, as well as handling during construction or repair), water (water supply systems, ice machines, hydrotherapy tanks and pools), and environmental services (laundry, housekeeping). The infection control program of a facility has oversight of these measures, and more discussion on the topic is included in the Infection Control section. Air Droplets of microorganisms can be transmitted in the air, causing infection in patients either directly or indirectly (through contamination of devices or equipment). Cleaning activities, such as sweeping, dry mopping, dusting, or shaking linen, can contribute to the transmission of airborne microorganisms. Bacteria in the air primarily consist of gram-positive cocci from the skin, and they can be eliminated with appropriate ventilation and circulation of air [2]. Airborne viruses such as influenza and other respiratory viruses and measles do not
carry far from the source, whereas others, such as tuberculosis and varicella zoster, may be spread over long distances [1]. The most common fungal spore to be transmitted through air is Aspergillus, which is carried through dust particles, can survive for long periods, and is easily inhaled [19; 20]. Under normal circumstances, the level of contamination with this airborne fungus spores is not high enough to cause disease in otherwise healthy individuals. However, in the healthcare setting, the fungus causes respiratory infection, primarily pneumonia, in susceptible hosts. The prevalence of infection with Aspergillus within a healthcare setting has been strongly associated with Aspergillus spore counts. Consequently, air conditioning systems with high-efficiency particulate air (HEPA) filters are needed to minimize contamination [19]. One study showed that a conditioning system with these filters eliminated all Aspergillus spores, as documented with microbiologic testing. In comparison, evidence of Aspergillus spores was found in hospital wards that had no conditioning or a conditioning system with minimum efficiency filters [21]. Routine inspection and cleaning of conditioning equipment is also needed to ensure proper filtration [2]. HEPA filters are especially needed to prevent infection with Aspergillus in patients at high risk, such as those in organ and bone marrow transplantation units, where mortality rates associated with such infection can reach 95% [22]. In these units, the air exchange rate should be high (more than 15 exchanges per hour), rooms should be tightly sealed, and the air pressure in the rooms should be positive in relation to the hallway [19]. HEPA filters are also used in the hoods in microbiology laboratories and pharmacies, laminar flow units in intensive care units, and unidirectional flow units in operating room suites [1].
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In regards to environmental infection control in healthcare settings, the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend ensuring that heating, ventilation, and air conditioning (HVAC) filters are properly installed and maintained to prevent air leakages and dust overloads. (http://www.guidelines.gov/summary/summary. aspx?doc_id=3843. Last accessed January 23, 2007.) Strength of recommendation: IB (Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretic rationale)
Introduce all air at the ceiling and exhaust near the floor. Do not use ultraviolet radiation in the operating room to prevent surgical site infection. Keep operating room doors closed except as needed for passage of equipment, personnel, and the patient. Air During Construction Special care must be taken to protect patients during repair or renovation of a healthcare facility, as construction work can facilitate the spread of airborne organisms such as Aspergillus species [1]. It is estimated that approximately 5% of deaths attributed to nosocomial infections are related to construction and maintenance practices within the healthcare setting [22]. Some construction issues that contribute to the spread of infection include water-damaged building materials, disruption of duct work, open windows, and improper setting of fans or installation of filters [25]. JCAHO requires an inspection process for construction on a facility, and a risk assessment is part of that process [25]. Risk factors to consider include the patient population, the extent and duration of the project, the impact of the project on mechanical systems, and whether space with construction will be occupied [25]. A representative from a facilitys infection control program should review any plans for construction to ensure that barriers are used as appropriate and patients, especially those with compromised immune systems, are moved to an area away from construction [2]. Water Water is a reservoir for several types of microorganisms, including bacteria, fungi, and viruses, with viruses accounting for only a small percentage [26; 27]. The quality of water within a healthcare setting must meet standards that vary according to use. Tap water must be safe to drink and use for baths (for hygiene and therapy) according to criteria dictated by local regulations and public health standards. No bacteria, viruses, or parasites may
Air in the Operating Room Maintaining a high quality of air in operating rooms is an essential factor in preventing postoperative infection. The number and movement of activity of staff within the operating room together create the primary sources of airborne bacteria. Other factors influencing airborne contamination include the type of surgery, the rate of air exchange, the initial quality of the air, the quality of the staff clothing and cleaning processes, and the level of compliance with infection control practices [1]. The CDC makes several suggestions about ventilation in the operating room in its guideline for prevention of surgical site infections [23]. The Level I recommendations (those with the greatest strength of evidence) include [23; 24]: Maintain positive-pressure ventilation in the operating room with respect to the corridors and adjacent areas. Maintain a minimum of 15 air changes per hour, of which at least three should be fresh air. Filter all air, recirculated and fresh, through the appropriate filters per recommendations of the American Institute of Architects (AIA).
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be present in the water, the levels of disinfectant should be minimal, and the turbidity should be low [17]. The water supply to the healthcare facility can be disinfected by several methods, including chlorination, thermal eradication, ultraviolet light and metal ionization [19]. The most common pathogen identified in tap water is the gram-negative bacteria Pseudomonas aeruginosa. In one study, researchers evaluated the association between tap water from faucets in a surgical intensive care unit and patients with colonization or infection with P. aeruginosa [28]. The pathogen was found in 58% of water samples taken from individual faucets but was not identified in the main water supply. The genotypes of the microorganism in 21 of the 45 patients were identical to those found in the tap water from the sink in the patients room (15 patients) or in the adjacent room (6 patients). According to epidemiologic analysis, transmission of the pathogen had occurred from faucet to patient as well as from patient to faucet. P. aeruginosa is also the primary bacterial pathogen found in bath water [29]. The effect of infection with P. aeruginosa may be mild, as in folliculitis and external otitis, but wound infection may be more severe. Greater morbidity is associated with infection in individuals who have a compromised immune system or who have another health condition, such as diabetes [1]. Legionella, which causes infection of the respiratory tract, is another microorganism commonly found in tap water and bath water. The highest concentrations of Legionella are found in areas of water distribution systems (hot water storage, cooling towers, condensers), where it colonizes [19]. Infection with Legionella is transmitted only through water, not through person-to-person contact. Inhalation of contaminated water droplets from shower heads or faucet aerators may cause disease [26]. In addition, high humidity levels in a room (through mists produced by respiratory equipment, for example) may promote the growth of Legionella and molds [22].
WHO suggests that there is potential risk for nosocomial infections if tap water is used for such purposes as ice machines or devices for washing eyes or ears, or for cleaning equipment [1]. Point-of-use filtration may help to reduce the risk of nosocomial infections related to water [27]. Ducts, humidifiers, dehumidifiers, and other areas of a ventilation system should be kept clean and dry, as microorganisms can colonize in water that accumulates in these areas [22]. Architectural Design Another factor in the transmission of infection in the healthcare setting is the architectural design of the facility, although it has not been shown to have an appreciable effect [30]. The AIA and the Facility Guidelines Institute (FGI) released the Guidelines for Design and Construction of Hospital and Health Care Facilities in 2001, and an updated edition was published in 2006 [24; 31]. A primary difference in the most recent version is setting single-bed private rooms as the minimum standard for new hospital construction [31]. This change is based on a report of literature review that showed, in part, that private rooms have been associated with lower rates of nosocomial infections as well as with a reduction in risk factors for nosocomial infections, such as prolonged hospital stays and patient transfers [32]. The WHO guideline on infection control refers to architectural segregation according to risk [1]. Four areas of a healthcare facility are defined, with administrative sections considered as low-risk areas; regular patient wards as moderate-risk areas; intensive care units, burn units, or isolation units as high-risk areas; and operating rooms as very highrisk areas. WHO and others have recommended that traffic flow should be limited in higher risk areas [1; 17].
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The choice of floor, wall surfaces, and ceilings is of minimal concern, as bacteria are rarely found on these surfaces unless they become moist or damaged [17; 19]. The surfaces should be smooth, to resist accumulation of dust; water-resistant; and easily cleaned. The use of carpet should be limited to low-risk areas, such as office space, as bacteria can survive in carpet. Microorganisms can colonize in wet acoustical tiles, so they too should be avoided in high-risk areas. Some antimicrobial resistant bacteria have been found on furniture, but the risk of infection is thought to be low [19]. The type of sink and the placement of sinks throughout a healthcare facility have been of critical concern because of the substantial role of handwashing in reducing the transmission of infection. As a result, sinks have been placed within easy access in each patient room. However, it is unclear that such placement promotes better hand hygiene. A study was undertaken to assess handwashing compliance when a new hospital was built. In the new hospital design, sinks were placed within five meters of every place where clinical activity occurred. Handwashing improved over the first month but no clinically significant improvement was found over nine months [33]. With the advent of alcohol-based handrub solutions as more effective hand hygiene, the placement of handrub dispensers has become more important than the placement of sinks [9]. The CDC guideline on hand hygiene recommends placing dispensers in convenient locations, such as at the entrance of each patient room or at the bedside. Specific guidelines regarding the cleaning of the environment and management of waste will be discussed in detail later in this course. PATIENT-rELATED FACTorS Patient-related risk factors for nosocomial infection include age, general health status and the type of procedure to be carried out, and risk can be classified as minimal, medium, or high [1]. Patients are at minimal risk if they have no significant underlying disease, have an intact immune system, and will
not undergo an invasive procedure. Medium risk is assigned to older patients who are susceptible to disease for a variety of reasons, including decreased immune function, comorbid conditions, and low nutritional status. In a study of 185 hospitalized patients who were a mean of 82 years of age, the rate of nosocomial infection was 59%; the patients altered nutritional status was another independent risk factor for infection [34]. Medium risk also refers to patients who are to have a nonsurgical invasive procedure, such as a peripheral venous catheter or a urinary catheter. Advances in medical treatments have led to longer lives for individuals of all ages who have had organ transplantation, cancer, or infection with human immunodeficiency virus (HIV), and their compromised immune system puts them at high risk for nosocomial infection. High risk is also assigned to patients with multiple trauma or severe burns, or those who have surgery or an invasive procedure that is considered to be high risk, such as endotracheal intubation or insertion of a central venous catheter. Special Patient Populations The highest rates of infection are found in intensive care units (adult and neonatal), burn units, and organ transplant units. While only 15% to 20% of all hospital beds are located in intensive care units, 40% to 60% of all life-threatening nosocomial infections occur in these units [35; 36]. Neonatal intensive care units have been reported to have rates of nosocomial infection of 6% to 25% [37]. The rate in an organ transplantation unit was reported to be 62% among patients who had received a kidney from a deceased donor; the rate was 40% for patients who had received the kidney from a living related donor [38]. The etiology of the infection and the types of infection vary among the settings. One study found that, for patients in burn units, the body surface area burned, comorbidities, and the use of invasive devices were significantly associated with nosocomial infection, and Staphylococcus aureus and Pseudomonas were the most common resistant organisms identified [39].
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IATroGENIC FACTorS Three primary iatrogenic factors contribute to the development of nosocomial infections: devices and equipment used in the healthcare setting, surgery, and the use of antibiotics. The four most common nosocomial infectionsurinary tract infection, surgical site infection, pneumonia, and intravascular device-related bloodstream infectionare related to invasive procedures or the use of invasive devices; these infections comprise approximately 80% of all nosocomial infections [3]. Devices and Equipment Nosocomial infection has been associated with several types of devices and equipment in healthcare facilities. The Spaulding classification, developed in 1968, is widely used to categorize devices according to their associated risk of infection [17; 40]. The system includes three categories: Critical: A device that enters normally sterile tissue or the vascular system Semicritical: A device that comes into contact with intact mucous membranes and does not ordinarily penetrate sterile tissue Noncritical: A device that does not ordinarily touch a patient or touches only intact skin Most nosocomial infections can be attributed to devices in the critical and semicritical categories, including intravascular catheters, surgical drains, urinary catheters, and endoscopic instruments [2]. Discussion here is limited to endoscopic instruments, as infections related to the other devices are addressed in detail later. In general, the transmission of pathogens on endoscopic devices has been attributed to noncompliance with appropriate reprocessing (cleaning, disinfection, and sterilization) [41; 42; 43; 44]. Bronchoscopes and gastrointestinal endoscopes are the primary diagnostic scopes used in healthcare settings, with the possible exception of orthopedic procedures. Both types of devices are associated with a low risk of infection transmission. Approximately
500,000 flexible bronchoscopies are done in the United States each year, and the rate of infection has been low [44]. Few studies, however, have been carried out to evaluate the risk of infection. A 1993 meta-analysis identified eight studies of nosocomial infection related to flexible bronchoscopy, and 96 infections were found [42]. The cause of the infections varied, with the most common causes being inadequate disinfection with iodophor and contamination of the biopsy channel or suction valve. The pathogens also varied, with Mycobacterium species predominating. In a later report, the primary cause of infection remained inadequate disinfection, and P. aeruginosa and Mycobacterium tuberculosis were the primary causative agents [44; 45]. More studies have evaluated the risk of infection associated with gastrointestinal endoscopy, which is performed on 10 to 20 million people each year [45]. The American Society for Gastrointestinal Endoscopy (ASGE) estimates that infectious organisms are transmitted in 1 of 1.8 million gastrointestinal endoscopies [41; 43]. Furthermore, all instances of infection during endoscopy have been the result of noncompliance with established guidelines, highlighting the importance of adhering to recommendations for reprocessing of endoscopy equipment [43; 45; 46]. The pathogen with the highest rate of transmission associated with endoscopy is P. aeruginosa [45]. As is true for other pathogens associated with endoscopy, infection with P. aeruginosa has resulted from nonadherence to guidelines; however, this pathogen differs from the others because of its predilection for a moist environment. Many cases of infection with P. aeruginosa have been linked to the water supply to the endoscope and to failure to completely dry the endoscope channels with a 70% alcohol solution and forced air [45]. Salmonella species have also been associated with endoscopy, but no cases have been reported since the publication of the 1988 guideline for standardized cleaning and disinfection of the devices [45]. Infection with Helicobacter pylori has also been related to suboptimal cleaning
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and disinfection [45]. Low rates of hepatitis B and C virus transmission have been reported, and most cases of infection with hepatitis C were found to be related to the inappropriate use of multiple-dose vials and/or syringes rather than to the endoscope itself [43; 45]. Noncritical devices are often overlooked by healthcare workers as vectors for infection. These devices include diagnostic equipment, stethoscopes, and other commonplace items. A systematic review of 23 studies found bacterial contamination of 87% of sampled healthcare equipment, primarily stethoscope membranes, as well as diagnostic ultrasound equipment, otoscopes, and auriscopes [47]. Contamination, as quantified by the number of colony-forming units, was approximately four times the tolerated level [48]. Most (27%) of the organisms were Staphylococcus aureus, 15% of which were multidrug resistant. Other pathogens identified included Pseudomonas spp., Acinetobacter spp. and Pasteurella spp. Contamination of therapeutic ultrasound transducer heads and ultrasound gels were evaluated in another study, and the rate of contamination was 27% for the heads and 28% for the gels [49]. The transducer heads had low levels of contamination, and most of the microorganisms were normal flora; however, high levels of contamination were found in the gels, and the microorganisms included such pathogens as Stenotrophomonas maltophilia, S. aureus, A. baumannii and Rhodotorula mucilaginosa. In two other studies, contamination of dermatoscopes was evaluated. One study indicated colonization of only nonpathogenic bacteria and the other showed that use of an alcohol-based antibacterial gel as immersion fluid yielded no bacterial growth [50; 51]. Ward-based computer terminals have also been shown to have low levels of contamination. In a study of two hospitals, methicillin-resistant S. aureus (MRSA) was found on one of 13 computer terminals in one hospital and on 5 of 12 in another hospital. The rate of MRSA transmission was significantly higher at the hospital with the greater number of contaminated computers [52].
In summary, a high rate of microorganism colonization has been found on equipment within a hospital setting, but contamination is usually at low levels and the risk of direct infection is low. Adequate disinfection with a 70% alcohol solution can reduce the levels of contamination, with one report of an 82% reduction [47]. In general, the findings of studies have suggested that adequate cleaning of equipment can prevent as many as one-third of nosocomial infections [47]. Cleaning, Disinfecting, and Reprocessing Equipment Before discussing recommendations for the cleaning and sterilization of diagnostic endoscopes, it is helpful to define the various levels of cleaning and disinfection [1; 17]. Decontamination: use of a 0.5% chlorine solution to reduce the number of microorganisms on the device to make it safer to handle for cleaning Cleaning: use of soap and water to remove all visible dust, soil, blood, or other body fluids Low-level disinfection: use of disinfectant to eliminate microorganisms (may not eliminate resistant bacteria or most viruses or fungi) Intermediate-level disinfection: use of disinfectant to eliminate microorganisms (eliminates most bacteria, viruses, and fungi) High-level disinfection: use of chemical disinfectants, boiling, or steaming to eliminate all microorganisms (may not eliminate all bacterial spores) Sterilization: use of high-pressure steam (autoclave), dry heat (oven), chemical sterilants, or radiation to eliminate all microorganisms reprocessing: a multistep procedure that consists of meticulous cleaning, high-level disinfection with a liquid chemical sterilant or disinfectant, and proper drying
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It is important to note that decontamination and cleaning must be carried out before any of the higher level processes [1; 17]. The cleaning and disinfection of devices varies according to the Spaulding classification, with critical devices requiring sterilization and semicritical devices requiring high-level disinfection; noncritical devices may be cleaned with low-level disinfection [1; 17; 40; 43]. Endoscopic instruments present a challenge to proper reprocessing because of the complex internal design and long, narrow channels [1]. Reprocessing should be carried out by trained and accredited personnel according to the manufacturers recommendations, and the process should be monitored regularly for quality control [46]. Guidelines and recommendations for reprocessing of gastrointestinal endoscopes have been developed by several federal agencies, such as the U.S. Food and Drug Administration (FDA) and the CDC, as well as many professional organizations [1; 43; 45; 46; 53; 54]. The reprocessing procedure should begin immediately after use to prevent secretions from drying and consists of the following steps [1; 53; 54]: 1. Use forced air to clear the air-water channel, and suction or pump tap water or detergent through the aspiration/biopsy channel(s) to remove organic debris. 2. Remove all detachable parts (hoods, suction valves) and soak in a detergent solution. 3. Gently wipe external parts of the endoscope. 4. Use tap water or a detergent solution to irrigate all accessible channels, and then brush (using a sterile or single-use brush) and purge the solution. 5. Clean all parts of the endoscope with an approved detergent. 6. Rinse with tap water. 7. Completely immerse the endoscope in a liquid chemical sterilant to achieve high-level disinfection.
8. Rinse with bacteriologically controlled or sterile water. 9. Use 70% to 90% ethyl or isopropyl alcohol on the external surfaces and the internal channels to facilitate drying and follow with compressed or forced air. Some inconsistencies across reprocessing guidelines and manufacturer recommendations have been found, primarily with regard to drying [53]. Also, various steps in the procedure have been emphasized as being the most critical. For example, one report notes that meticulous mechanical cleaning is the most important step because it removes the majority of the contaminating bacteria [46]. Another report emphasizes the importance of drying to avoid waterborne bacteria, such as P. aeruginosa [53]. Reprocessing of bronchoscopes has received less attention, perhaps because of the low risk of infection, but general recommendations, similar to those for gastrointestinal endoscopes, are currently available [44; 55]. A report of four patients with infection with P. aeruginosa after transrectal ultrasound-guided prostate biopsies raised awareness about the need for thorough cleaning of equipment. Evaluation of the findings on the four patients demonstrated that the infection was caused by contamination of the needle guide as a result of inadequate cleaning (with a brush) and improper rinsing (with tap water) after reprocessing [56]. The report led to the FDA issuing a Public Health Notification on proper reprocessing of such devices, which highlighted several points, with special emphasis on three [57]: Use a brush to clean the device, especially the lumens and the needle-guide channel; check to be sure that no visible soil remains. Inspect the entire device to make sure it is clean. Always use sterile water to rinse or to remove residual germicides after processing with liquid chemical germicides.
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DEVICE-rELATED INFECTIoNS
Type of Device Prevalence Probable Cause Typical Duration to occurrence after Implantation Within 2 to 6 weeks Most Common Microorganisms Signs and Symptoms Diagnosis Treatment
Left ventricular assist devices
25% to 50%
Biofilm formation
Methicillin-resistant staphylococcal spp., Pseudomonas spp., Klebsiella spp., E. coli, Enterobacter spp., Proteus spp., Serratia spp., Candida spp., Enterococcus spp. Staphylococcus epidermidis (40% to 45%), S. aureus (25%), Klebsiella spp., Enterobacter spp., Pseudomonas aeruginosa, Acinetobacter baumanii, Corynebacterium spp., Propionibacterium spp., and streptococci/ enterococci Coagulase-negative staphylococci, specifically methicillinresistant S. epidermidis, S. aureus
Signs of poor Blood cultures healing, localized inflammation, pocket abscess, frank sepsis, new and persistent drainage
Empiric therapy with vancomycin and antipseudomonal agent (ceftazidime or ciprofloxacin) or empiric antifungal therapy
Cerebrospinal fluid (CSF) shunts
10%
Bacteria originating from patients skin introduced at time of operation
Within 30 days
Fever, focal pain, ventriculitis, with lethargy and malaise (proximal shunts), infected intraperitoneal fluid cysts or frank peritonitis (distal shunts)
CSF analysis (cell count, glucose, protein), gram stain, culture; abdominal ultrasonography (distal shunts)
Antimicrobial agent effective against noted microorganisms, modified with results of culture; removal of shunt
Prosthetic cardiac valves
3% to 5.7%
Contamination of the valve at time of implantation or transient bacteremia
Within 60 days (early)
Fever, new or Blood cultures, changing regurgitant transesophageal murmurs, CHF, echocardiography shock, cardiac conduction disturbances on EKG
Delayed antibiotic therapy until results of culture available (if subacute course and hemodynamically stable); empiric antibiotic therapy with vancomycin, gentamicin, rifampin (evidence of significant valve dysfunction); valve replacement (new or increasing murmurs, severe CHF, persistent fever) Empiric antibiotic therapy with ciprofloxacin or a cephalosporin for 10-12 weeks; removal of implant if pain persists or recurs after antibiotic treatment or if purulent discharge Antibiotic therapy, incision and drainage, local wound care; removal of device if extrusion of device or implant-related sepsis
Penile implants
2% to 8%
Contamination at time of implantation
Not Available
S. epidermidis
Erythema, Culture of induration, specimen from tenderness, fever, the operative site discharge, device extrusion; prosthesisassociated pain
Cochlear implants
1.7% to 3.3%
Contamination at time of implantation
Within 30 to 90 days
S. aureus, Streptococcus pneumoniae, Haemophilus influenzae
Skin flap necrosis, wound dehiscence, wound infection
Not Available
Table 3 continues on next page
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DEVICE-rELATED INFECTIoNS (Continued)
Type of Device Prevalence Probable Cause Typical Duration to occurrence after Implantation Within 30 days (early); within 60 days (late) Most Common Microorganisms Signs and Symptoms Diagnosis Treatment
Transvenous permanent pacemakers/ automatic implantable cardioverter defibrillators
1% to 7%
Intraoperative contamination of the device or the pocket (early); contamination of pocket as a result of erosion of generator/ defibrillator through skin (late) Not Available
S. aureus, Propionibacterium acnes, Micrococcus spp., Eschieria coli, Klebsiella spp., Enterobacter spp., Serratia spp. (early); coagulase-negative staphylococci (late)
Erythema, pain, warmth at site (pocket cellulitis), draining sinus tract or erosion of overlying skin, systemic symptoms (fever, chills, mailaise, nausea)
Blood cultures, transesophageal echocardiography
Prolonged antibiotic therapy, removal of all hardware; empiric therapy with vancomycin, gentamicin, or rifampin
Breast implants
1.7% to 2.5%*
Within 2 to 4 weeks
S. aureus, peptostreptococci, Clostridium perfringens
Erythema, edema, poor healing, purulent discharge, inflammatory symptoms (breast or axillary pain, paresthesia of upper extremity) Persistent pain, fever, evidence of wound infection (early); loosening of prosthesis, sinus tract formation with discharge
Wound or fluid culture
Empiric antibiotic therapy, local debridement
Orthopedic implants
<1% to 2%
Intraoperative contamination (early and late)
<2 to 4 weeks (early); >30 days (late)
S. aureus, coagulasenegative staphylococci, Propionibacterium spp. (early and late)
Joint aspiration, complete blood count, erythrocyte sedimentation rate, C-reactive protein, imaging
Surgical exploration and debridement followed by empiric antibiotic therapy
*After augmentation mammoplasty; rates may be higher after mastectomy.
Source: [58]
Table 3
Implanted Devices Surgically implanted devices are a major source of nosocomial infection, and the past several years has seen an increase in devices such as intracardiac devices, orthopedic implants (prostheses and fixation devices), neurosurgical devices, cochlear implants, and breast and penile implants. The most common complication with all of these devices is infection [58; 59; 60]. The prevalence of infection associated with these devices varies, with the prevalence highest for left ventricular assist devices (Table 3) [58]. Orthopedic implants, such as joint prostheses and fracture fixation devices, are associated with the lowest rate of infection, but reported mortality rates have been as high as 18% [58].
Many implanted device-related infections are caused by contamination during insertion, but these infections are not always the result of microorganisms transmitted in the healthcare setting. Rather, bacteria (and sometimes fungi) colonize by adhering to the surface of the implant through the development of a biofilm [58]. Biofilm presents another challenge in managing infection; biofilms provide bacteria with an extremely high level of resistance to antimicrobial agents. In fact, biofilms can tolerate antibiotic concentrations of 10 to 1,000 times of that needed to destroy free-floating (planktonic) bacteria [58].
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The CDC defines implanted device-related nosocomial infection as those occurring within one year after implantation of a device, and the typical interval between implantation and infection varies according the type of implant (Table 3) [61]. For some implants, early and late infections differ with respect to etiology and the causative microorganisms [58]. The treatment of infections related to these devices depends on the severity of the infection and the patients underlying condition. A multidisciplinary approach involving antibiotic therapy and surgical intervention (either debridement or removal of the device) can have a substantial impact on morbidity and mortality. For example, prosthetic valve endocarditis is associated with mortality rates of 42% to 100%, but the rate can be decreased 20-fold through an approach that combines medical and surgical therapy rather than medical therapy alone [58]. Empiric antibiotic therapy is usually appropriate once specimens have been obtained for culture, with the antibiotic agent chosen on the basis of the most common microorganisms. Surgery According to the most recent data, approximately 45 million operations are performed each year on an inpatient basis [62]. This represents a large population at risk for nosocomial infections, which can have a tremendous impact on morbidity, mortality, and financial costs. As mentioned previously, postoperative sepsis and wound dehiscence were the two most costly Patient Safety Indicators in a 2003 report [5]. The rate of infection after surgery varies according to the wound classification and type of surgery. The wound classification system, developed in 1964, has been widely used to predict the rate of infection after surgery. It consists of the following four categories [63; 64].
Clean (Class I): Noninfected wound with no inflammation (elective surgery, with no entrance into respiratory, gastrointestinal, biliary, or genitourinary tract; wound closed at end of surgery) Clean-contaminated (Class II): Wound in which the respiratory, gastrointestinal, biliary, or genitourinary tract was entered but no or minimal spillage (usually emergency or urgent surgery) Contaminated (Class III): Open, fresh accidental wound or incision with acute, nonpurulent inflammation; surgery with gross spillage from gastrointestinal tract, entry into biliary or genitourinary tract in the presence of infected bile or urine; or major break in aseptic technique Dirty (Class IV): Old wound with dead tissue or with existing clinical infection, or preoperative perforation of respiratory, gastrointestinal, biliary, or genitourinary tract Before antibiotics were given prophylactically prior to surgery, the rates of infection were 1% to 2% for clean wounds, 6% to 9% for clean-contaminated wounds, 13% to 20% for contaminated wounds, and 40% for dirty wounds [64]. Since the routine use of preoperative antibiotics, the rates have dropped for clean-contaminated, contaminated, and dirty wounds (3%, 6%, and 7%, respectively); the rate for clean wounds has remained stable [64]. The type of surgery is also a factor in whether infection develops postoperatively. According to data collected by the NNIS, abdominal surgery is associated with the highest rate of infection, and the use of a laparoscope has lowered the rates of infection after cholecystectomy, colon and gastric operations, and appendectomy [12]. Coronary artery bypass grafting is also associated with high rates of infection, at both the donor site in the leg and the primary incision in the chest [12]. Postoperative infection is discussed in detail later in this course.
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ANTIBIoTIC uSE Antibiotic use is another important factor in the development of nosocomial infections. The inappropriate use of antibiotics is a major contributor to the increase in drug-resistant strains of bacteria, and coupled with the natural selection and exchange of genetic resistance elements with microorganisms, drug resistance has emerged as a worldwide problem, with an increasing number of microorganisms becoming resistant to treatment each year [65]. Resistance typically emerges first in the healthcare setting before the community, and drug-resistant bacteria have become the source of approximately 70% of nosocomial infections [3]. In addition, nosocomial infections caused by drug-resistant bacteria are associated with higher rates of morbidity and mortality and other costs [65; 66; 67; 68; 69]. Recognizing the importance of drug-resistant bacteria to infection control, a joint committee of SHEA and IDSA published a position paper in 1997 to recommend that all hospitals take steps to control the use of antibiotics [68]. In addition, the JCAHO requires that healthcare facilities review their antibiotic formulary as part of compliance to JCAHO standards [70]. Thus, over the past several years, the management of antibiotic use has been a priority of healthcare institutions infection control programs [66]. Staphylococci, enterococci, and pneumococci present some of the most serious problems with drug resistance [65]. S. aureus was treatable with penicillin when the drug was introduced over 60 years ago. As strains became resistant to penicillin, other antibiotics were developed, including methicillin, oxacillin, nafcillin, and vancomycin. MRSA has become one of the most common bacteria involved in nosocomial infections [65; 68; 69]. According to a NNIS report on data collected between 1995 and 2004, the percentage of S. aureus isolates in intensive care units that were resistant to methicillin, oxacillin, or nafcillin was nearly 60% [12]. Other trends found in that data included a 50% increase in Klebsiella pneumoniae isolates that were resistant to third-generation cephalosporins
between 2002 and 2003, a steadily increasing rate of vancomycin-resistant enterococci (VRE), and a decrease in fluoroquinolone-resistant P. aeruginosa between 2002 and 2004 [12]. A review of studies published between 1966 and 2005 showed that the frequency of multidrug-resistant P. aeruginosa has also increased, with rates ranging from 0.6% to 32%. In addition, multidrug-resistant P. aeruginosa developed in 27% to 72% of patients who had P. aeruginosa isolates that were initially sensitive to treatment [71]. A study reported in 2006 suggested that Corynebacterium striatum was an emerging multidrug-resistant nosocomial pathogen in patients who were hospitalized for a prolonged period and had underlying disease [72]. The development of new, effective antimicrobials has not kept pace with the increases in resistance. When the efficacy of antibiotics was first demonstrated in the late 1920s, their development and manufacture increased rapidly, and they began to be widely used, even inappropriately. However, for 40 years no new class of antibiotics was developed, until 2000, when the oxazolidinones were introduced with the approval of linezolid by the FDA. As a class, the oxazolidinones were found to be particularly effective against gram-positive microorganisms, especially those that had become resistant to most other antibiotics, including Staphylococcus aureus, Streptococcus pneumoniae, and Enterococcus spp. [73]. It was recommended that linezolid be used judiciously, to help delay its resistance. However, one year after its approval, a report was published about resistance in three patients with VRE who had been treated with linezolid for a long time [74]. Another emerging antibiotic, tigecycline, belongs to the glycylcyclines, a new class of antibiotics. This broad-spectrum drug has shown activity against a wide range of microorganisms, including MRSA, VRE, and penicillin-resistant Streptococcus pneumoniae [75; 76]. Tigecycline was approved by the FDA in June 2005 for the treatment of complicated skin and skin structure infections and complicated intra-abdominal infections [77].
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As noted, the widespread use of antimicrobials as treatment or prophylaxis, both in the community and in the healthcare setting, is the primary determinant of drug-resistant strains of bacteria [65; 68; 69]. Resistance is fostered by the high number of inappropriate antibiotic prescriptions written each year and antibiotic treatment courses that are not completed by patients. In the healthcare setting, the prophylactic use of antibiotics preoperatively and the empiric use of antibiotics have helped bacteria to develop resistance. Many guidelines for the treatment of nosocomial infection and other statements have been published on the appropriate use of antibiotics in these situations [23; 69; 78; 79; 80; 81]. A 2002 review of 74 published studies identified several risk factors for nosocomial infection caused by one of a diverse group of multidrug-resistant organisms (MRSA; VRE; C. difficile; extendedspectrum, beta-lactamase-producing, gram-negative bacilli; and Candida) [82]. These risk factors included [82]: Older age Underlying disease and severity of illness Transfer of patients from another institution, especially from a nursing home Exposure to antimicrobial drugs, especially cephalosporins Prolonged hospitalization Gastrointestinal surgery or transplantation Exposure to invasive devices of all types, especially central venous catheters In addition to causing resistance, the inappropriate use of antibiotics can be a risk factor for infection itself. For example, C. difficile, the primary cause of nosocomial diarrhea, is almost always related to antibiotic use [66]. The role of infection control programs in minimizing the development of resistant pathogens will be discussed later.
TYPES oF INFECTIoNS
Nosocomial infection is clearly defined by the CDC in the NNIS system as a localized or system condition (1) that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s); and (2) that was not present or incubating at the time of admission to the hospital [61]. Thus, infections that are unrelated to the admitting diagnosis that develop within 48 hours after admission are considered to be nosocomial infections. According to the CDC definitions, the diagnosis of infection is made on the basis of a combination of clinical findings and the results of laboratory studies or other diagnostic testing [61]. The definitions also note that an infection should be considered nosocomial if it is thought to be acquired in the hospital but did not become evident until after discharge [61]. The NNIS system provides comprehensive details about the criteria for infection at 13 major anatomic sites and has developed clinical and biologic criteria for 48 specific sites or types of infection [61; 83]. WHO has simplified the criteria to facilitate infection control in healthcare institutions with limited resources [1]. As noted previously, the most common nosocomial infections are urinary tract infections, surgical site infections, pneumonia, intravascular device-related bloodstream infections, and gastrointestinal tract infections (Table 4). Other nosocomial infections defined by the NNIS include infection of bones and joints; the central nervous system; the cardiovascular system; the eye, ear, nose, throat, or mouth; the lower respiratory tract (other than pneumonia); the reproductive tract; the skin and soft-tissue; and systemic infection. Many of these infections are complications of surgically implanted devices [58].
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CoSTS oF THE MoST CoMMoN NoSoCoMIAL INFECTIoNS Infection Proportion of All Nosocomial Infections 35% 20% to 40% Incidence Excess Length of Stay 1 to 3 days 7 to 10 days Mortality Cost Per Patient $700$1,900 $14,000$20,000
Urinary tract infection Surgical site infection
20% of patients with an indwelling catheter 2% to 5% of extraabdominal surgeries; 20% of intraabdominal surgeries 10% to 65% of critically ill patients 1% of all hospitalized patients 30% of all hospitalized adults
Not Available Not Available
Ventilator-associated pneumonia Intravascular devicerelated bloodstream infection Clostridium difficileassociated diarrhea
15% to 20% 15%
4 to 13 days 7 days
6% to 20% 4% to 20%
$20,000$40,000 $35,000
Not Available
18 to 30 days
0.6% to 5%
$3,700$10,000 Table 4
Source: [80; 88; 106; 140; 155]
The risk factors for the most common nosocomial infections have been delineated in many studies (Table 5). Yet, predicting which patients are at risk can be difficult. In one study, medical staff in a surgical intensive care unit were asked to assess at admission the individual risk of major nosocomial infection during the patients stay in the unit. The investigators found that the physicians could not accurately predict risk, with positive predictive values that ranged from 8.4% to 14.5% and negative predictive values that ranged from 92.1% to 100% [84]. The microorganisms causing nosocomial infection vary by anatomic site. Gram-negative bacilli account for a high percentage of infections in intensive care units. In an analysis of NNIS data from 2003, gram-negative bacilli were associated with 71% of urinary tract infections, 65% of cases of pneumonia, 34% of surgical site infections, and
24% of bloodstream infections [85]. These figures represent decreases for surgical site infections and bloodstream infections, which were reported by the NNIS as 57% and 33%, respectively, in 1986. In the overviews of the nosocomial infections that follow, the most common microorganisms specific to each infection are noted. Infectious agents also vary among healthcare facilities and even units within a single institution. Knowledge of trends in the pathogens responsible for nosocomial infections is important in determining appropriate empiric therapy. This information changes frequently, and healthcare professionals should remain up-to-date with the pathogens identified in their own healthcare facilities and even on specific units within the facility. Comprehensive surveillance programs may also help guide the selection of empirical treatment regimens [86].
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rISK FACTorS For NoSoCoMIAL INFECTIoNS Infection Urinary tract infection Patient-related Factors Female gender Diabetes mellitus Renal insufficiency Other site of infection Urethral stent Age Nutritional status History of smoking Obesity Hypovolemia Poor tissue perfusion Use of steroids or other immunosuppressant agents Pre-existing infection (local or other site) Anesthesia score Nonviable tissue in wound Hematoma Dead space Wound classification Age Severity of illness Chronic lung disease Head trauma Elevated gastric pH Upper abdominal or thoracic surgery Severity of illness Burns or surgical wounds Compromised immune system Nutritional status Iatrogenic Factors Use of catheter to measure output Disconnection of catheter from drainage tube Duration of catheterization; insertion of catheter late in hospital stay Retrograde flow of urine from drainage bag Foreign material (including drains and sutures) Skin antisepsis Duration of operation Intraoperative contamination Duration of preoperative hospital stay Hypothermia during operation Duration of surgical scrub Antimicrobial prophylaxis Preoperative preparation (wash/shave) Surgical technique
Surgical site infection
Ventilator-associated pneumonia
Reintubation Supine head position Aspiration of gastric contents Nasogastric tube Use of paralytic agents Duration of mechanical ventilation Heavy colonization on skin at site of insertion Location in internal jugular or femoral vein Length of time in place Contamination of catheter hub Type of infusate Total parenteral nutrition Location of insertion Antibiotic use Nasogastric intubation
Intravascular devicerelated bloodstream infections
Clostridium difficileassociated diarrhea
Age Severity of illness Compromised immune system Gastrointestinal surgery or manipulation Debilitation Length of stay
Source: [2; 17; 36; 144; 156]
Table 5
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urINArY TrACT INFECTIoNS The urinary tract is the most common site of nosocomial infection, accounting for approximately 35% of such infections [3; 87]. Their costs, in terms of morbidity, mortality, and economics, are low, especially compared with the other types of nosocomial infections [87; 88; 89]. A urinary tract infection will develop in approximately 20% of patients who have an indwelling catheter, and a catheter is associated with nearly 80% of all nosocomial urinary tract infections [1; 91]. The rate of nosocomial urinary tract infection is especially high in some patient populations, including patients who have had kidney transplant [38]. Several risk factors have been identified, including female gender, diabetes, renal insufficiency, duration of catheterization, insertion of a urinary catheter late in the hospital stay, and others [2; 17; 144].
Causes and Common Pathogens Urinary tract infections can be caused by both endogenous and exogenous transmission. Normal flora from the gastrointestinal tract can spread to the urinary tract, or pathogens can be transmitted by caregivers carrying out tasks related to the catheter or drainage bag [2]. Occasionally, pathogens are transmitted through urologic equipment that has not been adequately disinfected [2]. Nosocomial urinary tract infections are usually caused by gram-negative pathogens, the most common being Escherichia coli, Proteus mirabilis, Klebsiella spp., and P. aeruginosa; other causal pathogens include enterococci and Enterobacter spp. [85]. Candida is the leading cause of nosocomial urinary tract infections in intensive care units [2]. Most nosocomial infections are caused by only one pathogen.
SuMMArY oF MAJor rECoMMENDATIoNS FroM THE CENTErS For DISEASE CoNTroL AND PrEVENTIoN (CDC) For THE PrEVENTIoN oF NoSoCoMIAL urINArY TrACT INFECTIoNS Strongly recommended Educate personnel in correct techniques of catheter insertion and care Catheterize only when necessary Emphasize handwashing Insert catheter using aseptic technique and sterile equipment Secure catheter properly Maintain closed sterile drainage Obtain urine samples aseptically Maintain unobstructed urine flow Periodically re-educate personnel in catheter care Use smallest suitable bore catheter Avoid irrigation unless needed to prevent or relieve obstruction Refrain from daily meatal care (with either povidone-iodine solution or soap and water) Do not change catheters at arbitrary fixed intervals Consider alternative techniques of urinary drainage before using an indwelling urethral catheter Replace the collecting system when sterile closed drainage has been violated Spatially separate infected and uninfected patients with indwelling catheters Avoid routine bacteriologic monitoring Table 6
Moderately recommended
Weakly recommended
Source: Reprinted from Wong ES, Hooten TM. Guideline for prevention of catheter-associated urinary tract infections. Available at http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html. Last accessed January 19, 2007.
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Prevention Both the CDC and WHO have provided evidencebased guidelines for preventing nosocomial urinary tract infections (Table 6) [1; 91]. The most important principles for prevention are: Use indwelling catheters only when necessary. Use aseptic technique and sterile equipment when inserting catheter. Secure catheter properly. Use a closed sterile drainage system. Maintain unobstructed urine flow. Obtain urine samples aseptically. Remove catheter as soon as feasible. As with prevention of all nosocomial infections, handwashing is an essential element of aseptic technique and care of patients with catheters. In addition, healthcare staff should be educated and trained in proper techniques of catheter insertion and care. Alternatives to indwelling catheters have also been evaluated as an approach to preventing nosocomial urinary tract infections. Suprapubic catheters have been shown to produce less bacteriuria and more patient satisfaction. However, trained personnel are necessary to insert these catheters, and the procedure is usually carried out in the operating room [87]. A comparison of condom and indwelling catheters demonstrated that condom catheters significantly decreased the rate of adverse events, including bacteriuria, symptomatic urinary tract infection, or death. Compared to condom catheters, the likelihood of an adverse event was five times greater for men with an indwelling catheter who did not have dementia [92]. However, condom catheters must be carefully maintained, and no equivalent alternative is available for women, for whom the risk of nosocomial urinary tract infection may be higher [2]. The use of catheters coated with an antimicrobial surface has been evaluated, especially those coated with silver, a highly effective antibacterial substance.
A meta-analysis reported in 1998 demonstrated a significant decrease in bacteriuria with silver alloy catheters [93]. Since the time of the meta-analysis, other studies have also shown benefit to this type of catheter [65; 94; 96; 97]. However, one study indicated no significant benefit, and another found that the benefit applied when catheters were used for approximately five days rather than for 14 days [98; 99]. One 2006 study in which silicone-based, hydrogel-coated urinary catheters with and without silver impregnation were compared showed that the addition of silver did not reduce the incidence of bacteriuria [100]. A meta-analysis published in 2006 evaluated 12 trials (13,392 patients or catheters) in which nitrofurantoin-coated silicone or silver-coated latex catheters were compared with silicone or latex catheters. The antimicrobialcoated catheters prevented or delayed the onset of bacteriuria in select patients but the magnitude of the effect varied substantially according to several variables, including catheter type and publication year [101]. Advances in technology have shown promise in preventing nosocomial urinary tract infections. A study of prompts in a computerized order-entry system and handheld bladder scanners showed that the combination of these two techniques led to an 81% decrease in the use of catheters and a 73% reduction in nosocomial infections [102]. For hospitals without order-entry systems, a handwritten reminder that the patient has a catheter has been effective in reducing the rate of infection [103]. Diagnosis Nosocomial urinary tract infections are classified by the CDC as symptomatic urinary tract infection, asymptomatic bacteriuria, or other infection of the urinary tract, and the results of urinalysis and urine cultures (using a clean catch technique or catheterization) are necessary for diagnosis [61]. For a diagnosis of symptomatic urinary tract infection in an adult, one of the following two criteria must be met [61].
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Criterion 1 At least one of the following with no other recognized cause: Fever (>38 degrees Centigrade) Urgency, frequency, dysuria, or suprapubic tenderness and positive urine culture (>105 microorganisms per cm3 of urine with no more than two species of microorganisms) Criterion 2 At least two of the following with no other recognized cause: Fever (>38 degrees Centigrade) Urgency, frequency, dysuria, or suprapubic tenderness and at least one of the following: Positive dipstick for leukocyte esterase and/or nitrate Pyuria (urine specimen with >10 wbc/mm3 or >3 wbc/high power field of unspun urine) Organisms seen on gram stain of unspun urine At least two urine cultures with repeated isolation of the same uropathogen (gramnegative bacteria or S. saprophyticus) with >102 colonies/mL in nonvoided specimens <105 colonies/mL of a single uropathogen (gram-negative bacteria or S. saprophyticus) in a patient being treated with an effective antimicrobial agent for a urinary tract infection Physician diagnosis of a urinary tract infection Physician institutes appropriate therapy for a urinary tract infection A diagnosis of asymptomatic bacteriuria in an adult is made when one of the following two criteria are met [61].
Criterion 1 Indwelling urinary catheter within seven days before the culture and positive urine culture (>105 microorganisms per cm3 of urine with no more than two species of microorganisms) and no frequency, dysuria, or suprapubic tenderness Criterion 2 No indwelling urinary catheter within seven days before the first positive culture and at least two positive urine cultures (>105 microorganisms per cm3 of urine with repeated isolation of the same microorganism and no more than two species of microorganisms) and no fever (>38 degrees Centigrade), urgency, frequency, dysuria, or suprapubic tenderness The CDC notes that a positive culture of a catheter tip is not acceptable for a diagnosis of bacteriuria. Treatment Most catheter-associated urinary tract infections are asymptomatic, and many will resolve on their own once the catheter is removed. Treatment of these urinary tract infections has not been found to be beneficial, and the IDSA has recommended that these infections need not be treated [89; 104]. If symptoms develop, urine and blood should be obtained for cultures before empiric antibiotic treatment is started [89]. For patients who have had an indwelling catheter for long time, it may be useful to replace the catheter before obtaining urine for culture, as pathogens in the catheter may differ from those in the urinary tract [2]. The antibiotics suggested for initial treatment include quinolones, third-generation and fourth-generation cephalosporins, and penicillin, as well as trimethoprim, TMP-SMX, nitrofurantoin, meropenem, gentamicin, and fosfomycin [89]. Patients with suspected urinary tract infection should be evaluated to rule out another source of infection. If infection persists, a repeat urine culture can be useful. A persistent infection can lead to infection of other genitourinary organs, such as the bladder, kidney, or prostate, or to gram-negative bacteremia, especially in high-risk patients [105].
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SurGICAL SITE INFECTIoNS Surgical site infections account for approximately 40% of infections acquired in a healthcare setting and are costly in terms of length of stay, morbidity and mortality, and actual costs [3; 5; 139; 140]. These costs are even higher for patients 70 years of age and older. One study showed that mortality associated with surgical site infection with S. aureus was higher for this population than for either younger patients with S. aureus infection or for older patients with no infection [141]. Length of stay and actual costs were similarly elevated. Of all patients who have surgery, infection will develop postoperatively in approximately 3% to 5% [139; 140; 142]. The rate of surgical site infection has become lower over the past few years, but that decrease is not thought to be an accurate
representation because of an increased number of operations done on an outpatient basis; a decrease in the length of the postoperative hospital stay; and a wound infection incubation period of five to seven days [2; 3]. This potential for underestimation of the number of surgical site infections is reflected in the findings of a study in which one-third of nosocomial wound infections were detected after the patient had been discharged [143]. Causes and Common Pathogens Surgical site infections arise from both endogenous and exogenous transmission, and several patientrelated and surgery-related factors have been implicated as risk factors. In addition to older age, patient-related factors include [2; 23; 139; 140; 142; 144]:
PATHoGENS MoST LIKELY To CAuSE SurGICAL SITE INFECTIoNS ACCorDING To TYPE oF SurGErY Type of Surgery Appendectomy Biliary tract Breast Cardiac Colorectal Gastroduodenal Head and neck Neurosurgery Noncardiac thoracic* Obstetric and gynecologic Ophthalmic Orthopedic** Placement of all grafts, prostheses, or implants Urologic Vascular Most Likely Pathogens Gram-negative bacilli; anaerobes Gram-negative bacilli; anaerobes S. aureus; coagulase-negative staphylococci S. aureus; coagulase-negative staphylococci Gram-negative bacilli; anaerobes Gram-negative bacilli; streptococci; oropharyngeal anaerobes (e.g., peptostreptococci) S. aureus; streptococci; oropharyngeal anaerobes (e.g., peptostreptococci) S. aureus; coagulase-negative staphylococci S. aureus; coagulase-negative staphylococci; Streptococcus pneumoniae; gram-negative bacilli Gram-negative bacilli; enterococci; group B streptococci; anaerobes S. aureus; coagulase-negative staphylococci; streptococci S. aureus; coagulase-negative staphylococci; gram-negative bacilli S. aureus; coagulase-negative staphylococci Gram-negative bacilli S. aureus; coagulase-negative staphylococci
*Includes lobectomy, pneumonectomy, wedge resection, other noncardiac mediastinal procedures, and closed tube thoracostomy. **Includes total joint replacements; closed fractures/use of nails, bone plates, and other internal fixation devices; functional repair
without implant or device; and trauma-related operations.
Source: Modified from Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Cont Hosp Epidemiol. 1999;20(4):247-264.
Table 7
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Existing infection Low serum albumin concentration Obesity Nutritional status History of smoking Diabetes mellitus Trauma Blood transfusion Hypothermia, hypoxia, or hyperglycemia
Among the surgery-related factors are anesthesia score, duration of the operation, the use of drains, and inadequate aseptic technique. The microbial sources of surgical site infections vary according to the type of surgery (Table 7), and the most common microorganisms are S. aureus, coagulase-negative staphylococci, Enterococcus spp., Escherichia coli, P. aeruginosa, and Enterobacter spp. [23]. According to data from the NNIS, the frequency of infection with gram-negative bacilli has decreased over the past two decades, but these pathogens are still responsible for about one-third of surgical site infections [85]. The incidences of S. aureus and coagulase-negative staphylococci have increased over the past two decades, while the frequency of the other pathogens has remained the same or decreased. Prevention The CDC guideline for preventing surgical site infections address a wide variety of issues, including preoperative preparation of the patient, antisepsis of the surgical team, management of surgical personnel with colonization or infection, antimicrobial prophylaxis, ventilation, cleaning and disinfection of environmental surfaces, microbiologic sampling, sterilization of surgical instruments, surgical attire and drapes, asepsis and surgical technique, postoperative incision care, and surveillance (Table 8) [23]. In addition, maintaining a warm body temperature and good glycemic control have also been recommended [139; 140]. Many studies have shown that providing feedback to surgeons about their rates of infection can have a substantial effect on lowering the rates [23].
It is generally accepted that the use of antibiotic prophylaxis is the most important preventive measure for surgical site infection. Perioperative administration of an appropriate antibiotic substantially reduces the relative risk of a surgical site infection, and timing is crucial [1; 23; 146]. However, studies have indicated that the antibiotic regimen, timing of administration, or duration of prophylaxis used is inappropriate for 25% to 50% of patients [146]. Evidence-based guidelines recommend that prophylactic antibiotics be administered such that the serum concentration is optimal when the surgical incision is made and should be maintained until a few hours after the incision is closed [1; 23]. Meta-analyses have demonstrated lower rates of infection with a single-dose (long-acting) antibiotic and broader spectrum antibiotics, such as third-generation cephalosporins [146]. The CDC guideline references appropriate antibiotics on the basis of the type of surgery [23]. A complication of perioperative antibiotic prophylaxis is an increased frequency of adverse events, the most serious of which is infection with C. difficile. This risk may be higher in association with a broad-spectrum antibiotic [146]. Systematic reviews reported in 2006 have shown that two traditional measures for preventing postoperative infection have no effect on the rate of surgical site infection. One review involved six trials in which preoperative washing was evaluated in a total of 10,007 patients. There was no significant difference in the rate of surgical site infections when 4% chlorhexidine gluconate was compared with placebo or with no washing [147]. The other review involved 11 randomized controlled trials in which preoperative hair removal practices were evaluated. Comparison of a razor, depilatory cream, or no hair removal showed no significant difference in the rate of surgical site infection [148]. However, when shaving was compared with clipping, there were significantly more surgical site infections after shaving. No difference was found in the rate of surgical site infections between clipping one day preoperatively or on the day of surgery.
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KEY rECoMMENDATIoNS For THE PrEVENTIoN oF SurGICAL SITE INFECTIoNS* Preoperative Whenever possible, identify and treat all infections remote to the surgical site before elective operation, and postpone elective operations on patients with remote site infections until the infection has resolved. Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. If hair is removed, remove immediately before the operation, preferably with electric clippers. Adequately control serum blood glucose levels in all diabetic patients and particularly avoid hyperglycemia perioperatively.** Encourage tobacco cessation. At minimum, instruct patients to abstain for at least 30 days before elective operation from smoking cigarettes, cigars, pipes, or any other form of tobacco consumption (e.g., chewing/dipping).** Do not withhold necessary blood products from surgical patients as a means to prevent surgical site infection.** Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day.** Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation.** Use an appropriate antiseptic agent for skin preparation.** Antimicrobial prophylaxis Administer a prophylactic antimicrobial agent only when indicated, and select it based on its efficacy against the most common pathogens causing surgical site infection for a specific operation and published recommendations. Administer by the intravenous route the initial dose of prophylactic antimicrobial agent, timed such that a bactericidal concentration of the drug is established in serum and tissues when the incision is made. Maintain therapeutic levels of the agent in serum and tissues throughout the operation and until, at most, a few hours after the incision is closed in the operating room. Before elective colorectal operations in addition to above recommendation, mechanically prepare the colon by use of enemas and cathartic agents. Administer nonabsorbable oral antimicrobial agents in divided doses on the day before the operation. Postoperative incision care Protect with a sterile dressing for 24 to 48 hours postoperatively an incision that has been closed primarily.** Wash hands before and after dressing changes and any contact with the surgical site.** *Recommendations that are strongly recommended for implementation and supported by well-designed experimental, clinical,
or epidemiologic studies, except as otherwise noted. **Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and strong theoretical rationale.
Source: [23]
Table 8
The IHI promotes a strategy for decreasing the rate of surgical site infections by focusing on four key components: appropriate use of prophylactic antibiotics, avoidance of preoperative shaving, maintaining adequate glycemic control, and maintaining a warm body temperature [149]. In addition, the organization has recommended specific, practical steps to help healthcare personnel ensure that these measures are carried out [149].
Appropriate Use of Prophylactic Antibiotics Use preprinted or computerized standing orders specifying antibiotic, timing, dose, and discontinuation. Change operating room drug stocks to include only standard doses and standard drugs, reflecting national guidelines. Reassign dosing responsibilities to anesthesia or holding area nurses to improve timeliness. Use visible reminders, checklists, and/or stickers.
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Involve pharmacy, infection control, and infectious disease staff to ensure appropriate timing, selection, and duration. Avoidance of Preoperative Shaving Remove all razors throughout the hospital. Work with the purchasing department to ensure that razors are no longer purchased by the hospital. Use signs or posters as reminders. Educate patients about not shaving preoperatively. Maintaining Adequate Glycemic Control Implement a glucose control protocol (sliding scale or insulin drip). Regularly check preoperative blood glucose levels on all patients. Assign responsibility and accountability for blood glucose monitoring and control. Maintaining a Warm Body Temperature Use hats and booties on patients preoperatively. Use warmed forced-air blankets preoperatively, during surgery, and in the recovery room. Use warmed intravenous fluids. Use warming blankets under patients on the operating table. Evidence of the efficacy of this group of interventions is found in a report on the National Surgical Infection Prevention Collaborative, a one-year demonstration project sponsored by the Centers for Medicare & Medicaid Services. For this quality improvement project, 56 hospitals volunteered to carry out strategies aimed at decreasing the rate of surgical site infection; the group of strategies was similar to that proposed by the IHI, with the addition of appropriate oxygenation. Data from 35,543 surgical cases showed a 27% decrease in the rate of infection, from 2.3% to 1.7% [150].
Diagnosis Surgical site infections are classified as superficial incisional, deep incisional, and organ/space infections. Strict criteria and standardized definitions are used in reporting infections and in surveillance programs [23; 146]. The CDC described the criteria for each type of infection in its guideline for the prevention of surgical site infections and defined the infections in the NNIS system according to this classification [23; 61]. Superficial Incisional Classification Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision and at least one of the following: Purulent draining from the superficial incision Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat, and superficial incision is deliberately opened by surgeon, unless incision is culture-negative Diagnosis of superficial incisional surgical site infection by the surgeon or attending physician Deep Incisional Classification Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following: Purulent drainage from the deep incision but not from the organ/space component of the surgical site Deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (>38 degrees Centigrade) or localized pain or tenderness, unless incision is culture-negative
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Abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiographic examination Diagnosis of a deep incisional surgical site infection by a surgeon or attending physician Organ/Space Classification Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if the implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and at least one of the following: Purulent drainage from a drain that is placed through a stab wound into the organ/space Organisms isolated from an aseptically obtained culture or fluid or tissue in the organ/space Abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiographic examination Diagnosis of an organ/space surgical site infection by a surgeon or attending physician In its guideline on the diagnosis and management of skin and soft tissue infections, the IDSA notes that fever occurring within the first 48 hours postoperatively is usually not associated with a surgical site infection. After that time, these infections are the most common source of fever [151]. Treatment The treatment of surgical site infections varies widely according to the type of surgery. For most surgical wounds, a combined-modality approach is used, with drainage or surgical excision to remove infected and/or necrotic tissue and administration of antibiotic therapy targeted to the most likely pathogen [2]. Care should be taken if pulsatile lavage is used to clean or debride a wound, as a study of an outbreak of multidrug-resistant A. baumannii linked the pathogen to this procedure [152].
According to the IDSA guideline, observation, dressing changes, and opening of the incision site is appropriate for patients who have a temperature of less than 38.5 degrees Centigrade and no tachycardia [151]. For patients with a higher temperature and/or heart rate, the suture line should be opened and antibiotic therapy should be started. The guideline also suggests that the choice of antibiotic varies according to the operative site [151]. The IDSA recommends the following medications be used in the defined cases: Intestinal or Genital Tract Single agents: cefoxitin, ceftizoxime, ampicillin/ sulbactam, ticarcillin/clavulanate, piperacillin/ tazobactam, imipenem/cilastatin, meropenem, ertapenem Combination agents: fluoroquinolone, third-generation cephalosporin, aztreonam, aminoglycoside (for facultative and aerobic activity); clindamycin, metronidazole, chloramphenicol, penicillin agent plus beta-lactamase inhibitor (for anaerobic activity) Trunk and Extremities (away from axilla or perineum) Oxacillin, first-generation cephalosporin Axilla or Perineum Cefoxitin, ampicillin/sulbactam, other single agents as described above for intestinal and genital operations The guideline cautions that aztreonam and metronidazole should not be used together, as the combination is not active against gram-positive cocci. For surgical site infections after implantation of a joint prosthesis, the approach depends on the duration of infection, stability of the implant, antimicrobial susceptibility of the pathogen and condition of the surrounding soft tissue [153]. In this setting, rifampin has shown excellent activity against adherent staphylococci and may be useful in combination with beta-lactams, glycopeptides, fluoroquinolones, minocycline, trimethoprim or fusidic acid [154].
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PNEuMoNIA Another common nosocomial infection is pneumonia, accounting for 15% to 20% of all nosocomial infections [2; 3; 17]. The rate is especially high (10% to 65%) for critically ill patients and is 6 to 21 times higher for patients receiving continuous mechanical ventilation than for those who are not receiving such support [36; 106; 107]. Thus, most research on hospital-acquired pneumonia has focused on ventilator-associated pneumonia, which is defined as pneumonia that develops within 48 hours after tracheal intubation [106]. Ventilator-associated pneumonia develops in approximately 9% to 27% of patients who are intubated, and approximately 25% to 60% of deaths for patients with nosocomial infection can be attributed to ventilator-associated pneumonia [3; 106]. The costs in terms of morbidity, mortality, and economics are among the highest for nosocomial infections [2; 17; 88; 106]. Determining whether pneumonia is nosocomial can be difficult when the onset is early after admission to a healthcare facility, as the infection may have been acquired in the community [106]. The classification of nosocomial pneumonia has also been expanded to include another category, healthcareassociated pneumonia, to distinguish pneumonia in patients that is present at the time of admission to a hospital from a high-risk environment, such as a nursing home, long-term care facility, or home, if extensive therapy is provided there [106]. Nosocomial pneumonia in such patients is more likely to be caused by multiple drug-resistant bacteria. The risk of ventilator-associated pneumonia correlates with the duration of intubation; the risk has been estimated to be 3% per day during the five-day period after intubation, decreasing to 2% per day for days 5 through 10 and to 1% per day for longer durations [106]. Nearly half of all cases of ventilator-associated pneumonia develop within the first four days of mechanical ventilation [106]. In addition to duration of ventilation, several other risk factors have been identified, including a supine head position, presence of a nasogastric tube, and use of paralytic agents; age, chronic lung
disease, and head trauma are also factors [2; 36]. In one study, ventilator-associated pneumonia was most frequently associated with intensive care unit admission diagnoses of postoperative care, neurologic conditions, sepsis, and cardiac complications [108]. Causes and Common Pathogens Most cases of nosocomial pneumonia are caused by aspiration of bacteria originating in the oropharynx or the stomach [17]. Approximately 50% of all cases occur after surgery, with the highest risk associated with cardiac and lung surgery, and crosscontamination, either through staff or equipment, is another cause [17]. It is unclear whether the most common causative pathogens for nosocomial pneumonia are the same for patients in the intensive care unit and those in other units. Timing of the onset of pneumonia has been thought to be an aid in identifying the causative pathogens, with early onset (within four to five days after hospitalization) most likely being caused by an antibiotic-sensitive pathogen, such as Streptococcus pneumoniae, Haemophilus influenzae, E. coli, nonresistant enteric gram-negative bacilli, or methicillin-sensitive S. aureus [106; 109]. Under this same theory, late onset pneumonia (beyond five days after hospitalization) is more likely caused by resistant bacteria, such as Pseudomonas aeruginosa, Acinetobacter species, other resistant enterobacter species, and MRSA [109]. However, in a study of more than 3,600 patients admitted to an intensive care unit, Pseudomonas was the cause of pneumonia in 25% of patients; MRSA, in 18%; and Acinetobacter, in 6% [109]. Additional data from that study indicated that previous treatment with antibiotics and prior hospitalization may be more predictive of the causative microorganisms [109]. Other studies have shown that S. aureus is common among patients who are in a coma or have diabetes or renal failure; Pseudomonas is common among patients who have had a prolonged stay in the intensive care unit, have received prior antibiotics or corticosteroids or who have structural lung disease; and Legionella is usually found in patients who have compromised immune systems [109].
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The most common pathogen associated with ventilator-associated pneumonia is S. aureus, followed by P. aeruginosa, other Staphylococcus spp., and Enterobacter spp. [106; 110]. These microbes are among those that have become resistant to antibiotics, and the frequency of infection with MRSA is increasing [106]. Almost half of all cases of ventilator-associated pneumonia are caused by infection with more than one pathogen [2; 106]. While bacteria are the primary causative agents, viral and fungal microorganisms are beginning to emerge as causes [111]. Prevention The CDC recommends that all patients who are at high risk for severe nosocomial pneumonia should receive a pneumococcal vaccination [112]. With regard to postoperative pneumonia, several strategies have been shown to reduce the risk for patients who are not mechanically intubated [17; 113]: Deep breathing Frequent coughing Early movement (in bed and/or walking) Limited use of narcotic agents Incentive spirometry for patients at high risk
of sedation interruption has been further demonstrated to reduce the complications of prolonged mechanical ventilation [115]. Other preventive measures are targeted primarily to the care and use of ventilator equipment and practices in direct patient care. Meticulous attention to aseptic care of the equipment is necessary, and all reusable components, such as nebulizers, should be disinfected or sterilized. Tubing circuits should be replaced at more than 48 hours, or earlier if there are signs of malfunction or contamination [2; 112]. Changes in the design of the endotracheal tube have also been evaluated, and a tube with a dorsal lumen that allows for intermittent drainage of subglottic secretions has led to a significant decrease in the incidence of ventilator-associated pneumonia [116; 117]. As with all approaches to preventing infection, aseptic technique when suctioning is essential [2; 112]. The use of noninvasive ventilation is another measure that has reduced the incidence of ventilatorassociated pneumonia [112; 118; 119; 120]. In one study, the incidence decreased from 20% to 8% when noninvasive ventilation was used routinely for critically ill patients with acute exacerbation of chronic obstructive pulmonary disease or severe cardiogenic pulmonary edema [118]. Other preventive strategies are designed to reduce the risk of aspiration and contamination with gastric secretions. The risk of aspiration has been significantly reduced by positioning the patient with the head of the bed at an angle of 30 to 45 degrees [35; 36; 117; 121]. In one randomized controlled trial, there were 18% fewer cases of ventilatorassociated pneumonia among intubated patients in the group assigned to the recumbent position (45 degrees) compared with the group assigned to the supine position [121]. In another study, elevation of the head of the bed at 30 degrees was the most effective measure among a group of preventive interventions, explaining a 52% variance in the rate of ventilator-associated pneumonia [122].
In addition to guidelines from the CDC, recommendations for prevention have been proposed on the basis of independent studies or meta-analyses [109]. The evidence points to the benefit of an overall, multicomponent preventive strategy [109; 113]. Because of the increasing risk of ventilatorassociated pneumonia as the length of time on mechanical ventilation increases, the primary goal is to extubate the patient as early as possible. Thus, assessment of the readiness for extubation and weaning protocols are key aspects in the preventive approach [79; 109; 113]. Daily interruption of sedation until the patient is awake has been shown to significantly decrease the number of days on mechanical ventilation, from 7.3 days to 4.9 days in one study [114]. There are risks to this approach, such as the potential for increased pain, anxiety, and desaturation [113]. However, the use
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Another strategy has evolved with some conflicting views. Antacids, histamine-2 antagonists, and sucralfate have been traditionally given to patients receiving mechanical ventilation to prevent the formation of stress ulcers. However, reducing the amount of gastric acid can increase the risk of colonization of gram-negative bacilli in the stomach. As a result, WHO recommended avoiding the use of these agents [1]. In its guideline on preventing ventilator-associated pneumonia, the CDC noted that there was insufficient evidence on the use of peptic ulcer prophylaxis and included no recommendations in this regard in its updated guideline [112]. Most recently, the American Thoracic Society and IDSA deem it acceptable to use either a histamine-2 antagonist or sucralfate and recommend such prophylaxis in their evidence-based guideline on preventing ventilator-associated pneumonia [79]. Oral care interventions have been suggested by some, in part because of an association between a high level of dental plaque and a high rate of colonization with aerobic pathogens, including S. aureus, gram-negative bacilli, and P. aeruginosa [123]. Studies have shown that oral decontamination with chlorhexidine leads to a significant reduction in the colonization of pathogens in the oropharynx, but the intervention has not had a significant effect on the rate of ventilator-associated pneumonia or associated mortality [122; 124; 125; 126]. As part of its efforts to improve the quality of health care by reducing the rate of nosocomial infections, the IHI promoted implementation of a so-called ventilator bundle, defined as a series of interventions related to ventilator care that, when implemented together, will achieve significantly better outcomes than when implemented individually [113]. The interventions are based on the strength of the evidence, the ease of implementation, and cost. The key components of the ventilator bundle are:
Elevation of the head of the bed Daily interruptions of sedation and assessment of readiness to extubate Prophylaxis of peptic ulcer disease Prophylaxis of deep venous thrombosis In advocating the last intervention, the IHI acknowledged the lack of a clear relation between prophylaxis of deep vein thrombosis and ventilatorassociated pneumonia. However, the organization included the intervention on the basis of a clinical practice guideline by the American College of Chest Physicians and experience with a decrease in the rate of ventilator-associated pneumonia when such prophylaxis was implemented as part of a package of interventions [127]. To foster implementation of the ventilator bundle, the IHI developed a publication to provide information on ventilator-associated pneumonia and practical suggestions on carrying out the interventions [113]. The IHI recommends posting compliance with the ventilator bundle in a prominent place in the intensive care unit to encourage and motivate staff [113]. Other recommendations to help effect change include [113]: Elevation of the Head of the Bed Include the intervention on nursing flow sheets and discuss at multidisciplinary rounds. Encourage respiratory therapy staff to notify nursing staff if the head of the bed is not elevated or empower respiratory therapy staff to place the bed in this position with help of nursing staff. Include the intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care.
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Sedative Interruptions and Assessment of Readiness to Extubate Implement a protocol to lighten sedation daily at an appropriate time to assess for neurologic readiness to extubate. Include precautions to prevent self-extubation, such as monitoring and vigilance, during the trial. Include a sedative interruption strategy in the overall plan to wean the patient from the ventilator; add the strategy to the weaning protocol, if available. Assess compliance each day on multidisciplinary rounds. Consider implementation of a sedation scale, such as the Riker scale, to avoid oversedation. Prophylaxis of Peptic Ulcer Disease Include intervention as part of the intensive care unit admission order set and ventilation order set. Make application of prophylaxis the default value on the form. Include intervention as an item for discussion on daily multidisciplinary rounds. Empower pharmacy staff to review orders for patients in the intensive care unit to ensure that some form of prophylaxis is in place at all times for patients. Prophylaxis of Deep Venous Thrombosis Include intervention as part of the intensive care unit admission order set and ventilation order set. Make application of prophylaxis the default value on the form. Include intervention as an item for discussion on daily multidisciplinary rounds. Empower pharmacy staff to review orders for patients in the intensive care unit to ensure that some form of prophylaxis is in place at all times for patients.
Hospitals have begun to report substantial reductions in the number of cases of ventilator-associated pneumonia per 1,000 ventilator days using the bundle approach. A hospital in Mississippi implemented four changes as part of an IHI initiative to decrease rates of nosocomial infections in its 28-bed medical-surgical intensive care unit. Use of the ventilator bundle, along with physicianled multidisciplinary rounds and a focus on team decision making, led to a significant reduction in ventilator-associated pneumonia, from 7.5 to 3.2 cases per 1,000 ventilator days [128]. Strong downward trends were also found for the average length of stay in the intensive care unit and the financial costs per patient. The results of structured preventive strategies as part of IHI initiatives at other healthcare facilities are available on the IHI website. The results are presented with highlights of practical steps to implement change and lessons learned. Case Example: Success in Reducing Ventilator-Associated Pneumonia In 2003, St. Vincent Mercy Medical Center, Toledo, Ohio, launched a program to decrease the rate of ventilator-associated pneumonia in its eight intensive care units [145]. A multidisciplinary team of 11 staff first reviewed the literature to identify best practices for care of patients receiving mechanical ventilation. The team then evaluated the current policies and procedures at the institution to determine opportunities for improvement. Based on their findings, they developed a plan to carry out several changes, and they successfully reduced the prevalence of ventilator-associated pneumonia. Their changes were as follows [145]: Use sterile solution for irrigation of drains and catheters for patients receiving mechanical ventilation. Initiate standing order for pneumococcal and influenza vaccines throughout the facility. Update Adult Admission History form to include screening questions for vaccines.
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Provide education for staff, residents, and physicians in a variety of formats (written modules, one-on-one training, and lectures). Develop computer-assisted educational program on measures to reduce ventilator-associated pneumonia for all staff (mandatory for nurses and respiratory therapy staff). Develop signs for the head of patients bed, placed as a reminder of best practices: Follow proper hand hygiene. Elevate head of bed. Use sterile water for irrigation. Hold tube feeding for high residuals. Carry out oral care every two hours. Reposition patient every two hours. Secure endotracheal tube. Drain circuit condensate before repositioning patient. Give vaccines. Keep manual resuscitation bags clean. Install waterless hand sanitizer dispensers throughout the facility and educate all staff and physicians on usage. Post signs instructing visitors to use hand sanitizer. Implement daily rounds by respiratory therapists and infection control practitioner on best practices for patients receiving mechanical ventilation. Report quarterly measure to Infection Control Committee, unit staff, leadership team, and Multidisciplinary Quality Committee, then to Board of Trustees.
The CDC and HICPAC recommend educating healthcare workers about the epidemiology of, and infection-control procedures for, preventing healthcareassociated bacterial pneumonia to ensure worker competency according to the workers level of responsibility in the healthcare setting, and involve the workers in the implementation of interventions to prevent healthcare-associated pneumonia by using performance improvement tools and techniques. (http://www.guidelines.gov/summary/summary. aspx?doc_id=4872. Last accessed January 23, 2007.) Strength of recommendation: IA (Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies)
Diagnosis The difficulty in diagnosing nosocomial pneumonia is well recognized [79; 107; 129]. The clinical signs can resemble other, noninfectious conditions, and the specificity of clinical criteria is low [2; 106]. According to the CDC definition, the diagnosis in adults is made on the basis of clinical signs and results of laboratory testing or imaging and must meet one of the following two criteria [61]. Criterion 1 Rales or dullness to percussion on physical examination of the chest and at least one of the following: New onset of purulent sputum or change in character of sputum Organisms cultured from blood Isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy
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Criterion 2 Chest radiograph that shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion and at least one of the following: New onset of purulent sputum or change in character of sputum Organisms cultured from blood Isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy Isolation of virus from or detection of viral antigen in respiratory secretions Diagnostic single antibody titer (immune globulin M [IgM]) or fourfold increase in paired sera (immune globulin G [IgG]) for pathogen Histopathologic evidence of pneumonia In 2005, a consensus panel developed a set of clinical diagnostic criteria for pneumonia [106]. The criteria include the presence of a new and persistent (more than 48 hours) infiltrate in addition to one of the following: Radiographic evidence of cavitation or necrosis Histopathologic evidence of pneumonia Positive pleural or blood culture for the same microorganism as that found in respiratory secretions Plus two of the following signs: Core temperature greater than 38.3 degrees Centigrade White blood cell count of more than 10,000 cells/mL Purulent tracheal secretions There are no compelling data to recommend a specific approach to diagnosing nosocomial pneumonia. For patients who are not receiving mechanical ventilation, collection of a sputum specimen should be attempted before antibiotic therapy is begun [109; 130]. Specimens for culture can be obtained by bronchoscopy with a protected specimen brush to limit contamination or by bron-
choalveolar lavage. The latter method has been found to lead to higher rates of treatment than that based on the CDC definition, but there are disadvantages to such invasive diagnostic testing, including cost, need for technical expertise, and the potential for false-negative results [109; 131]. The guideline developed by the American Thoracic Society/IDSA recommends collecting specimens from the lower respiratory tract for culture, noting that the specimens can be obtained by bronchoscopy or another means and that cultures can be quantitative or semiquantitative [79]. Treatment There is wide variation in treatment practices for nosocomial pneumonia, with one study finding that more than 100 different antibiotic regimens had been prescribed as initial treatment [108]. Treatment is complicated by two divergent needs: (1) the need for empiric therapy with a broad-spectrum antibiotic, to aid in reducing mortality rates; and (2) the need to avoid the indiscriminate use of antibiotics, to avoid the development of resistance. To address this complex issue, the strategy of de-escalation therapy was developed. With this treatment approach, a broad-spectrum antibiotic targeted to likely pathogens is administered, and the antibiotic regimen is altered once the results of cultures are known [111; 132]. This strategy has reduced the mortality rate while achieving an overall objective of a more judicious use of antibiotics [111; 133]. In one study, de-escalation led to a significantly lower mortality rate compared with either escalation therapy or therapy that was neither escalated nor de-escalated (17% compared with 43% and 24%, respectively) [108]. However, de-escalation therapy was used for only 22% of the patients. It has been emphasized that this approach, and empiric treatment of nosocomial pneumonia in general, calls for knowledge of the infection history of the healthcare facility and of individual patient units [106; 109; 134]. Microbiology laboratory reports can provide such details, and physicians should prescribe initial antibiotics that are likely to be active against these pathogens.
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The 2005 American Thoracic Society/IDSA guideline provides the following key recommendations for the treatment of nosocomial pneumonia [79]: Obtain a specimen from the lower respiratory tract for culture before beginning antibiotic therapy. Do not delay initiation of therapy for critically ill patients in order to obtain specimen. Prescribe early, appropriate, broad-spectrum, antibiotic therapy with adequate doses. Choose an empiric therapy regimen that includes agents from a different antibiotic class than what the patient has recently received. Use combination therapy for a specific pathogen judiciously and consider shortduration (five-day) therapy with an aminoglycoside in combination with a beta-lactam to treat pneumonia caused by Pseudomonas aeruginosa. Consider de-escalation of antibiotics once data are available on the results of cultures of specimens from lower respiratory tract cultures and the clinical response. Use a shorter duration of antibiotic therapy (seven to eight days) for patients with uncomplicated ventilator-associated pneumonia who have received appropriate therapy initially, have had a good clinical response and who have no evidence of infection with nonfermenting gramnegative bacilli. Ventilator-associated pneumonia is often caused by drug-resistant bacteria, and vancomycin has been thought to be the best treatment strategy [111]. However, the guideline also notes that linezolid may be useful for ventilator-associated pneumonia caused by MRSA, and that aerosolized antibiotics may be beneficial as adjunctive therapy against multidrug-resistant bacteria [79]. Other research has shown that linezolid improves survival and is associated with lower costs when compared with vancomycin for the treatment of pneumonia caused
by MRSA [129; 135; 136; 137; 138]. Colistin may be considered for ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter spp. [79]. INTrAVASCuLAr DEVICE-rELATED BLooDSTrEAM INFECTIoNS Bloodstream infections, such as septicemia and bacteremia, can develop from other types of nosocomial infections or infections at other sites in the body, but about half are caused by intravascular devices, primarily central venous catheters [2]. Bloodstream infections stemming from intravascular devices account for approximately 15% of all nosocomial infections, affecting approximately 1% of all hospitalized patients [155; 156]. It has been estimated that 5.3 infections occur per 1,000 catheter days in the intensive care unit. The costs of these infections are the highest among nosocomial infections, with an attributable mortality of 18%, or about 14,000 deaths each year [3; 157; 158; 159; 160; 161]. In addition, the costs of intravascular device-related bloodstream infections have increased with the rise in cases caused by resistant bacteria. These infections have gained even more attention because of the growing number of patients with central venous catheters in the community [162]. There are several types of intravascular catheters, and the risk of intravascular device-related bloodstream infections varies according to type. These catheters include: Peripheral venous catheters Peripheral arterial catheters Midline catheters Nontunneled central venous catheters Pulmonary artery catheters Pressure monitoring system catheters Peripherally inserted central venous catheters Tunneled central venous catheters Totally implantable devices
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The type most often associated with intravascular device-related bloodstream infections is the nontunneled central venous catheter, accounting for approximately 90% of all intravascular device-related bloodstream infections [17]. The risk is higher when the catheter is inserted in the internal jugular vein [17]. The risk for peripheral arterial catheters may also be high, but the risk with peripheral venous catheters is low (about 1%) [17]. Other risk factors are related to the patients health status (severity of illness, presence of burns or surgical wounds, compromised immune system, nutritional status) and the length of time the catheter is in place. Causes and Common Pathogens Intravascular device-related bloodstream infections are transmitted by both endogenous and exogenous routes. Lack of aseptic technique can cause contamination of the catheter from either the patients skin or the caregivers hands, with microorganisms entering the bloodstream by moving along the catheter-tissue interface to the catheter tip, usually during the first week after insertion [2; 17]. Contamination of the hub of the catheter can also lead to intravascular device-related bloodstream infections; in fact, for devices that have been left in place for more than 30 days, the infection is most likely a result of contamination of the hub [17]. Contamination of infusion fluid is rare, but is the most common cause of epidemic intravascular device-related bloodstream infection [2]. In 2002, the CDC reported that the most common pathogens, for the period of 1992 to 1999, were coagulase-negative staphylococci, enterococci, and gram-negative rods [158]. In a more recent report, based on data from the NNIS for the period of 19862003, gram-negative bacilli were among the most common microorganisms causing intravascular device-related bloodstream infections, although the rate has decreased over the past two decades [85]. Other common bacterial pathogens include S. aureus, K. pneumoniae, E. coli, and P. aeruginosa [2; 17; 158]. Fungal infection with Candida has also been reported to be the cause of 8% of intravascular device-related bloodstream infections
[158]. Creating further challenge to treatment is the increase in VRE, which rose from 0.5% in 1989 to 25.9% in 1999 [158]. Prevention As with preventive approaches for all nosocomial infections, handwashing and aseptic technique are paramount. The CDC updated its guideline on the prevention of intravascular device-related bloodstream infections in 2002, with emphasis on the following points [158]: Education and training for healthcare providers who insert and maintain catheters Using maximal sterile barrier precautions during central venous catheter insertion Using a 2% chlorhexidine preparation for skin antisepsis Avoiding routine replacement of central venous catheters Using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies Despite the clear guideline, a study has shown that a low percentage of intensive care units have incorporated these practices into their policies and procedures. In a study of 25 intensive care units in 10 academic tertiary-care hospitals, 80% of the units had written policies for insertion of a central venous catheter. However, only 28% of units had a policy regarding the use of maximal sterile barrier precautions, and 52% had formal educational programs about insertion practices [163]. The CDC guideline recommends the use of maximum sterile barrier precautions, defined as the use of sterile gloves, long-sleeved gowns, a nonsterile mask (and sometimes a nonsterile cap), and a fullsize drape during insertion of the catheter [158]. Compared with use of standard precautions (gloves and a small sterile drape), maximal barrier precautions have reduced colonization [161]. In addition, two prospective studies showed that infection was 2.2 to 6.3 times more likely when maximal barrier precautions were not used [164; 165]. The use of a
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maximal sterile barrier is challenged by the additional time needed to prepare for catheter insertion, the costs of precaution materials, and the time and expense to train healthcare providers in the proper technique [161]. The appropriate aseptic technique has been determined to be a 2% chlorhexidine gluconate solution rather than other antiseptic agents, such as povidone-iodine solutions, and the updated guideline from the CDC supports the use of this solution [158]. In a meta-analysis of eight studies (4,143 catheters, primarily central line catheters), the chlorhexidine solution was found to reduce the risk for bloodstream infection by 49% [166]. In a subsequent study, use of this solution led to a 1.6% decrease in the rate of bloodstream infection, a 0.23% decrease in the incidence of death, and a cost savings of $113 per catheter used compared with povidone-iodine solutions [167]. The cost-benefit of a chlorhexidine solution has been confirmed, with an estimated potential savings of $275 million to $1.97 billion each year in the United States [168]. Most intravascular device-related bloodstream infections develop at the site of insertion, due to the density of skin flora [158]. Rates of infection vary according to insertion site, with catheters in the internal jugular vein being associated with a greater risk of infection than catheters in the subclavian vein [158; 164; 169]. A 2005 study indicated that the site of insertion was not a risk factor for infection when experienced or trained healthcare workers inserted the catheters [170]. However, such experience will not always be the norm, and the subclavian vein has been recommended by the CDC and others as the preferred site when possible [158; 171].
Another strategy to prevent infection has been the development of central venous catheters with antimicrobial coatings. These coatings have included a combination of chlorhexidine and silver sulfadiazine and a combination of minocycline and rifampin [172]. Both types of catheters are associated with a significantly lower rate of infection than that associated with standard catheters. When compared with each other, catheters impregnated with minocycline and rifampin were 12 times less likely to cause bloodstream infections than those coated with chlorhexidine and silver sulfadiazine [161]. The chlorhexidine-silver sulfadiazine coating has since been enhanced and was shown to significantly reduce bacterial colonization, with a trend toward fewer bloodstream infections [173]. Each coating adds to the cost of the catheter, and cost-effective analyses are necessary. However, the resultant cost savings associated with the reduction in infection should also be considered. For example, one study found that use of catheters impregnated with minocycline and rifampin in the medical and surgical intensive care units led to significant decreases in nosocomial bloodstream infections, catheter-related infections, and length of stay in the ICU and the hospital, with a resultant net savings of at least $1.4 million [174]. The IHI has also developed a central line bundle consisting of five preventive measures that should be implemented together for maximum effectiveness [171]. These measures are: Compliance with appropriate hand hygiene Use of maximal barrier precautions Use of 2% chlorhexidine solution for skin antisepsis Selection of optimal site for the catheter, with the subclavian vein as the preferred site for nontunneled catheters Daily review of the need for the line, with prompt removal if line is deemed unnecessary
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As with its proposed ventilator bundle, the IHI developed a publication to provide practical suggestions for implementing the bundle in the healthcare setting [171]. The IHI recommends that nursing staff be empowered to enforce use of a checklist to ensure that all processes related to placement of a central line are executed for each line placement. Specific recommendations to help effect change include [171]: Hand Hygiene Include hand hygiene as part of the checklist for placement of central lines. Keep soap/alcohol-based hand hygiene dispensers prominently placed, and make universal precautions equipment, such as gloves, available only near hand sanitation equipment. Post reminder signs at the entry and exits to patient rooms. Initiate a campaign using posters including photos of celebrated hospital physicians/ employees recommending hand hygiene. Create an environment in which reminding each other about hand hygiene is encouraged. Maximal Barrier Precautions Include maximal barrier precautions as part of the checklist for placement of central lines. Keep equipment stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions. If a full-size drape is not available, apply two drapes to cover the patient or consult with the operating room staff to determine how to obtain full-size sterile drapes, as they are used routinely in surgical settings.
Chlorhexidine Skin Antisepsis Include chlorhexidine antisepsis as part of the checklist for placement of central lines. Include chlorhexidine antisepsis kits in carts or grab bags storing central line equipment. (Many prepared central line kits include povidone-iodine kits, and these must be avoided.) Ensure that the solution dries completely before attempting to insert the central line. Selection of Optimal Insertion Site Include optimal site selection as part of the checklist for placement of central lines, with room to note appropriate contraindications (e.g., bleeding risks). Daily Review of Need for Central Line Include daily review of the need for the central line as part of multidisciplinary rounds. Include assessment for removal of central lines as part of daily goal sheets. Record time and date of line placement for record-keeping purposes and evaluation by staff to aid in decision making.
In order to prevent intravascular catheter-related infections, the CDC and HICPAC recommend prompt removal of any intravascular catheter that is no longer essential. However, central venous or arterial catheters should not be routinely replaced solely for the purposes of reducing the incidence of infection. (http://www.guidelines.gov/summary/summary. aspx?doc_id=3387. Last accessed January 23, 2007.) Strength of recommendation: IA/IB (Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies, or experimental, clinical, or epidemiologic studies and a strong theoretical rationale)
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Case Example In 2003, a 14-member multidisciplinary team at Florida Hospital, Orlando, planned an approach to decrease the rate of central venous catheter-related blood stream infections by 20% [215]. The initiative led to a greater than 40% decrease in the rate, from 0.64 to 0.36 in 2004. In addition, from January through July of 2005, the number of cases decreased by 17, exceeding the target for the entire year (16 cases). The approach that led to this substantial reduction included the following specific measures: Implemented a policy banning artificial nails for staff providing bedside care Distributed self-learning packet on bloodstream infections (with post-test) to nursing staff Created customized trays with maximal barrier precautions, 2% chlorhexidine with alcohol skin prep, and antimicrobial catheter for use in the emergency department and inpatient nursing units Introduced campaign on hand hygiene Drafted criteria for physician privileges to insert central venous catheters Revised infection control policy and procedure to align with changes in practice Published articles in internal newsletters for physicians and nurses Developed standard operating procedures for distribution of trays to ensure that emergency department and inpatient nursing units received trays with sterile garb Identified need to error proof the customized trays by including maximal barrier precautions in all customized trays (as anesthesia trays, which do not include the maximal barrier precautions, are occasionally distributed to those areas) Included IHI checklist with each tray
Diagnosis As defined by the CDC, bloodstream infections fall into two categories: laboratory-confirmed infection and clinical sepsis. For a diagnosis of laboratoryconfirmed bloodstream infection, one of the two following criteria must be met [61]. Criterion 1 Recognized pathogen found on one or more blood cultures and organism cultured from blood is not related to an infection at another site Criterion 2 At least one of the following signs or symptoms: Fever (>38 degrees Centigrade) Chills Hypotension and signs and symptoms and positive laboratory results are not related to an infection at another site and at least one of the following: Common skin contaminant (e.g., diphtheroids, Bacillus spp., Propionibacterium spp., coagulase-negative staphylococci, or micrococci) is cultured from two or more blood cultures drawn on separate occasions Common skin contaminant (e.g., diphtheroids, Bacillus spp., Propionibacterium spp., coagulase-negative staphylococci, or micrococci) is cultured from at least one blood culture from a patient with an intravascular line, and the physician institutes appropriate antimicrobial therapy Positive antigen test on blood (e.g., Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, or group B Streptococcus) A diagnosis of clinical sepsis in an adult is made when the following criterion is met [61]:
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Criterion At least one of the following clinical signs or symptoms with no other recognized cause: Fever (>38 degrees Centigrade) Hypotension (systolic pressure <90 mm Hg) Oliguria (<20 cm3/hr) and blood culture not done or no organisms or antigen detected in blood and no apparent infection at another site and physician institutes treatment for sepsis In a study evaluating these definitions, only 29% of primary bloodstream infections were microbiologically documented, leading the authors to conclude that laboratory-based surveillance underestimates the actual incidence of infection [155]. Clinical sepsis is diagnosed primarily by signs of infection at the site of insertion, as well as other criteria as noted by the CDC [2; 155]. There are several approaches to diagnosing an intravascular device-related bloodstream infection. A meta-analysis of 51 studies published between 1966 and 2004 was designed to identify which method was the most accurate [157]. The studies had involved the eight most commonly used diagnostic methods: culture (qualitative, semiquantitative, or quantitative) of a catheter segment; culture (qualitative or quantitative) of blood obtained through the catheter; paired quantitative cultures (blood obtained through the catheter as well as from a peripheral site); differential time to positivity (monitoring of cultures of blood obtained through the catheter and from a peripheral site); and acridine orange leukocyte cytospin. The paired cultures method was the most accurate, with a pooled specificity of 99%, followed by qualitative culture of blood drawn through the catheter and acridine orange leukocyte cytospin [157].
Treatment The authors of the consensus guidelines advise that the decision to remove a tunneled catheter or implanted device suspected to be the source of bacteremia or fungemia should be based on the following factors [2; 80; 175]: Underlying health status of the patient Type of catheter Strength of the evidence that the catheter is the source of the infection Responsible pathogens Presence of local or systemic complications Established guidelines recommend that nontunneled central venous catheters should be removed in most cases of bacteremia or fungemia [80]. Antibiotic therapy alone has resolved 80% of infections caused by coagulase-negative staphylococcal bacteria, but in cases of infection with S. aureus or Candida, infection has persisted when the catheter has been maintained [175]. One strategy was developed in an attempt to retain the catheter. With so-called antibiotic lock therapy, antibiotics are instilled through the catheter after injection of an anticoagulant, locking a high concentration of the antibiotic in the lumen [2; 175]. This approach is used in combination with systemic antibiotic therapy, and the antibiotics used have included vancomycin, cefazolin, and clindamycin. Fluconazole and amphotericin B have been used occasionally for infection with Candida spp., and another flush solution (low concentrations of minocycline and EDTA) has demonstrated activity against staphylococci, gram-negative bacilli and Candida spp. [175]. Early empiric antifungal therapy is important if infection with Candida is suspected, as delayed treatment has been associated with higher mortality [176].
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TrEATMENT oF INTrAVASCuLAr DEVICE-rELATED BLooDSTrEAM INFECTIoNS Pathogen Staphylococcus aureus Sensitive to methicillin Resistant to methicillin Resistant to vancomycin Coagulase-negative staphylococci Sensitive to methicillin Resistant to methicillin Escherichia coli and Klebsiella spp. Enterobacter species and Serratia marcescens Acinetobacter baumannii Pseudomonas aeruginosa Candida albicans or Candida spp. Corynebacterium spp. Source: [80] Preferred Antimicrobial Agent Penicillinase-resistant penicillin Vancomycin Linezolid or quinupristin/dalfopristin Penicillinase-resistant penicillin Vancomycin Third-generation cephalosporin Carbapenem Ampicillin/sulbactam or carbapenem Third or fourth-generation cephalosporin or carbapenem or antipseudomonal beta-lacatam plus aminoglycoside Amphotericin B or fluconazole Vancomycin Table 9
The guideline for management of intravascular device-related bloodstream infection suggests antimicrobial treatment according to the pathogen (Table 9) [80]. Empiric antibiotic therapy should be selected according to likely pathogens, with vancomycin recommended as initial treatment for coagulase-negative staphylococci; this treatment should be changed to semisynthetic penicillin if the identified pathogen is sensitive [80]. Vancomycin should not be used as a front-line treatment for infections with S. aureus. If fever or other signs of infection persist after removal of the catheter, the patient should be evaluated for other infection, especially endocarditis. Bacterial endocarditis has been found in 25% of patients with intravascular device-related bloodstream infection caused by S. aureus [2; 175]. The findings of one study suggested that patients with MRSA bacteremia and underlying chronic liver disease were at higher risk for endocarditis [177]. Transesophageal echocardiogram can aid in determining the presence of this infection.
GASTroINTESTINAL TrACT INFECTIoNS Gastrointestinal tract infections in adults in the healthcare setting are caused primarily by C. difficile, a pathogen that causes diarrhea in about 30% of hospitalized adults [178; 179]. The prevalence and severity of C. difficile has increased significantly over the past few years, and more than twice as many cases were documented on hospital discharge records in 2003 than in 1996 (178,000 compared with 82,000) [180]. These infections can have a substantial impact [66; 178; 180; 181]. C. difficileassociated disease may occasionally develop in the community, but it is most commonly found in hospitals and long-term facilities [182]. Within these settings, epidemic strains may be transmitted [180; 183]. In fact, one strain of C. difficile was associated with outbreaks in 11 states, as well as in Canada, in the early 2000s [181; 183].
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In some patients, only colonization with C. difficile occurs, but usually, the production of toxins (A and B) leads to inflammation, secretion of mucous and fluid, and damage to the mucosa, resulting in diarrhea or colitis [181]. Disease can further progress to toxic megacolon, sepsis with or without intestinal perforation, and death [180; 183]. Causes C. difficile is an exogenous infection that is transmitted through the fecal-oral route. Spread occurs through contact with surfaces (commodes, bath tubs), devices (rectal thermometers), or materials that are contaminated with feces. The primary risk factor for infection with C. difficile is antibiotic use; up to 90% of nosocomial infections with C. difficile are associated with use of an antibiotic [181; 184]. In one study, clindamycin was associated with a 3.9-fold likelihood of the development of C. difficile-associated disease, and first-generation cephalosporins and fluoroquinolones have also been implicated [179; 184; 185]. Aminoglycosides have not been associated with the infection [181]. In addition to antibiotic use, several other risk factors have been identified, with patients older than 65 years of age at greatest risk [179; 180; 181]. Prevention and Control As mentioned, the primary step in preventing infection with C. difficile is the judicious use of antibiotics. Once infection develops in a patient, barrier precautions will help to reduce the risk of transmission. A review of studies demonstrated that the incidence of C. difficile was reduced by the implementation of enhanced barrier precautions [178]. These precautions include use of gowns and gloves for all contact with patients who were either colonized or infected with C. difficile, use of dedicated or disposable equipment, and cohorting of patients and/or staff. In addition to barrier precautions, appropriate handwashing is critical. Soap and water should be used rather than alcohol-based handrubs, as alcohol is not effective at killing C. difficile spores [183].
All surfaces and devices that may be contaminated should be cleaned and disinfected according to the guideline developed by the CDC [18]. A study of four disinfectants showed that acidified nitrite and peracetyl ions were active against C. difficile spores and were environmentally safe. A 70% alcohol solution was not effective [186]. Diagnosis According to the CDC definition, the clinical sign of gastrointestinal infection is watery diarrhea for more than 12 hours [61]. Other symptoms include fever, nausea, vomiting, abdominal pain or tenderness, and loss of appetite [181]. A diagnosis of gastroenteritis is based on one of the following two criteria [61]. Criterion 1 Acute onset of diarrhea (liquid stools for more than 12 hours) with or without vomiting or fever (>38 degrees Centigrade) and no likely noninfectious cause (e.g., diagnostic tests, therapeutic regimen, acute exacerbation of a chronic condition, or psychologic stress) Criterion 2 At least two of the following signs or symptoms with no other recognized cause: Nausea Vomiting Abdominal pain Headache
and at least one of the following: Enteric pathogen cultured from stool or rectal swab Enteric pathogen detected by routine or electron microscopy Enteric pathogen detected by antigen or antibody assay on blood or feces Evidence of an enteric pathogen detected by cytopathic changes in tissue culture (toxin assay) Diagnostic single antibody titer (IgM) or fourfold increase in paired sera (IgG) for pathogen
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There are several diagnostic tests to detect C. difficile, and they vary in terms of sensitivity, specificity, and turnaround times. Enzyme-linked immunosorbent assays are used most often; they are easy to perform, have a turnaround time of about two hours, and have a sensitivity of 80% to 95% [181]. Tissue cytotoxic assay has the highest sensitivity, but the rate of false-positive results is high, technical expertise is needed, and the turnaround time is 48 hours [181]. Because of the high rate of colonization with C. difficile, culture should be done on a specimen of loose, watery stool [181]. Treatment The most important step in treating C. difficileassociated diarrhea is to discontinue the offending antibiotic. This approach alone will lead to resolution of diarrhea in approximately 25% of patients [181]. Antibiotic treatment of the diarrhea should not begin until the culture results are known. Metronidazole is most often recommended as first-line therapy, although the response to this treatment strategy has decreased to approximately 78% [179; 181]. Vancomycin was once considered to be the standard of care, but its use has been limited because of the risk of resistance. However, it is used as so-called rescue therapy and for severe disease [179; 181].
Viral Infection of the Gastrointestinal Tract Another group of gastrointestinal tract infections are noroviruses, a group of highly contagious viruses previously referred to as Norwalk-like viruses [187]. These viruses gained increased attention through highly publicized outbreaks on cruise ships. The viruses are transmitted primarily through the fecal-oral route and thrive in a small environment populated by many people. In the healthcare setting, transmission occurs through person-to-person contact, fecally contaminated food or water, and hand transfer of the virus to the oral mucosa [187]. The CDC notes that 30% of norovirus infections may be asymptomatic [187]. The clinical symptoms associated with norovirus infection include acute-onset vomiting, nausea, watery diarrhea, and abdominal cramps. Other common symptoms are myalgia, headache, and low-grade fever. Symptoms usually last one to three days. Dehydration is the most common complication, and administration of intravenous fluids may be necessary [187]. The diagnosis of norovirus infection should begin by ruling out other causes of gastroenteritis and assessing the clinical manifestations, as diagnostic laboratory methods are limited. For optimum identification of the virus in the stool, a specimen should obtained within 48 to 72 hours after the onset of symptoms. The CDC recommends that if an outbreak is suspected, specimens should be sent to the CDC or a state public health laboratory at which reverse transcription-polymerase chain reaction (RT-PCR) assays are available. Standard precautions should be used for patients who are suspected of having norovirus infection, and appropriate hand hygiene is essential. Barrier protection (gloves, gowns, and masks) should be used when caring for patients with the virus and when cleaning contaminated areas. It may be helpful to cohort patients suspected of having the virus.
According to the Infectious Diseases Society of America, the critical initial treatment of infectious diarrhea must include rehydration, which can be accomplished with an oral glucose or starch-containing electrolyte solution in the vast majority of cases. (http://www.guidelines.gov/summary/summary. aspx?doc_id=2791. Last accessed January 23, 2007.) Strength of recommendation/Level of Evidence: AI (Good evidence from at least one properly randomized, controlled trial to support a recommendation for use)
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No hospital disinfectants registered by the U.S. Environmental Protection Agency (EPA) have specific claims for activity against noroviruses. The CDC recommends that, in the event of an outbreak, chlorine bleach (in a dilution of one part household bleach to 50 parts water) should be used to clean hard, non-porous, environmental surfaces [187]. Disinfection with heat (at a temperature of at least 60 degrees Centigrade) is recommended for items that cannot be cleaned with chemical disinfectants.
INFECTIoN CoNTroL
The development of formal infection control programs in hospitals and other healthcare facilities was spurred by the JCAHO accreditation standards for infection control, published in 1976. According to the standards, accredited facilities must have a program for the surveillance, prevention, and control of nosocomial infections [2]. In 1985, the CDC Study on the Efficacy of Nosocomial Infection Control noted that success was associated with four components: an effective hospital epidemiologist, one infection control practitioner for every 250 beds, active surveillance mechanisms, and ongoing control efforts. These programs led to a one-third reduction in the rate of nosocomial infection [188]. An infection control program is usually overseen by a committee chaired by an infectious disease physician and consisting of staff representing departments throughout the facility, such as nursing, pharmacy, clinical microbiology, central sterilization services, housekeeping, maintenance, food services, and laundry services. Among the responsibilities of an infection control program are to:
Conduct surveillance of nosocomial infections. Develop policies regarding prevention and control, such as hand hygiene and precautions. Ensure adherence to standards for environmental services. Establish a program to monitor and evaluate antimicrobial therapy. Provide education to healthcare personnel about adherence to infection control policies. Develop guidelines for outbreak preparedness. The policies and procedures in each of these areas, as well as guidelines for adherence, should be documented in an infection control manual. All physicians and staff within a healthcare facility have responsibility for helping to advance infection control goals. Physicians should assume the following responsibilities [1]: Protect their patients from other infected patients or staff. Comply with the practices approved by the infection control committee. Obtain appropriate microbiologic specimens when infection is suspected or present. Notify the infection control committee about confirmed cases of nosocomial infection. Comply with the institutions recommendations regarding the use of antibiotics. Educate patients, visitors, and staff about techniques to prevent the transmission of infection.
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As direct providers of care in a healthcare facility, the nursing staff plays a substantial role in carrying out infection control practices. Nursing administrators should promote the development and enhancement of nursing techniques, review nursing policies regarding aseptic techniques, and offer educational training programs on best practices [1]. Nurses on patient care units have the following responsibilities [1]: Comply with established infection control practices. Monitor aseptic techniques, including handwashing and use of isolation. Report evidence of infection immediately to the attending physician. Initiate patient isolation and order culture specimens when infection is suspected and a physician is not immediately available. Limit patient exposure to infections from others (visitors, hospital staff, other patients, or equipment used for diagnosis or treatment). Community hospitals have had success with participating in an infection control network. In 12 community hospitals in North Carolina and Virginia that joined such a network, there were significant decreases in the annual rates of nosocomial bloodstream infections (23%), nosocomial infection and colonization with MRSA (22%), ventilator-associated pneumonia (40%), and exposure of staff to bloodborne pathogens (18%) [189]. The cost savings were also substantial. Most prevention and control policies focus on general measures, such as surveillance, hand hygiene, the use of precautions and isolation techniques, standards for environmental services, monitoring and evaluation of antimicrobial therapy, and education of healthcare personnel. These strategies are simple yet have a tremendous impact on reducing rates of nosocomial infection.
SurVEILLANCE Surveillance is an essential component of an infection control program. The infection control team has traditionally conducted surveillance through open communication with the nursing staff and physicians and meticulous review of patient records and microbiology results. The advent of electronic health systems has enabled some infection control programs to create algorithm-driven surveillance [2]. In addition, newer technology is adding to changes in the way surveillance is conducted. An electronic, laboratory-based marker has been developed and compared with traditional medical record review and hospital-wide detection methods (Study on the Efficacy of Nosocomial Infection Control chart review and intensive care unit detection by NNIS techniques). Analysis with the marker was significantly better than the hospital-wide detection methods and had sensitivity comparable to medical record review [190]. The infections most commonly targeted for surveillance are those associated with substantial costs in terms of morbidity, mortality, or economics, and those difficult to treat [2]. In addition, infections with a predilection for epidemics are a focus. The data gathered should be evaluated in relation to regional and national norms, and temporal trends should also be noted. Continuing analysis of the data allows the infection control team to evaluate the efficacy of programs designed to enhance compliance with hospital-wide strategies to prevent nosocomial infections. The infection control team can compare its data to that for other hospitals by reviewing data in reports from the NNIS system. However, care must be taken in interpreting comparisons as the approximately 350 hospitals that participate in the NNIS system are not considered to be a representative sample and adjustments for the wide range in risk factors are not always made [2].
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HAND HYGIENE As has been established, hand hygiene is the most important preventive measure in hospitals. A CDC Fact Sheet states that improved adherence to hand hygiene has been shown to terminate outbreaks in healthcare facilities, to reduce transmission of antimicrobial resistant organisms, and to reduce overall infection rates [215]. Studies have borne out this fact, with reductions in overall rates of nosocomial infections, including those caused by MRSA and VRE [191; 192; 193; 194]. However, compliance with hand hygiene has been low, ranging from 16% to 81%, with most reports in the 30% to 50% range [3; 9; 195]. The reasons given for the lack of compliance have included inconvenience, understaffing, damage to skin, denial about risks, forgetfulness, and belief that gloves are sufficient [2; 9; 195]. The development of effective alcohol-based handrub solutions has addressed many of these concerns, and the 2002 CDC guideline on hand hygiene recommends the use of such solutions on the basis of several advantages, including [9]: Better efficacy against both gram-negative and gram-positive bacteria, mycobacteria, fungi, and viruses than either soap and water or antimicrobial soaps (such as chlorhexidine) More rapid disinfection than other hand hygiene techniques Less damaging to skin Time savings (18 minutes compared with 56 minutes per eight-hour shift) The guideline suggests that healthcare facilities promote compliance by making the handrub solution available in dispensers in convenient locations (such as the entrance to patients room or at the bedside) and provide individual pocket-sized containers [9]. The handrub solution may be used in all clinical situations except for when hands are visibly dirty or are contaminated with blood or body fluids. In such instances, soap (either antimicrobial or nonantimicrobial) and water must be used.
As part of its guideline, the CDC asked healthcare facilities to develop a system for measuring improvement in adherence to its recommendations. Studies have demonstrated that alcohol-based handrub solutions have increased compliance [192; 193; 194; 196]. Frequent performance feedback has also been shown to enhance compliance, and other interventions have included automatic sinks, mass campaigns (posters, buttons, newsletters), education, and behavioral modification programs [191]. Most of these interventions have shown significant improvement in hand hygiene, although no single strategy has shown hand hygiene to remain improved over the long-term [196]. Because enhancing compliance with recommendations for hand hygiene requires behavioral changes, it has been suggested that input from behavioral and social sciences may aid in the effort [197]. Studies have also suggested that education programs about hand hygiene may be more effective if patterns of care and levels of risk are incorporated into recommendations [198]. The cost-effectiveness of efforts to enhance hand hygiene was evaluated in one study; the cost of a patient education campaign was weighed against an estimated cost of $5,000 for each nosocomial infection. The annual savings was approximately $57,600 for a 300-bed hospital with 10,000 admissions annually [199]. The JCAHO mandates that hospitals and other healthcare facilities comply with the Level I recommendations in the CDC guideline for hand hygiene (Table 10) [9]. These recommendations address the indications for handwashing and hand antisepsis, the technique for hand hygiene, surgical hand antisepsis, selection of hand-hygiene agents, skin care, educational and motivational programs for healthcare workers, and administrative measures.
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CDC LEVEL 1 rECoMMENDATIoNS For HAND HYGIENE Indications for Handwashing and Hand Antisepsis When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water [IA].* If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands in all other clinical situations [IA]. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations [IB]. Decontaminate hands before having direct contact with patients [IB]. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter [IB]. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure [IB]. Decontaminate hands after contact with a patients intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) [IB]. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled [IA]. Decontaminate hands after removing gloves [IB]. Before eating and after using a restroom, wash hands with a nonantimicrobial soap and water or with an antimicrobial soap and water [IB]. Technique for Hand Hygiene When decontaminating hands with an alcohol-based handrub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry [IB]. Follow the manufacturers recommendations regarding the volume of product to use. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis [IB]. Liquid, bar, leaflet, or powdered forms of plain soap are acceptable when washing hands with a nonantimicrobial soap and water [II]. Surgical Hand Antisepsis Use either an antimicrobial soap or an alcohol-based handrub with persistent activity before donning sterile gloves to perform surgical procedures [IB]. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2-6 minutes. Longer scrub times are not necessary [IB]. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturers instructions. Before applying the alcohol solution, prewash hands and forearms with a nonantimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves [IB]. Selection of Hand-Hygiene Agents Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift [IB]. This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel. To maximize acceptance of hand-hygiene products by healthcare workers, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand-hygiene products should not be the primary factor influencing product selection [IB]. Do not add soap to a partially empty soap dispenser. This practice of topping off dispensers can lead to bacterial contamination of soap [IA]. Table 10 continues on next page
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CDC LEVEL 1 rECoMMENDATIoNS For HAND HYGIENE (Continued) Skin Care Provide healthcare workers with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing [IA]. Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution [IB]. other Aspects of Hand Hygiene Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) [IA]. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur [IC]. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients [IB]. Educational and Motivational Programs for Healthcare Workers Monitor healthcare workers adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance [IA]. Administrative Measures Make improved hand-hygiene adherence an institutional priority and provide appropriate administrative support and financial resources [IB]. Implement a multidisciplinary program designed to improve adherence of healthcare workers to recommended hand-hygiene practices [IB]. As part of a multidisciplinary program to improve hand-hygiene adherence, provide healthcare workers with a readily accessible alcohol-based handrub product [IA]. To improve hand-hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol-based handrub available at the entrance to the patients room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by healthcare workers [IA]. Store supplies of alcohol-based handrubs in cabinets or areas approved for flammable materials [IC]. *Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with nonantimicrobial
soap and water. Because they are not as effective as alcohol-based handrubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of healthcare workers, they are not a substitute for using an alcohol-based handrub or antimicrobial soap [IB].
Source: Reprinted with permission from Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. MMWR. 2002; 51(RR16): 1-44. Table 10
Strength of recommendations
rating IA IB IC II Definition Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale Required for implementation, as mandated by federal or state regulation or standard Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale
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The CDC guideline states that healthcare workers must decontaminate their hands in the following instances: Before having direct contact with patients Before putting on sterile gloves when inserting a central intravascular catheter Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure After contact with a patients intact skin After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. After removing gloves The guideline also states that healthcare workers who have direct contact with high-risk patients may not wear artificial fingernails or extenders. In addition, gloves must be worn when there is potential for contact with blood or other potentially infectious materials, mucous membranes, or nonintact skin. Gloves should be changed after use for each patient. Case Example The HealthEast Care System in St. Paul, Minnesota, partnered with 3M Health Care to initiate a project to improve compliance with appropriate hand hygiene in a 20-bed medical-surgical intensive care unit [90]. The project led to significantly improved compliance, increasing from 36% to 70%, with a corresponding significant increase in the volume of hand sanitizer used. The nine-member team achieved the improvement by making the following changes [90]: Updated hand hygiene policy to reflect current CDC Guidelines and HealthEast expected practice Developed a theme around creating champions of excellent hand hygiene as a patient safety initiative Designed a CHAMPS logo, an acronym meaning Clean Hands Are Making Patients Safer
Used CHAMPS logo golf towels as a recognition award for personnel who had become champions Identified and educated infection control liaisons/staff champions on the unit Identified and educated physician champions on the unit Engaged staff, physicians, and administration by developing a hand hygiene pledge banner that was signed by all hospital and unit leaders/champions and posted in the unit Developed hand hygiene champion posters depicting staff and physicians who work on the unit Provided targeted training during staff meetings and unit reports Updated site and unit orientation to include a more engaging hand hygiene message Provided evidence-based education with a physician champion during quarterly critical care education Developed a learning packet with pretest and post-test assessment Developed a computer module addressing hand hygiene best practices and supporting rationale Provided monthly theme posters for awareness and weekly fact/fiction informational flyers Created a screen saver hand hygiene message on all unit computer monitors and changed it periodically Collected environmental and personnel cultures as a part of an education/awareness initiative Implemented games with prizes, including a question of the week Implemented a if you touch this, clean your hands awareness using Post-It note reminders Conducted an environmental assessment with staff and physicians for location/accessibility of hand hygiene supports, and implemented a master plan for best locations on the unit as well as on portable equipment
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Created a housekeeping hand hygiene support verification as part of daily cleaning checklist Trialed and implemented a new sanitizing soap on the unit that was then implemented throughout the hospital Provided pocket size hand sanitizer to staff and physicians Developed a patient/visitor hand hygiene brochure and education/awareness plan to include the admission packet and the family lounges Posted a message on the white board in each room, Its OK to Ask, reminding patients and visitors of the importance of hand hygiene and encouraged them to remind healthcare personnel PrECAuTIoNS AND ISoLATIoN TECHNIquES In 1996, the CDC issued a guideline for isolation precautions in hospitals, which synthesized a variety of recommendations for precautions based on the type of infection and the route of transmission. As defined by the CDC, Standard Precautions represented measures that should be followed for all patients in a healthcare facility, regardless of diagnosis or infection status. Standard Precautions apply to blood; all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; nonintact skin; and mucous membranes [200]. For patients who are known to have or are highly suspected to have colonization or infection, Contact Precautions should be followed. This type of precaution is designed to reduce exogenous transmission of microorganisms through direct or indirect contact from healthcare workers or other patients. Airborne Precautions are used for patients who have or are highly suspected of having infection that is spread by airborne droplet nuclei, such as tuberculosis, measles, or varicella. Droplet Precautions target infections that are transmitted through larger droplets generated through talking, sneezing, or coughing, such as invasive Haemophilus influenzae type b disease, diphtheria (pharyngeal), pertussis, group A streptococcal pharyngitis, influenza, mumps, and rubella [200].
The CDC has described all the elements involved in the four types of precautions, including hand hygiene; the use of gloves, gown, and face protection; the handling of patient-care equipment; environmental services; occupational health; and placement of the patient. The following sections describing the precautions used to reduce the risk of transmission of nosocomial infections are reprinted from Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Cont Hosp Epidemiol. 1996;17:53-80. Standard Precautions Handwashing Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent crosscontamination of different body sites. Use a plain (nonantimicrobial) soap for routine handwashing. Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (e.g., control of outbreaks or hyperendemic infections), as defined by the infection control program. Gloves Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.
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Mask, Eye Protection, Face Shield Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Gown Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible, and wash hands to avoid transfer of microorganisms to other patients or environments. Patient-Care Equipment Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that single-use items are discarded properly. Environmental Control Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being followed. Linen Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and that avoids transfer of microorganisms to other patients and environments.
Occupational Health and Bloodborne Pathogens Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of a needle toward any part of the body; rather, use either a one-handed scoop technique or a mechanical device designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers, which are located as close as practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable. Patient Placement Place a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in a private room. If a private room is not available, consult with infection control professionals regarding patient placement or other alternatives. Contact Precautions (in addition to Standard Precautions) Patient Placement Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, consider the epi-
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demiology of the microorganism and the patient population when determining patient placement. Consultation with infection control professionals is advised before patient placement. Gloves and Handwashing In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, nonsterile gloves are adequate) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). Remove gloves before leaving the patients room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patients room to avoid transfer of microorganisms to other patients or environments. Gown In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean, nonsterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patients room, or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. Remove the gown before leaving the patients environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments. Patient Transport Limit the movement and transport of the patient from the room to essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.
Patient-Care Equipment When possible, dedicate the use of noncritical patient-care equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient. Airborne Precautions (in addition to Standard Precautions) Patient Placement Place the patient in a private room that has (1) monitored negative air pressure in relation to the surrounding areas; (2) 6 to 12 air changes per hour; and (3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital. Keep the room door closed and the patient in the room. When a private room is not available, place the patient in a room with a patient who has active infection with the same microorganism, unless otherwise recommended, but with no other infection. When a private room is not available and cohorting is not desirable, consultation with infection control professionals is advised before patient placement. Respiratory Protection Wear respiratory protection (N95 respirator) when entering the room of a patient with known or suspected infectious pulmonary tuberculosis. Susceptible persons should not enter the room of patients known or suspected to have measles (rubeola) or varicella (chickenpox) if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have measles (rubeola) or varicella, they should wear respiratory protection (N95 respirator). Persons immune to measles (rubeola) or varicella need not wear respiratory protection.
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Patient Transport Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a surgical mask on the patient, if possible. Droplet Precautions (in addition to Standard Precautions) Patient Placement Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection. When a private room is not available and cohorting is not achievable, maintain spatial separation of at least 3 feet between the infected patient and other patients and visitors. Special air handling and ventilation are not necessary, and the door may remain open. Mask In addition to wearing a mask as outlined under Standard Precautions, wear a mask when working within 3 feet of the patient. (Logistically, some hospitals may want to implement the wearing of a mask to enter the room.) Patient Transport Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplets by masking the patient, if possible. STANDArDS For ENVIroNMENTAL SErVICES The infection control manual should contain details on preventive measures in the area of environmental services. The procedures should follow those set forth by the CDC [18]. These procedures are related to the routine cleaning and disinfection of environmental surfaces, the cleaning of spills of blood and other body fluids, the cleaning and maintenance of laundry and bedding, carpeting, and cloth furnishings, and the handling of medical wastes.
Cleaning the Environment Every healthcare facility should have a written housekeeping schedule for the routine cleaning of the environment. Routine cleaning removes so-called visible dirt, which can harbor microorganisms. Soap and water can be used to remove visible dirt from most surfaces, such as walls, doors, ceilings, and floors. A disinfectant should be used when there are signs of contamination. The level of asepsis in cleaning depends on the likelihood of contamination. WHO suggests classifying areas within a healthcare facility into four zones [1]: Zone A: No patient contact Zone B: Care of patients who are not infected and are not highly susceptible Zone C: Infected patients (isolation units) Zone D: Highly susceptible patients (protective isolation) or protected areas such as operating suites, delivery rooms, intensive care units, neonatal intensive care, transplant, units, oncology units, and hemodialysis units. Cleaning according to this classification should be as follows [1]: Zone A: Normal cleaning Zone B: Cleaning procedures that do not raise dust. (Dry sweeping or vacuum cleaners are not recommended.) Use of a detergent solution and disinfection of any areas with visible contamination with blood or body fluids before cleaning. Zone C: Cleaning with a detergent/ disinfectant solution, with separate cleaning equipment for each room Zone D: Cleaning with a detergent/ disinfectant solution and separate cleaning equipment
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Written policies should specify how frequently each area should be cleaned and should note the cleaning agents used for various surfaces and items such as beds, curtains, screens, fixtures, and furniture. In general, all surfaces in the environment (walls, doors, floors, etc.) must be cleaned daily to remove soil. Sinks, toilets, and baths should be scrubbed daily, or more often if needed, with a disinfectant cleaning solution using a separate mop, brush, or cloth. Patient rooms should also be cleaned daily and after each patient is discharged. Surfaces and countertops in procedure rooms, examination rooms, and the laboratory must be cleaned with a disinfectant solution after any activity.
The CDC and HICPAC recommend using caution when considering use of antimicrobial mattresses, textiles, and clothing as replacements for standard bedding and other fabric items; the Environmental Protection Agency (EPA) has not approved public health claims asserting protection against human pathogens for such treated items. (http://www.guidelines.gov/summary/summary. aspx?doc_id=3843. Last accessed January 23, 2007.) Strength of recommendation: II (Suggested for implementation and supported by suggestive clinical or epidemiologic studies, or a theoretic rationale)
Sharps (needles, scalpels, blades, knives) Pharmaceutical waste (expired pharmaceutical agents) Chemical waste (laboratory reagents, solvents) Heavy metal waste (broken blood pressure gauges, batteries) Radioactive waste As with cleaning, written policies should document the appropriate handling, storage, and transportation of all types of waste. MoNITorING AND EVALuATIoN oF ANTIMICroBIAL THErAPY The increasing number of drug-resistant bacteria has led to a serious depletion in the antibiotics available to effectively treat infections in critically ill patients. The cornerstones of limiting antibiotic resistance are to prevent infection and to use antibiotics judiciously [65]. Because resistance typically develops in the healthcare setting before the community, an infection control program has an essential role in limiting the use of antibiotics and promoting strategies for their appropriate use. The principles underlying the optimization of antibiotic use are the limitation of unnecessary antibiotics, obtaining timely culture and sensitivity data, selecting the most appropriate treatment, and prescribing the appropriate dose [201]. In addition, studies have shown that antimicrobial use can be decreased by using explicit criteria to identify patients with nosocomial infections as well as those at highest risk for infection [39]. WHO reported that, in studies of teaching hospitals worldwide, 41% to 91% of all antimicrobials prescribed were considered inappropriate [69]. Education appears to be key. Several professional societies and government agencies have sought to establish recommendations for systems-based as well as physician-based solutions to the problem of inappropriate use of antimicrobials. Some suggestions, such as cycling of antibiotics, have not been found to be effective, while others, such as computerized order forms, have had mixed results
Spills of blood or other body fluid should be removed and cleaned immediately. The area should first be cleaned with a 0.5% chlorine solution and then washed clean with a disinfectant solution. Gloves should be worn while cleaning. Managing Waste Management of waste is a concern in healthcare facilities, but 75% to 90% of waste poses no risk of infection. The following types of waste are considered to be hazardous [1]: Infection-associated waste (from isolation units, laboratory cultures, tissue swabs) Pathologic waste (blood, body fluids, human tissue)
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[69]. Among the recommendations that have met with success are [68; 69; 200]: Establish a system for monitoring bacterial resistance and antibiotic usage, including the quantity and patterns of use, and provide feedback of results to prescribers. Develop and regularly update guidelines for antimicrobial treatment and prophylaxis. Conduct an ongoing review of the hospital formulary. Adhere to the CDC guideline for isolation precautions in hospitals. Develop local policies, and evaluate and adopt, as appropriate, guidelines from state advisory boards and national societies. The CDC has launched the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, which is directed to physicians and other clinicians [78]. The campaign is designed around four strategies: Prevent infection. Diagnose and treat infection effectively. Use antimicrobials wisely. Prevent transmission.
If an interpreter is necessary, the practitioner must acknowledge that an interpreter is more than a body serving as a vehicle to transmit information verbatim from one party to another [217]. Instead, the interpreter should be regarded as part of a collaborative team, bringing to the table a specific set of skills and expertise [217]. In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. When providing care for patients for whom English is a second language, the consideration of the use of an interpreter and/or patient education materials in their native language may improve patient understanding and outcomes. EDuCATIoN For HEALTHCArE PErSoNNEL An essential component of infection control is to heighten awareness of the importance of prevention and provide education on ways to implement preventive strategies. These strategies have been shown to be effective in decreasing the rates of nosocomial infections. A focused educational program with frequent performance feedback led to an increase in hand hygiene compliance from 23% to 64%, with a corresponding decrease in the overall rate of nosocomial infections from 47.55 per 1,000 patient days to 27.93 per 1,000 patient days [191]. In other studies, the combination of a self-study module (with pretest and post-test), inservice lectures, posters, and fact sheets on the prevention of intravascular device-related bloodstream infections and appropriate practices led to substantial reductions in the prevalence of such infections. In one study, the rate of infection decreased from 4.9 per 1,000 catheter days before the intervention to 2.1 per 1,000 catheter days after the intervention [202]. In another study, there was
These strategies form the core for 12-step fact sheets, pocket cards, posters, and slide sets, available for a variety of patient populations, including hospitalized adults, surgical patients, dialysis patients, long-term care patients, and hospitalized children. All of the resources are available on the CDC website at http://www.cdc.gov/drugresistance/ healthcare/patients.htm. Communication with patients regarding prevention of infection, appropriate use of antimicrobials, and preventing or limiting transmission are vital aspects of limiting the development of drug-resistant bacteria. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patients lack of proficiency in the English language, an interpreter is required. Frequently, this may be easier said than done, as there may be institutional and/or patient barriers.
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a 66% decrease in the rate of infection before and after the intervention (10.8 per 1,000 days to 3.7 per 1,000 days) [203]. Education should also focus on measures healthcare workers should take to protect themselves against infection with bloodborne pathogens, such as hepatitis viruses (B and C), and HIV. Proper handling and disposal of sharps, as well as appropriate use of precautions when handling blood or body fluids, should be emphasized to all staff in the healthcare facility. The risk of acquiring infection with these pathogens varies. The risk of HIV transmission through a needlestick or cut exposure to infected blood is approximately 0.3%; the risk of hepatitis C is 1.8% [204]. The risk is highest for hepatitis B. Susceptible individuals (those who have not received the hepatitis B vaccination) have a risk of 6% to 30% [204]. The prevalence of infection with these viruses among healthcare workers is extremely low, and the annual number of occupationally acquired hepatitis B infection has decreased 95% since the introduction of the hepatitis B vaccine [204]. The CDC recommends that all healthcare workers receive vaccination against hepatitis B, and the Occupational Safety & Health Administration (OSHA) requires employers to offer the series of three injections free of charge to employees who are occupationally exposed to blood or other potentially infectious materials [205]. The vaccination not only protects healthcare workers from acquiring infection with the hepatitis B virus through accidental exposure to blood, but it also protects patients from becoming infected through unknowing transmission. Serologic screening before vaccination is not necessary. Individuals who do not have a response to the primary vaccine series should complete a second three-injection vaccine series or have blood tested to determine the hepatitis B surface antigen status [206]. There are no vaccination options for HIV or hepatitis C. For healthcare workers who have been exposed to blood that is known or suspected to be positive for hepatitis B surface antigen, prophylaxis with hepatitis B immune globulin and/or vaccine should be given [206].
The CDC also recommends that all healthcare workers receive the influenza vaccination each year, yet the rates of such vaccination are low. In the 20042005 flu season, 43% of healthcare workers were vaccinated [207]. Again, vaccination protects both healthcare workers and patients from infection. PrEPArEDNESS AND CoNTroL oF ouTBrEAKS Another responsibility of an infection control team is establishing response plans for outbreaks and epidemics and controlling them should they occur. An outbreak is defined by WHO as an unusual or unexpected increase of cases of a known nosocomial infection or the emergence of cases of a new infection [1]. The number of individuals affected can vary from a few to one hundred or more. Outbreaks and epidemics account for approximately 5% to 10% of nosocomial infections, and most hospitals lack adequate equipment, isolation space, and staff to treat a large increase in the number of patients with an infectious disease [2; 3; 208]. The two primary concerns are to confirm the existence of the outbreak and to establish control measures to confine the spread. An outbreak should be identified and investigated as early as possible to prevent morbidity and mortality. Any healthcare professional who suspects an outbreak should notify infection control staff, and an outbreak team should be established. Investigating an outbreak involves [1; 209]: Establishing the existence of an outbreak Verifying the diagnosis Defining and identifying cases Describing and orienting the data in terms of time, place, and person Developing and evaluating hypotheses Refining hypotheses and carrying out additional studies Implementing control and prevention measures Communicating findings
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The outbreak team should collaborate with all appropriate healthcare workers to identify either the carriers or the common sources of the infection and to review aseptic practices and disinfectant use for a breach in compliance. Data on potential cases should be reviewed and a case definition should be developed. The case definition should include [1; 209]: Unit of time and place Specific biologic and/or clinical criteria Inclusion/exclusion criteria Gradient of definition (definite, probable, or possible) Differentiation between colonization and infection Specific criteria to identify the index case, if relevant information is available Data should be collected from all available sources, such as patient charts, microbiology reports, pharmacy reports, and log books from patient units. Describing the outbreak in terms of individuals, place, and time helps to create an epidemic curve, which shows the distribution of cases by time of onset [1]. An attack rate can then be defined as number of people at risk who are infected compared to the total number of people at risk. Developing and evaluating hypotheses will yield the source of the outbreak and/or the index case. The data should be reviewed carefully to evaluate the characteristics and similarities among affected individuals. The team must then determine the extent of the outbreak. Cohort isolation is implemented as needed (Table 11). Throughout the investigation, the team should communicate routinely with hospital administration. At completion, data on the outbreak should be documented and published, as the information can provide valuable education to the healthcare community at large and can help staff prepare for future outbreak investigations [210].
Case Example The following case outlines an investigative process and illustrates that the source of an outbreak may be unusual [211]. A cardiac surgeon noticed a cluster of cases of sternal wound dehiscence among his patients who had had surgery. Specimens from the wounds were obtained for culture. Microbiologic evaluation indicated that the infections were predominantly caused by Enterobacter cloacae, and molecular typing and serotyping demonstrated that the isolates were similar. No infections had developed after operations the surgeon had performed at other hospitals. No breach in aseptic technique was identified. All of the infected patients had been operated on in the same operating room, and the environment was screened. No source was found. Further questioning of the surgeons operative practice revealed one difference from other cardiac surgeons: he used semi-frozen Hartmanns solution to achieve cardioplegia. Swabbing of the freezer used for the solution identified E. cloacae of the same typing as that found in the wound infections. The hypothesis was that contamination of the freezer led to contamination of the ice/slush solution, and the microorganism was transmitted to the patients. The freezer was replaced, a rigorous cleaning schedule was instituted, and no further cases have occurred. Potential outbreaks The following are overviews of some potential outbreaks. Identification and early action in the case of any of these outbreaks will limit the adverse effects. Group A Streptococci Most outbreaks of group A streptococci involve surgical wounds, and the source can usually be traced to an asymptomatic carrier in the operating room or on the wound care team [2; 212]. Standard Precautions are sufficient if the wound is minor; if it is major, Contact Precautions should be instituted and followed for 24 hours after initiation of effective therapy [200]. The healthcare worker should receive antimicrobial therapy as appropriate and leave the setting until completion of therapy.
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TYPE AND DurATIoN oF PrECAuTIoNS rEquIrED For INFECTIoNS WITH PoTENTIAL For ouTBrEAKS
Infection/Condition Anthrax (cutaneous or pulmonary) Aspergillosis Botulism Diphtheria (cutaneous/ pharyngeal) Ebola (viral hemorrhagic fever) Clostridium difficile gastroenteritis Influenza Precaution Type Standard Standard Standard Contact/Droplet Precaution Duration Ongoing Ongoing Ongoing Until antibiotic therapy is completed and two cultures taken at least 24 hours apart are negative Duration of illness Contact the state department and the CDC for specific advice about management of a case. Notes
Contact
Contact Droplet
Duration of illness Duration of illness The CDC guideline for the prevention of nosocomial pneumonia recommends surveillance, vaccination, antiviral agents, and use of private rooms with negative air pressure as much as feasible when influenza is suspected or diagnosed.* Install screens in windows and doors in endemic areas.
Malaria Measles (rubeola), all presentations Meningitis (Haemophilus influenzae or Neisseria meningitidis [meningococcal] known or suspected) Meningococcal pneumonia Multidrug-resistant organisms, infection or colonization (gastrointestinal; respiratory; skin, wound, or burn)** Norovirus Plague, Bubonic Plague, Pneumonic Pneumonia caused by Adenovirus Legionella Meningococcal Mycoplasma (primary atypical pneumonia)
Standard Airborne Droplet
Ongoing Duration of illness Until 24 hours after initiation of effective therapy
Droplet Contact
Until 24 hours after initiation of effective therapy Until antibiotic therapy completed and cultures are negative
Contact Standard Droplet
Duration of illness Ongoing Until 72 hours after initiation of effective therapy Duration of illness Ongoing Until 24 hours after initiation of effective therapy Duration of illness
Contact/Droplet Standard Droplet Droplet
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TYPE AND DurATIoN oF PrECAuTIoNS rEquIrED For INFECTIoNS WITH PoTENTIAL For ouTBrEAKS (Continued)
Infection/Condition Scabies Staphylococcus aureus, skin, wound, or burn Major: no dressing or dressing does not contain drainage adequately Minor or limited: dressing covers and contains drainage adequately Group A streptococci, skin, wound, or burn (major: no dressing or dressing does not contain drainage adequately) Toxoplasmosis Toxic shock syndrome (staphylococcal disease) Tuberculosis Extrapulmonary, draining lesion (including scrofula) or meningitis Pulmonary, confirmed or suspected or laryngeal disease Standard Ongoing Patient should be examined for evidence of current (active) pulmonary tuberculosis. If evidence exists, additional precautions are necessary. Precaution Type Contact Precaution Duration Until 24 hours after initiation of effective therapy Notes
Contact
Duration of illness
Standard
Ongoing
Contact
Until 24 hours after initiation of effective therapy
Standard Standard
Ongoing Ongoing
Airborne
Only when therapy is effective, patient is clinically improving, and the cultures of three consecutive sputum smears, collected on different days, are negative, or tuberculosis is ruled out Ongoing
Skin-test positive with no evidence of current pulmonary disease Varicella zoster (chickenpox) Whooping cough (pertussis)
Standard
Airborne Droplet
Until all lesions are crusted (10 to 21 days) Until 5 days after initiation of effective therapy
*Many hospitals encounter logistic difficulties and physical plant limitations when admitting multiple patients with suspected
influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very least, avoid room sharing with high-risk patients. **Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance.
Source: [200]
Table 11
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Pulmonary Tuberculosis Dealing with pulmonary tuberculosis involves prompt identification of the disease and determining the susceptible individuals who were exposed to the patient before isolation [2]. Airborne Precautions should be instituted and remain in place until the patient is receiving effective therapy, is improving clinically, and the culture results for three consecutive sputum specimens, collected on different days, are negative. Comprehensive information is available in the CDC guideline for preventing the transmission of tuberculosis in healthcare facilities [213]. Legionella The source of nosocomial infection with Legionella pneumonia is usually contaminated water [2; 26]. The pathogen colonizes on water pipes, and inhalation of contaminated water droplets from shower heads or faucet aerators may cause disease [26]. Implementation of Standard Precautions for the patient is sufficient [200]. Laboratory-based surveillance for nosocomial Legionella should be performed, and samples of tap water should be obtained for culture. If the culture is positive, it is best to obtain cultures from patients who have nosocomial pneumonia. There are more than 40 known types of Legionella spp., but most outbreaks are caused by Legionella pneumophila serotypes 1 and 6 [26]. Antibiotic-Resistant Bacteria Outbreaks of antibiotic resistance have involved MRSA, VRE, and, most recently, vancomycinresistant S. aureus [214]. In such outbreaks, it is important to identify patients with colonization or infection early and isolate them or cohort them. Contact Precautions should be implemented and carried out until antibiotic therapy has been completed and cultures are negative [200]. The importance of adhering to proper hand hygiene and other elements of Contact Precautions should
be emphasized. Healthcare workers who were involved with patients before isolation should be evaluated for colonization and infection and treated appropriately. Diarrhea Several organisms have been implicated in outbreaks of diarrhea in healthcare facilities, including salmonella, shigella, and rotavirus. Salmonella is caused by contaminated food or drinks, and the incubation period is less than 72 hours [17]. Transmission of the infection can be rapid, and control of the outbreak may be difficult. New admissions may need to be restricted. Oral rehydration and supportive care are usually adequate treatment [17]. Outbreaks of shigella are less common than those of salmonella, and the usual source is fecal/oral transmission from acutely infected patients [17]. The incubation period is one to six days. Rotavirus has a shorter incubation period, about two to three days, and fever and upper respiratory symptoms will occur in about 50% of cases. Transmission is extremely rapid. Nearly all infants will become infected during an outbreak in a nursery [17]. The first step in managing an outbreak of diarrhea is to find the common source and eliminate it. Patients who have become infected should be grouped together, and staff caring for them should not care for uninfected patients. Patients (both infected patients and noninfected) should be discharged home if possible. Other Outbreaks The potential for other outbreaks or epidemics vary, and the CDC website, http://www.bt.cdc.gov, offers resources on emergency preparedness for outbreaks or epidemics caused by other pathogens, including anthrax and viral hemorrhagic fever. A Bioterrorism Readiness Plan template is also available on the site. Many aspects should be considered when planning for bioterrorism preparedness, and each department of a healthcare facility can play an important role [2].
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CoNCLuSIoN
Infections acquired in the healthcare setting raise a great risk for patients, leading to high rates of morbidity and mortality. Many of the 90,000 deaths caused by nosocomial infections could be prevented by following evidence-based guidelines and consensus statements on preventive strategies [2; 3]. Several institutions have implemented campaigns to enhance the quality of health care and patient safety by focusing on measures to reduce the four most common nosocomial infections: urinary tract infection, surgical site infection, pneumonia, and intravascular device-related bloodstream infection, which comprise approximately 80% of all nosocomial infections [3]. The single most effective preventive measure for all nosocomial infections is appropriate hand hygiene, and all efforts to reduce the rate of nosocomial infection must focus on enhancing compliance with this measure, which currently averages approximately 30% to 50% [3; 9; 195]. Alcohol-based handrub solutions have addressed many of the reasons for noncompliance with hand hygiene, especially because they offer more convenience and are less damaging to skin. More importantly, alcohol-based handrub solutions provide better efficacy against most potential pathogens and more rapid disinfection than other hand hygiene techniques. Along with hand hygiene, meticulous attention to aseptic technique when preparing for invasive procedures or using invasive devices is also essential for reducing the prevalence of nosocomial infection. Preventive measures specific for each of the most common types of nosocomial infection have been recommended in evidence-based guidelines and consensus statements (Table 12).
The common pathogens, diagnosis, and treatment vary among these infections and even within each type of infection. For example, the pathogens causing early-onset nosocomial pneumonia differ from those causing late-onset pneumonia and the pathogens causing surgical site infections vary according to the type of surgery. The CDC has detailed diagnostic criteria for each type of infection, and consensus statements have also proposed such criteria. The treatment of nosocomial infection varies according to the pathogen and the anatomic site. The prevailing principle is to use antibiotics judiciously, as the inappropriate use of antibiotics has led to an increasing number of resistant strains of bacteria. When using empiric antibiotic therapy, physicians should select an antibiotic on the basis of known pathogens in the healthcare facility as a whole, as well as on the specific unit within the facility. An effective infection control team is critical to reducing the incidence of nosocomial infections in a healthcare facility. All departments within a healthcare facility should be represented on this team to ensure widespread adherence to preventive measures. The responsibilities of an infection control team are to conduct surveillance of infections, provide training and education for healthcare personnel, and ensure compliance with policies, including those for precautions and isolation techniques, standards for environmental services, and monitoring and evaluation of antimicrobial therapy. Innovative campaigns and performance feedback have been shown to enhance educational efforts. The infection control team is also responsible for establishing response plans for outbreaks and epidemics and controlling them should they occur.
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SuMMArY oF PrEVENTIVE MEASurES For THE MoST CoMMoN NoSoCoMIAL INFECTIoNS Type of Infection All infections Urinary tract infection Evidence-Based recommended Measures Appropriate hand hygiene Meticulous aseptic technique for devices and equipment Indwelling catheters only when needed Proper securing of catheter Closed sterile drainage system Unobstructed urine flow Removal of catheter as soon as possible Deep breathing Frequent coughing Early movement (in bed and/or walking) Limited use of narcotic agents Incentive spirometry (for patients at high risk) Elevation of the head of the bed (30 degrees)* Daily interruptions of sedation and assessment of readiness to extubate* Prophylaxis of peptic ulcer disease* Prophylaxis of deep venous thrombosis* Appropriate antibiotic prophylaxis Avoidance of preoperative shaving Maintaining adequate glycemic control Maintaining a warm body temperature Maximal barrier precautions* 2% chlorhexidine solution for skin antisepsis* Selection of optimal site for the catheter (subclavian vein preferred for nontunneled catheters)* Daily review of the need for the line, with prompt removal if line is deemed unnecessary* Judicious use of antibiotics Barrier precautions (gowns and gloves, dedicated or disposable equipment, cohorting of patients and/or staff) Handwashing with soap and water (alcohol is not effective against C. difficile spores) Appropriate disinfectant for surfaces and devices Endotracheal tube with a dorsal lumen Noninvasive ventilation Alternative to indwelling catheter (suprapubic, condom) Antimicrobial-coated catheter Hand-held bladder scanners other Suggestions
Pneumonia (without mechanical intubation)
Ventilator-associated pneumonia
Surgical site infection
Performance feedback to surgeons
Intravascular devicerelated bloodstream infections
Catheter with antimicrobial coating Performance feedback to personnel
Clostridium difficileassociated diarrhea
*Component of a bundle of interventions proposed by the Institute for Healthcare Improvement, which, when implemented
together, achieves a significant outcome.
Source: Compiled by Author
Table 12
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oNLINE rESourCES
Prevention of Hospital-Acquired Infections. A Practical Guide, 2nd ed. World Health Organization http://www.who.int/csr/resources/publications/ drugresist/whocdscsreph200212.pdf Guideline for Hand Hygiene in Healthcare Settings Centers for Disease Control and Prevention http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5116a1.htm Environmental Infection Control Centers for Disease Control and Prevention http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5210a1.htm Guidelines for Isolation Precautions in Hospitals Centers for Disease Control and Prevention http://www.cdc.gov/ncidod/dhqp/gl_isolation. html Guideline for Prevention of CatheterAssociated urinary Tract Infections Centers for Disease Control and Prevention http://www.cdc.gov/ncidod/dhqp/gl_catheter_ assoc.html Guideline for Prevention of Surgical Site Infection Centers for Disease Control and Prevention http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/ SSI.pdf Guidelines for Preventing Healthcare-Associated Pneumonia Centers for Disease Control and Prevention http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5303a1.htm Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia The Canadian Critical Care Trials Group and the Canadian Critical Care Society http://www.annals.org/cgi/reprint/141/4/305.pdf
Guidelines for the Management of Adults with Hospital-Acquired, Ventilator-Associated, and HealthcareAssociated Pneumonia American Thoracic Society and Infectious Diseases Society of America http://ajrccm.atsjournals.org/cgi/content/ full/171/4/388 Guidelines for the Prevention of Intravascular Catheter-related Infections Centers for Disease Control and Prevention http://www.cdc.gov/mmwr/PDF/rr/rr5110.pdf Guidelines for the Management of Intravascular Catheter-related Infections Infectious Diseases Society of America, American College of Critical Care Medicine (for the Society of Critical Care Medicine), and Society for Healthcare Epidemiology of America http://www.journals.uchicago.edu/CID/journal/ issues/v32n9/001689/001689.html Clostridium Difficile Infections Centers for Disease Control and Prevention http://www.cdc.gov/ncidod/dhqp/id_Cdiff.html Antibiotic/Antimicrobial resistance Centers for Disease Control and Prevention http://www.cdc.gov/drugresistance/ Guidelines for the Prevention of Antimicrobial resistance in Hospitals Society for Healthcare Epidemiology of America and Infectious Diseases Society of America http://www.shea-online.org/Assets/files/position_ papers/AntimicroResist97.PDF Global Strategy for Containment of Antimicrobial resistance World Health Organization http://www.who.int/csr/resources/publications/ drugresist/en/EGlobal_Strat.pdf The resistance Phenomenon in Microbes and Infectious Disease Vectors: Implications for Human Health and Strategies for ContainmentWorkshop Summary Institute of Medicine http://www.nap.edu/catalog/10651.html Emergency Preparedness and response Centers for Disease Control and Prevention http://www.bt.cdc.gov/index.asp
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201. Raymond DP, Pelletier SJ, Sawyer RG. Antibiotic utilization strategies to limit antimicrobial resistance. Semin Respir Crit Care Med 2002;23(5):497-501. 202. Warren DK, Zack JE, Cox MJ, Cohen MM, Fraser VJ. An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center. Crit Care Med. 2003;31(7):1959-1963. 203. Coopersmith CM, et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med. 2002;30(1):59-64. 204. Centers for Disease Control and Prevention. Exposure to Blood. What Healthcare Personnel Need to Know. Rockville, MD: Department of Health & Human Services; 2003. 205. Occupational Safety & Health Administration. Bloodborne facts. Hepatitis B vaccinationprotection for you. Available at http://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact05.pdf. Last accessed November 10, 2006. 206. Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practice Advisory Committee (HICPAC). MMWR. 1997;46(RR18):1-42. 207. Centers for Disease Control and Prevention. Estimated influenza vaccination coverage among adults and children United States, September 1, 2004-January 1, 2005. MMWR. 2005;54(12):304-307. 208. United States General Accounting Office. Infectious disease outbreaks. Bioterrorism preparedness efforts have improved public health response capacity but gaps remain. Statement of Janet Heinrich. Testimony before the Committee on Government Reform House of Representatives; 2003. 209. Centers for Disease Control and Prevention. Steps of an outbreak investigation. Available at http://www.cdc.gov/excite/classroom/ outbreak/steps.htm. Last accessed November 10, 2006. 210. Gastmeier P, Stamm-Balderjahn S, Hansen S, Nitzschke-Tiemann F, Zuschneid I, Groneberg K, Ruden H. How outbreaks can contribute to prevention of nosocomial infection: analysis of 1,022 outbreaks. Infect Cont Hosp Epidemiol. 2005;26(4):357-361. 211. Breathnach AS, Riley PA, Shad S, Jownally SM, Law R, Chin PC, Kaufmann ME, Smith EJ. An outbreak of wound infection in cardiac surgery patients caused by Enterobacter cloacae arising from cardioplegia ice. J Hosp Infect. 2006;64(2):124-128. 212. Felkner M, Pascoe N, Shupe-Ricksecker K, Goodman E. The wound care team: a new source of group A streptococcal nosocomial transmission. Infect Control Hosp Epidemiol. May 2005;26(5):462-465. 213. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR. 2005;54(RR17):1-141. 214. Henderson DK. Managing methicillin-resistant staphylococci: a paradigm for preventing nosocomial transmission of resistant organisms. Am J Med. 2006;119(6 Suppl 1):S45-S52, S62-S70. 215. Institute for Healthcare Improvement. Six Sigma Approach to Reduction of Central Venous Catheter-Related Bloodstream Infections. December 2005. Available at http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/ SixSigmaApproachtoReductionofCVCRelatedBloodStreamInfections.htm. Last accessed December 6, 2006. 216. Anaissie EJ, Penzak SR, Dignani MC. The hospital water supply as a source of nosocomial infections: a plea for action. Arch Intern Med. 2002; 162(13): 1483-1492. 217. Lee E. Cross-cultural communication: Therapeutic use of interpreters. In Evelyn Lee (Ed.), Working with Asian Americans: A guide for clinicians. New York: The Guilford Press. 1997. 477-489.
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Sehulster L, Chinn RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) MMWR Recomm Rep. 2003 Jun 6;52(RR10):1-42. Summary retrieved from National Guideline Clearinghouse at http://www.guidelines.gov/summary/summary.aspx?doc_id=3843. Last accessed January 23, 2007. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-careassociated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar 26;53(RR3):1-36. Summary retrieved from National Guideline Clearinghouse at http://www.guidelines.gov/summary/ summary.aspx?doc_id=4872. Last accessed January 23, 2007. OGrady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep. 2002 Aug 9;51(RR10):1-29. Summary retrieved from National Guideline Clearinghouse at http://www.guidelines.gov/summary/summary.aspx?doc_id=3387. Last accessed January 23, 2007. Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001 Feb 1;32(3):331-51. Summary retrieved from National Guideline Clearinghouse at http://www.guidelines.gov/summary/summary.aspx?doc_id=2791. Last accessed January 23, 2007.
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__________________________________________________________________ #9447 Nosocomial 01/31/10 CourSE #9447 15 CoNTACT HourS/CrEDITS Release Date: 02/01/07 expiRation Date: Infections

Copyright 2007 CME Resource

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

CME Resource January 15, 2010

__________________________________________________________________ #9447 Nosocomial Infections

EPIDEMIoLoGY AND BACKGrouND

Excess* Length of Stay 10.89 days 9.42 days 9.58 days

Excess* Charges $57,727 $40,323 $38,656

Excess* Mortality 21.96% 9.63% 4.31%

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

#9447 Nosocomial Infections __________________________________________________________________

CME Resource January 15, 2010

__________________________________________________________________ #9447 Nosocomial Infections

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

#9447 Nosocomial Infections __________________________________________________________________

CME Resource January 15, 2010

__________________________________________________________________ #9447 Nosocomial Infections

SourCES oF NoSoCoMIAL INFECTIoNS

Water (tap and bath)

Aspergillus Exophiala jeanselmei

Source: [1; 26; 187; 216]

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

#9447 Nosocomial Infections __________________________________________________________________

CME Resource January 15, 2010

__________________________________________________________________ #9447 Nosocomial Infections

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

#9447 Nosocomial Infections __________________________________________________________________

CME Resource January 15, 2010

__________________________________________________________________ #9447 Nosocomial Infections

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

#9447 Nosocomial Infections __________________________________________________________________

CME Resource January 15, 2010

__________________________________________________________________ #9447 Nosocomial Infections

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

#9447 Nosocomial Infections __________________________________________________________________

CME Resource January 15, 2010

__________________________________________________________________ #9447 Nosocomial Infections

Left ventricular assist devices

Cerebrospinal fluid (CSF) shunts

Bacteria originating from patients skin introduced at time of operation

Prosthetic cardiac valves

Contamination of the valve at time of implantation or transient bacteremia

Within 60 days (early)

Contamination at time of implantation

Contamination at time of implantation

S. aureus, Streptococcus pneumoniae, Haemophilus influenzae

Skin flap necrosis, wound dehiscence, wound infection

Table 3 continues on next page

CME Resource Sacramento, California

Phone: 800 / 232-4238 FAX: 916 / 783-6067

#9447 Nosocomial Infections __________________________________________________________________

Transvenous permanent pacemakers/ automatic implantable cardioverter defibrillators

Blood cultures, transesophageal echocardiography

S. aureus, peptostreptococci, Clostridium perfringens

Wound or fluid culture

Empiric antibiotic therapy, local debridement