Uploaded byDr. Kanwal Deep Singh Lyall
Cabsi cauti-vap-nurses
The document discusses infection control and healthcare-associated infections (HAIs). It provides definitions for HAIs, noting they must manifest 48 hours or more after admission. The impact of HAIs is summarized as the leading cause of death in hospitals, with considerable economic costs including increased length of stay and resource allocation imbalances. Common types of HAIs discussed include urinary tract infections, catheter-associated bloodstream infections, and ventilator-associated pneumonia. Risk factors, prevention strategies, diagnosis, and treatment approaches are outlined for each infection type. The importance of appropriate catheter indication and maintenance to prevent catheter-associated UTIs and BSIs is emphasized.
In this document
Powered by AI
Introduction to infection control in healthcare settings by Dr. Kanwal Deep Singh Lyall.
Defines HAIs, their impacts including mortality, costs, length of stay, and role in multi-drug resistance.
Discusses microbial agents and patient susceptibility; focuses on urinary tract infections and related pathogens. Details on urinary catheter use, risk factors, etiology, diagnosis, and management for CAUTIs. CDC recommendations on catheter insertion and care; highlights prevention measures for CAUTIs. Discusses causes, risk factors, and management strategies for CLABSIs in healthcare settings.
Overview of VAP, associated bacteria, diagnosis, prevention strategies, and acceptable indications for catheter use.Guidelines for appropriate urinary catheter placement and criteria for diagnosing infections.
More Related Content
Similar to Cabsi cauti-vap-nurses
More from Dr. Kanwal Deep Singh Lyall
Cabsi cauti-vap-nurses
- 1. Infection Control Department ofMicrobiology Dr. Kanwal Deep Singh Lyall
- 2.
- 3. Working definition ofHAI Localized or systemic condition 1. that was not present or incubating at the time of admission to the hospital 2. that is acquired in a hospital or health care facility and 3. > 48 hours for most bacterial infections – OPD patients, shorter hospital stays- manifest after discharge
- 4. Impact of HAIs •Leading cause of death • Considerable economic costs • Increased length of stay • Direct costs to patients or payers • Indirect costs due to lost work, increased use of drugs, the need for isolation, and the use of additional laboratory and other diagnostic studies • Leads to imbalance between resource allocation for primary and secondary health care • Transmitting MDR into community
- 5.
- 6. CA - UrinaryTract Infections
- 7. Background: Urinary CatheterUse • 15-25% of hospitalized patients • Often placed for inappropriate indications • Physicians frequently unaware
- 8. 8 Catheter Associated UTI(CAUTI) • Catheter-risk of bacteriuria increases each day of use: • Per day: 5% • 1 week: 25% • 1 month: 100%
- 9. Evidence-based Risk Factorsfor CAUTI Symptomatic UTI Bacteriuria Prolonged catheterization* Disconnection of drainage system* Female sex Lower professional training of inserter* Older age Placement of catheter outside of OR† Impaired immunity Incontinence Diabetes Meatal colonization Renal dysfunction Orthopaedic/neurology services * Main modifiable risk factors
- 10. Etiology • Enterobacteriaceae • Enterococci •Streptococcus agalactiae • Pseudomonas • Streptococcus pyogenes • Staphylococcus aureus • CONS • Candida species
- 11.
- 12.
- 13. • Urine samplefrom catheter or MSU (if cath. Out with in 3 days of Dx UTI) – Culture • Plus S & S – UTI • Urgency/ Frequency / Dysuria / Loin Pain / Loin or suprapubic tenderness / Fever (≥ 38oC skin temp) / Pyuria (≥ 104WBC per ml) •
- 14.
- 15. EQUIPMENT • Non-sterile gloves •Alcohol swabs x 2 • 20 ml syringe • 21 gauge blunt cannula • Catheter clamp (if required) • Sterile specimen jar • Patient addressograph label, request form
- 16. Procedure • Perform handhygiene (Moment 1) • Clamp catheter below latex rubber & allow time for urine to collect Perform hand hygiene (Moment 2) and don non sterile gloves • Assemble sterile needle and syringe • Swab latex rubber port on catheter tubing with alcohol wipe and allow to dry for 30 seconds • Insert needle carefully into port and withdraw ≈20 mls of urine • Transfer to into sterile specimen jar
- 17.
- 18. Contd. • Dispose ofsharp in sharps container • Unclamp catheter • Dispose of other equipment appropriately • Remove gloves and perform Hand Hygiene (moment 3) • Label and transfer to lab immediately • Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag.
- 19. Specimen Patient preparationSpecial instructions Suprapubic aspirate Disinfect skin Needle aspiration above the symphysis pubis through abdominal wall into full bladder
- 20. CDC Recommendations Core Measures •Insert catheters only for appropriate indications • Leave catheters in place only as long as needed • Only properly trained persons insert and maintain catheters • Insert catheters using aseptic technique and sterile equipment • Maintain a closed drainage system • Maintain unobstructed urine flow • Hand hygiene Supplemental Measures • Alternatives to indwelling urinary catheterization • Portable ultrasound devices to ↓ unnecessary catheterizations • Antimicrobial/antiseptic- impregnated catheters
- 21. Catheter Care • UseStandard Precautions • Maintain closed system & unobstructed urine flow. • Don’t change catheters or drainage bags at routine, fixed intervals • Do not use systemic antimicrobials routinely to prevent CAUTI • Don’t clean periurethral area with antiseptics to prevent CAUTI while the catheter is in place. • Unless obstruction is anticipated, bladder irrigation is not recommended. • Routine irrigation of the bladder with antimicrobials is not recommended. • Clamping indwelling catheters prior to removal is not necessary. • Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended.
- 22. • For thehospital setting, Foleys should not be changed unless there is a mechanical problem, a break in the closed system of the catheter, or clinical indications
- 23. 23 Placement of UrinaryCatheter • Use smallest catheter size effective for patient (14 or 16F) • Catheters should be properly secured to prevent movement and urethral traction
- 24. Source • Healthcare InfectionControl Practices Advisory Committee (HICPAC) Guideline for prevention of catheter-associated urinary tract infections 2009 • Diagnosis, Prevention, and Treatment of CAUTIin Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America
- 25.
- 26.
- 27. IV Catheter RelatedInfections
- 28. Background: Impact • CABSI→ major cause of healthcare-associated morbidity and mortality • Increases the patient’s risk of death significantly • lead to longer length of stay
- 29. Which patients aremore susceptible to CRBSI ? •Age ≤1 or ≥60 years •Immunosuppressive chemotherapy •Loss of skin integrity (e.g., burn, psoriasis) •Severity of underlying illness •Granulocytopenia •Active infection at other site •Alteration in patient's cutaneous microflora
- 30. Etiology •CONS (≈40%) •Staphylococcus aureus •Enterococcusspp. •Candida spp. •P. aeruginosa •Enterobacter spp. •Acinetobacter spp. •Serratia spp. •Others
- 31. Pathogenesis CLABSI More CommonMechanisms 1. Pathogen migration along external surface - more common early (< 7days) 2. Hub contamination with intraluminal colonization -more common >10 days Less Common Mechanisms 1. Hematogenous seeding from another source 2. Contaminated infusatesHICPAC. Guideline for Prevention of Intravascular Device-Related Infections. Hub Contamination Contaminated Infusate Hematogenous spread Extraluminal Contamination Healthcare Personnel Hand Contamination Contamination of insertion site
- 32.
- 33. Volume of Blood •Do not overfill bottles(do not add more than 10 ml of blood to each bottle) • Adults – upto 20 ml • Paediatrics – upto 20 ml • Infants – upto 3 ml
- 34.
- 35. Materials • Swabs • 70% Alcohol • Tincture of iodine • Blood culture bottles (2 bottles per set) • Sterile Disposable Syringes (adult: 20 cc, pediatric: 5 cc) • Gloves (non-sterile) • Tourniquet • Sterile gauze pad • Adhesive strip or tape • Self-sticking patient labels
- 36. Prepare Cap • Removecap , disinfect septum with alcohol swab → allow to dry. • iodine may damage the septum
- 37. Skin preparation • Eitheralcohol or tincture of Iodine (TOI) of alcoholic chlorhexidine (>5%) rather than Povidone-iodine • If sample collection via C-line - clean hub with either alcohol or tincture of Iodine (TOI) of alcoholic chlorhexidine (>5%)
- 38. • Alcohol –apply in a circle ≈ 5 cm diameter & allow it to dry. • 2% TOI x 30 seconds → clean with alcohol • Don’t palpate the site again • Draw blood, do not change needle before injecting blood into culture bottle. • Clean site again with 70% alcohol.
- 39. • If abovesteps not followed → Contamination by skin flora → false positive → unnecessary antibiotic usage
- 40. Order of Draw/Collection: •1ST the aerobic vial → anaerobic vial. • Draw all other blood samples after blood culture has been collected. • Do not force blood into the bottle.
- 41. Mix • Gently rotatethe bottles to mix the blood & the broth (do not shake vigorously).
- 42. Diagnosis of CRBSI •Presenceof an intravascular device •Clinical evidence of infection (fever, chills, and/or hypotension) •and no apparent source for infection (except the catheter) and
- 43. 1. Positive peripheralvein blood culture and a or b a)Positive central line tip culture (Semi- quantitative, ≥ 15 CFU) with same organism & same antibiogram b)Positive central line blood culture with same organism and same antibiogram 2. Differential time to positivity •Positive result of central line blood culture obtained at least more than 2 hours earlier than Positive result of peripheral line blood culture
- 44. Prevention Strategies* • Removingunnecessary CL • Following proper insertion practices • Complying with hand hygiene • Performing adequate skin cleaning • Choosing proper CL insertion sites • Performing adequate hub/access port cleaning • Providing education on CL maintenance and insertion • Implementing chlorhexidine bathing* • Using antimicrobial- impregnated catheters • Applying chlorhexidine site dressings* Core Measures Supplemental Measures * Not part of 2002 HICPAC Guidelines for the Prevention of Intravascular Catheter-Related Infections
- 45. Femoral Vein Last choice SubclavianVein First Choice Internal Jugular Second choice CVL Insertion Bundle Component: CVL Site Choices Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis
- 46. Maximum Sterile BarrierPrecautions Hat and mask Persons within 6 feet also wear hat and mask Sterile gown Sterile gloves
- 47. Catheter Site DressingRegimens • Use CVC with minimum no. of ports or lumens • If place in medical emergency→ replace as soon as possible, i.e, within 48 hours • Use sterile gauze or sterile, transparent, semipermeable dressing to cover catheter site • Diaphoresis, bleeding or oozing, use gauze dressing until resolved • Replace dressing if the dressing becomes damp, loosened, or visibly soiled
- 48. • Don’t usetopical antibiotic ointment or creams on insertion sites, except for dialysis catheters • Showering permitted if precautions taken • Replace dressings gauze dressings every 2 days and transparent every 7 days • Monitor catheter sites visually → changing dressing or by palpation through an intact dressing on a regular basis
- 49. Management of CABSI •Consider line removal • If line is to be retained give intravenous antibiotics via the CVC • Consider antibiotic locks • Monitor & continue IV antibiotics for at least 48 hours after pyrexia resolves • If the patient fails to clinically improve after 48 hours of appropriate treatment the CVC should be removed and antibiotics continued.
- 50. Source • Healthcare InfectionControl Practices Advisory Committee (HICPAC) Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 • Clinical Practice Guidelines for the Diagnosis & Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America
- 51.
- 52.
- 53. Ventilator-associated Pneumonia inICU VAP - a form of nosocomial pneumonia that occurs in patients receiving mechanical ventilation for longer than 48 hours
- 54. Bacteria Associated WithVAP Early onset <96 hrs (4 days) of intubation • Staphylococcus aureus • Streptococcus pneumoniae • H. influenzae • Proteus spp. • Serratia marcescens • Klebsiella pneumoniae • E. coli • Enterobacter spp. Late onset > 96 hrs after intubation • P. aeruginosa • MRSA • Acinetobacter spp.
- 55. Bacterial Colonization –oropharynx, Stomach, Sinus Aspiration – Secretions, Vent condensate, Aerosol Ventilator Associated Pneumonia Pathogenesis of VAP
- 56. Diagnosis • Based on3 components 1. Systemic signs of infection 2. New or worsening infiltrates seen on chest X-ray 3. Bacteriological evidence of pulmonary infection 4. mCPIS Score
- 57. CPIS Points 01 2 Temperature(⁰C) ≥36.5 & ≤38.4 (97.7 – 101.2) ≥38.5 & ≤38.9 101.3 – 102.2) ≥39 or ≤36 (102.2 F) Leukocytes (Count/mm³) ≥4,000 & ≤11,000 <4,000 or >11,000 <4,000 or >11,000 + Band forms ≥500 Tracheal Secretions Rare Abundant Abundant + Purulent Oxygenation PaO₂/FaO₂ mmHg >240 or ARDS ≤240 & No evidence of ARDS Chest X-ray No infiltrate Diffused Localized Microbiology Negative Positive mCPIS Score
- 58. Recommendations To PreventHAP • Effective hand washing and PPE • Semi-recumbent position of patient • Avoidance of large gastric volumes • Oral (non-nasal) ventilation • Routine maintenance of ventilator circuits and suction equipment • Continuous subglottic suctioning • Humidification with heat and moisture exchangers • Respiratory physiotherapy • Chlorhexidine mouth wash
- 59. Securing position ofETT: • Secure with cloth tape (adhesive as indicated), with an approved ETT holder device or with trach ties. • Change ETT securing device when it becomes soiled / soaked • Move ETT to opposite side of the mouth when ETT securing device is changed or soreness / redness is noted • Verify proper position of ETT by auscultation of breath sounds, noting tube depth at lip / teeth line, and monitoring X-ray results.
- 60. Suctioning using in-linesuction device (preferred method) • Suctioning frequency determined by patient need – amount of secretions, respiratory pattern / workload, SpO2, breath sounds • PPE (mask, eye shield, gloves) during the suctioning procedure. • Hyperoxygenate (100% O2) before and after each suctioning “pass” unless contraindicated. • Allowed SpO2 to return to baseline in between suctioning passes • Apply intermittent suction during withdrawal of suction catheter. • Entire suctioning "pass" should not exceed 10 seconds. • Suction pressure should not exceed 150 mmHg or as outlined by unit protocol.
- 61. Intubation and mechanicalventilation. • Intubation and re-intubation should be avoided • NIV should be used whenever possible • Orotracheal and orogastric tubes preferred over nasotracheal intubation and nasogastric tubes • Continuous aspiration of subglottic secretions • Maintain ETT cuff pressure > 20 cm H2O to prevent leakage around the cuff into lower RT • Contaminated condensate should be carefully emptied from ventilator circuits
- 62. Notify Consultant for: •SpO2 < 90% or change greater than 5% • Unplanned extubation • Respiratory distress • Inadequate sedation • Increased peak airway pressure
- 63.
- 64. 64 Acceptable Indications for UrinaryCatheter Placement • Acute urinary retention or obstruction • Perioperative use in selected surgeries • Assist healing of perineal and sacral wounds in incontinent patients • Hospice/comfort/ palliative care • Required immobilization for trauma or surgery • Chronic indwelling on admission 64
- 65. 65 Unacceptable Reasons forPlacement • Urine output monitoring OUTSIDE intensive care • Incontinence • Morbid obesity • Immobility • Confusion or dementia • Patient request 65
- 66. Criteria 1 (Catheterin situ) • ≥104 micro-organisms per ml from a catheter specimen of urine and • ONE or more of the following with no other recognised cause: –Urgency/ Frequency / Dysuria / Loin Pain / Loin or suprapubic tenderness / Fever (≥ 38oC skin temp) / Pyuria (≥ 104WBC per ml)
- 67. Or (Criteria 1contd…) • The physician diagnoses UTI, institutes antibiotic therapy and • TWO or more of the following with no other recognised cause: –Urgency/ Frequency / Dysuria / Loin Pain / Loin or suprapubic tenderness / Fever (≥ 38oC skin temp) / Pyuria (≥ 104WBC per ml)
- 68. Criteria 2 (removedwithin 3 days prior to onset of UTI ) • ≥ 105 micro-organisms from a mid stream specimen • And ONE or more of the following with no other recognised cause: –Urgency/ Frequency / Dysuria / Loin Pain / Loin or suprapubic tenderness / Fever (≥ 38oC skin temp) / Pyuria (≥ 104WBC per ml)
- 69. Or (Criteria 2contd…) • The physician diagnoses UTI, institutes antibiotic therapy and • TWO or more of the following with no other recognised cause: –Urgency/ Frequency / Dysuria / Loin Pain / Loin or suprapubic tenderness / Fever (≥ 38oC skin temp) / Pyuria (≥ 104WBC per ml)
- 70. Indications for bloodculture • Clinical features of sepsis • Suspicion of infective endocarditis • Pyrexia of unknown origin • Unexplained leucocytosis or leucopenia • Systemic and localised infections including suspected meningitis, osteomyelitis, septic arthritis, acute untreated • Bacterial pneumonia or other possible bacterial infection
- 71. What is aBlood Culture? • Lab test in which blood is injected into bottles with culture media to determine whether microorganisms have invaded the patient’s bloodstream.
- 72. Site of Collection •First preference- peripheral (not through a line) • Second -central line • For paediatrics – physician’s decision
- 73. Number Of samples •Paired samples • Acute febrile episode. - 1 set before (before antimicrobials). • Non-acute disease - 1 set • Endocarditis, acute - +2 sets within 1 to 2 hours before antimicrobials if possible. • Endocarditis, sub-acute - + 2 sets ≥ 1 hour apart within 24 hours. If negative at 24 hours, obtain 2 or 3 more sets.
- 74. Timing of collection •2 or 3 samples → at intervals of several hours. • Before antibiotic therapy prior to next dose of antibiotics