The incidence of nosocomial pneumonia is #1 among critically ill patients requiring mechanical ventilation.
Nosocomial pneumonia is frequently encountered in ICUs where multidrug resistant bacteria are involved.
Risk of nosocomial pneumonia is
Ý with the following: intubation of the respiratory tract, tracheotomy, advanced age, debilitating disease, prolonged hospitalization, contaminated respiratory therapy equipment, use of antibiotics in the hospital setting, thoracoabdominal surgery, immunosuppression and myelosuppression, and don’t forget about contaminated nebulizers.
Aseptic suctioning technique is critical in RT
Studies show gram (-) bacilli have increased adherence to buchal cells due to change in cell surface CHO.
Pts with poor gag and cough reflex are at high risk for aspiration pneumonia. Don’t leave these patients supine.
TB must be considered in differential diagnosis. MDR TB outbreaks have been reported, affecting medical staff-70% died
Must have
Ý index of suspicion, test for multidrug resistance and maintain isolation until TB is clinically controlled
Diagnosis of Nosocomial Pneumonia
because pneumonia is the #1 cause of late death following trauma, we need to know how to catch it early
Clinical Criteria
: fever, leukocytosis, purulent brochotracheal secretions, new or progressive infiltrate on CXR
these criteria are sensitive, but only about 75% specific
Lab Tests:
Sputum/tracheal aspirate
quantitative studies: changing the threshold for diagnosis can give increased sensitivity or specificity, but not both
graded gram stain: better, but difficult to perform
elastin fibers: 100% specific for necrotizing bacterial pneumonia; 60% sesnsitive; changes occur days before CXR is evident; this method is seeing a rebirth
Broncho-alveolar lavage
: very sensitive and specific (up to 92% and 97%, respectively)
Protected Specimen Brush
: gold standard for ventilator acquired pneumonia; ‘protected’ refers to keeping the brush sterile while inserting the brochoscope so as not to catch bugs from the upper tree
used in conjunction with the clinical picture, this is the most sensitive and specific test
Urinary Tract infection
40% of all nosocomial infections; at least 2/3 occur in patients with catheterization or instruments in the urinary tract.
Bacteria, whether from patient’s flora or from other sources, may gain entrance to bladder as follows:
Poorly prepared periurethra or use of contaminated solutions b4 inserting catheters or other instruments.
Insertion of contaminated instruments as a result of either poor aseptic technique or inadequate disinfection.
Trauma to the urethra or pressure necrosis of the meatus due to too large a catheter.
Entry of bacteria at the junction of the catheter and the urethral meatus.
Contamination in the region of the connecting tube and catheter as a result of disconnection of tubes and unnecessary irrigation.
Contamination of the collection vessel (e.g. urinary bag) with retrograde flow.
Irrigation of the catheter with contaminated irrigating solutions.
risk of development of significant bacteriuria after a single urethral catheterization (15% of all hospital patients) is 1% to 2% in healthy young adults and 10 to 20% in elderly or debilitated patients.
Approximately 10% of patients admitted to general hospitals have indwelling urethral catheterization. About 0.3 to 1% have an episode of gram-negative bacteremia.
Methods are available to minimize infection in patients with indwelling urethral catheterization. e.g. closed-catheter-drainage, aseptic care of urinary catheter.
To avoid UTI: use nontraumatic aseptic technique, anchor catheter to prevent trauma, never invert or open catheter bag, avoid flushing the system (use sterile saline if you do) and isolate patients with UTI from others with catheter.
Intravenous Cannulation
bypasses dermal protection barrier.
small fibrin-platelet thrombus rapidly develops on that part of the cannula within the vein.
clot may be contaminated by organisms from the skin, blood or contaminated infusions that pass through cannula.
Can result from contamination of the IV bottle at the manufacturer.
are able to survive in the acid glucose containing solutions.
therefore they are the ones you see in these type infections.
¼ of all removed caths are culture positive. This does not correlate with bacteremia, but high loads do.
50K-100K blood stream infections yearly are related to vascular devices. Central Venous Catheters account for 90%
use of maximal barrier precautions during placement (sterile glove, sterile gowns, full size sterile drapes and masks has been shown to reduce the risk of this infection. Still compliance is less than 20%.
Prevention
The drug used to treat these infections have many side affect, (anaphylactic shock, arrhythmia, cardio-respiratory arrest, bone marrow aplasia, apnea, deafness, blindness, renal or hepatic failure, foliative dermatitis etc.) so try to prevent the disease
Studies indicate that less than 50% of healthcare worker wash their hands in-between patients.
Increase in washing hands in-between patients by 1-2 fold would result in a decrease in nosocomial infections by 25-50%.