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Nosocomial Infections

Nosocomial Infections is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Health care–associated infections (HAIs)
  • Infection must not have been present or incubating on admission to a health care facility.
  • CDC categories:
    • Catheter-associated urinary tract infection (CAUTI)
    • Surgical site infection (SSI)
    • Ventilator-associated pneumonia (VAP)
    • Central line–associated bloodstream infection (CLABSI)
    • Clostridium difficile infection (CDI; C. diff, C. difficile, CDAD)
  • The National Healthcare Safety Network (NHSN) at www.cdc.gov/nhsn monitors emerging HAI pathogens and their mechanisms of resistance to promote current prevention strategies.
  • Medicare and Medicaid will not pay for the treatment of certain HAI including CAUTIs, CLABSIs, and SSIs.

Epidemiology

  • General
    • 13/1,000 patient-days in the ICU (1)
    • 7/1,000 patient-days in high-risk nurseries
    • 2.6/1,000 patient-days in nurseries (1)
    • Estimated cost of HAIs is $20 billion per year (2).
  • Infection specific
    • CAUTI
      • Hospital stay increased by 1 to 3 days
      • Cost up to $600 per infection
    • VAP
      • Hospital stay increased by 6 days
      • Cost up to $5,000 per infection
    • CLABSI
      • Hospital stay increased by 7 to 20 days
      • Cost up to $56,000 per infection
    • SSI
      • Hospital stay increased by 7.3 days
      • Cost >$3,000 per infection
      • May not be apparent until 1 month after surgery
    • CDI (see topic “Clostridium difficile Infection”)

Incidence
  • 1 of 25 inpatients in the United States has at least one HAI (3).
    • 722,000 HAIs in U.S. acute care hospitals (3)
    • UTI: 13% of HAIs (3)
    • Pneumonia: 22% of HAIs (3)
    • Bloodstream infection: 10% of HAIs (3)
    • SSI: 22% of HAIs (3)
    • 107,000 C. difficile cases in 2011 (4)[A]
  • Infections caused by gram-negative rods resistant to almost all antibiotics are increasing. Up to 70% of nosocomial infections are resistant to at least one previously active antimicrobial.

Etiology and Pathophysiology

  • Endogenous spread: Patient host flora causes invasive disease (most common).
  • Exogenous spread: flora acquired from within health care facility
  • Causative organisms
    • UTI: Escherichia coli, Klebsiella spp., Serratia spp., Enterobacter, Pseudomonas aeruginosa, Enterococcus spp., Candida albicans (3)
    • Pneumonia: aerobic gram-negative bacilli, Staphylococcus aureus, P. aeruginosa, Streptococcus spp. (3)
    • Bloodstream infection: Staphylococcus spp., Candida spp., Enterococcus spp., gram-negative bacilli (3)
    • SSI: S. aureus, gram-negative bacilli, Enterococcus spp., Streptococcus spp., Enterobacter spp., Bacteroides spp. (3)

Risk Factors

  • Extremes of age
  • Invasive surgical procedures (abdominal surgeries, orthopedic surgeries, urogynecologic surgeries, neurosurgery)
  • Use of indwelling medical devices
  • Chronic disease (including diabetes, renal failure, and malignancy)
  • Immunodeficiency
  • Malnutrition
  • Medications (recent antibiotics, proton pump inhibitors, and sedatives)
  • Colonization with pathogenic strains of flora
  • Breakdown of mucosal/cutaneous barriers, including trauma and battle wounds
  • Anesthesia
  • Lack of attention to detail with universal precautions

General Prevention

  • Prevention should target both patient-specific and facility-related risk factors.
  • Hand hygiene—thoroughly wash hands (5)[C].
    • On entering and leaving any patient room (5)
    • After contact with blood, excretions, body fluids, wound dressings, nonintact skin, mucous membranes (5)
    • Before using and after removing gloves (gloves are permeable to bacteria)
    • When moving hands from contaminated to clean body site (5)
    • Alcohol-based products are satisfactory when hands are not visibly soiled (5).
    • Soap and water should be used when surfaces are visibly soiled or when contact with spores is anticipated.
  • Antibiotic stewardship—appropriate selection of antimicrobial therapy includes the following:
    • Judicious use of antibiotics to reduce the emergence of multidrug-resistant organisms and the occurrence of CDI (2)
    • Use of narrow-spectrum early-generation antibiotics when possible
    • Taking an antibiotic “time out” at 72 hours to review the patient’s clinical status and culture results and eliminate (“streamline”) any redundant or unnecessary antibiotics
    • Use shorter courses of antibiotics when appropriate.
  • Hospital-based surveillance programs and antibiograms
  • Infection control programs with specially trained employees (5)[C]
  • Employee education on HAIs (5)[C]
  • Disinfection of hospital rooms with hydrogen peroxide vapor or UV irradiation in addition to standard cleaning reduces environmental contamination and the risk of infection with multidrug-resistant organisms.
  • Minimize invasive procedures.
  • Caregiver stethoscope cleaning
    • Stethoscope bacterial contamination is common. Regular cleaning with alcohol-based preparations reduces bacterial load. Evidence is lacking to confirm whether stethoscope contamination causes nosocomial infections.
  • Isolation of known pathogen carriers (5)[A]
    • Contact precautions
      • Institute for known pathogens spread by direct contact including methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus (VRE), C. difficile, extended-spectrum β-lactamase–producing gram-negative rods, and carbapenemase-producing gram-negative rods.
      • Glove when entering room (5)[B]
      • Gown if clothing will touch patient or environment (5)[B]
    • Droplet precautions
      • Infectious particles measure >5 μm.
      • Institute for pathogens shed via talking, coughing, sneezing, mucosal shedding, airway suctioning, and bronchoscopy. These include Neisseria meningitidis, influenza, Haemophilus influenzae, Corynebacterium diphtheriae, and Bordetella pertussis.
      • Mask when entering room (5)[B].
    • Airborne precautions
      • Infectious particles measure <5 μm.
      • Institute for pathogens shed via coughing including tuberculosis, varicella-zoster virus, and measles.
      • Fit-tested National Institute for Occupational Safety and Health (NIOSH)-approved ≥ N95 respirator on entering room (5)[B]
  • Infection-specific measures
    • CAUTI
      • Employee education on urinary catheters (indications, placement, maintenance)
      • Sterile catheter placement technique (6)[C]
      • Closed urine collection system (6)[C]
      • Use catheter only for necessary duration and remove as early as possible (6)[B].
      • Use of nurse-driven protocols for catheter removal
      • Do not confuse catheter-associated asymptomatic bacteriuria with CAUTI.
      • Do not screen for bacteriuria by routinely performing a urine culture when the catheter is withdrawn.
    • VAP
      • Intubate only when clinically necessary.
      • Perform oral decontamination with oral chlorhexidine.
      • Avoid nasotracheal intubation.
      • Inline suctioning
      • Elevate head to 30 to 45 degrees.
    • CLABSI
      • Educate staff about appropriate use of IV catheters (indications, placement, maintenance).
      • Place catheters using sterile technique (including chlorhexidine prep and maximal barrier precautions).
      • Use order “bundles” to improve adherence to catheter insertion guidelines.
      • Remove catheter promptly when no longer clinically indicated.
      • Hand hygiene in addition to glove use
      • Regularly monitor catheter site.
      • With introduction of these measures, CLABSI rates fell 46% between 2008 and 2011.
    • SSI
      • Proper surgical hand hygiene (2)[B]
      • Prophylactic antibiotic therapy when indicated (2)[A]; eliminate underlying infections before surgery if possible (2)[A].
      • Remove hair with electric clippers/depilatory agent prior to incision (2)[B].
      • Poor postoperative blood sugar control increases risk of infection.
    • CDI
      • Gloves combined with hand hygiene with soap and water (Spores are resistant to alcohol-based products.) (2)
      • Restrict use of fluoroquinolones, cephalosporins, and clindamycin when possible (2).
      • C. difficile is associated with the use of proton pump inhibitors: H2 blockers are preferred for acid suppression (7).
    • Bloodstream infections
      • Use of chlorhexidine-impregnated washcloths to bathe ICU patients reduces bloodstream infections by 28% (8)[B].
      • Routine surveillance for systemic inflammatory response syndrome (SIRS) using established criteria

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Citation

Stephens, Mark B., et al., editors. "Nosocomial Infections." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116408/all/Nosocomial_Infections.
Nosocomial Infections. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116408/all/Nosocomial_Infections. Accessed April 25, 2019.
Nosocomial Infections. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116408/all/Nosocomial_Infections
Nosocomial Infections [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 25]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116408/all/Nosocomial_Infections.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Nosocomial Infections ID - 116408 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116408/all/Nosocomial_Infections PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -