Lim, Mary Lim, Phoebe Lim, Syndel Lipana, Kirk Liu, Johanna Case 3 Lim, Mary Lim, Phoebe Lim, Syndel Lipana, Kirk Liu, Johanna

A 38 y/o G3P3 diabetic delivered by Caesarian section due to a big baby. She was non-ambulatory and on indwelling catheter on the first 24 hours post operation. On the 3rd H.D she experienced fever and chills. Post operative wound was clean. CBC revealed leucocytosis with predominance of neutrophils and urinalysis with marked pyuria.

Salient Features 38 y/o pregnant diabetic female G3P3 Delivered big baby thru caesarean Non-ambulatory With indwelling catheter Post-op wound was clean On 3rd day of H.D.: fever and chills CBC: leukocytosis (↑neutrophils) Urinalysis: Pyuria

1. What is your diagnosis?

Urinary Tract Infection Diagnosis Urinary Tract Infection

Urinary tract infection (UTI) Characterized by BACTERIURIA and PYURIA May be symptomatic or asymptomatic May affect the kidneys (pyelonephritis) or the bladder (cystitis)

Etiology More than 85% - caused by Gram (-) bacilli that are normal inhabitants of the intestinal tract Most common: Escherichia coli Other causes: Proteus Klebsiella Enterobacter Streptococcus faecalis

2. What are the factors that predisposed this patient to this infection?

Risk factors Indwelling catheterization The daily risk of bacteriuria with catheterization is 3% to 10%, approaching 100% after 30 days Other risk factors: female sex, diabetes mellitus, older age, impaired immunity, and lack of antimicrobial exposure

PATHOGENESIS 2 ROUTES HEMATOGENOUS - through the bloodstream ASCENDING - from the lower urinary tract

PATHOGENESIS HEMATOGENOUS INFECTION - less common - results from seeding of the kidneys by bacteria from distant foci in the course of septicemia or infective endocarditis

PATHOGENESIS ASCENDING INFECTION Colonization of the distal urethra and introitus ( in the female) by coliforms From the urethra to the bladder –urethral catheterization Urinary tract obstruction and stasis of urine Vesicoureteral reflux Intrarenal reflux

3. How do you classify these infections acquired within the institutions?

Nosocomial infections Infections which are a result of treatment in a hospital but not secondary to the patient's original condition. Appear 48 hours or more after hospital admission or within 30 days after discharge

4. Differentiate these type of infections.

Nosocomial Infections Four most common types of nosocomial infections are: UTI SSI Nosocomial Pneumonia Nosocomial Bacteremia

Urinary Tract Infection 80% associated with the use of indwelling catheters Associated with less morbidity Gram-negative enterics, 50% Fungi, 25% Enterococci, 10%

Surgical Site Infection Are also frequent – 15% Presence of purulent discharge around the wound or the insertion site of a drain or – Presence of cellulites which is emanating from the wound Patients acquire infection either endogenously or exogenously Contamination varies with the length of the procedure and the health condition of the patient Staphylococcus aureus, 20% Pseudomonads, 16%

Nosocomial Pneumonia About 3% of patients on ventilators acquire pneumonia The source is often endogenous but may also be exogenous with transfer of an organism from the respiratory equipment

Risk factors mechanical ventilation (high risk), elderly, neonates, severe underlying disease, immunodeficiency, depressed sensorium, cardiopulmonary disease, recent thoraco-abdominal surgery

Pathogens infecting the Respiratory tract Bacterial pneumonia Legionnaires' disease Pulmonary aspergillosis Mycobacterium tuberculosis Viral pneumonias Respiratory Syncytial Virus (RSV) Influenza

Nosocomial Bacteremia About 5% of nosocomial infections may occur at the entry site of the intravascular device sources of infection-causing microorganism for these infections are endogenous Coagulase-negative staphylococci, 40% Enterococci, 11.2% Fungi, 9.65% Staphylococcus aureus, 9.3% Enterobacter species, 6.2% Pseudomonads, 4.9%

5. What are the recommended preventive measures?

Prevention Place bladder catheters only when absolutely needed (e.g. to relieve obstruction). Use aseptic technique. Minimize manipulation or opening of drainage systems. Remove bladder catheters as soon as is feasible. Healthcare providers clean their hands by washing them with soap and water or using an alcohol-based hand rub before and after touching the catheter. Avoid disconnecting the catheter and drain tube. This helps to prevent germs from getting into the catheter tube.

The catheter is secured to the leg to prevent pulling on the catheter. Avoid twisting or kinking the catheter. Keep the bag lower than the bladder to prevent urine from backflowing to the bladder. Empty the bag regularly. The drainage spout should not touch any­thing while emptying the bag

6. What are other organisms that cause pulmonary, gastrointestinal and post surgical wound infections?

Microorganism Infections caused Staphylococcus aureus, Coagulase negative Staphylococci, Enterococci Surgical wound infections, Pneumonia, Septicemia, Urinary Tract Infections Escherichia coli, Pseudomonas aeruginosa, Enterobacter spp. And Klebsiella Pnemoniae Pneumonia and surgical wound infections Clostridium difficile Causes nearly half of nosocomial diarrhea Candida Albicans Urinary tract infections and Septicemia Acinetobacter, Citrobacter, Haemophilus Urinary tract infections and surgical wound infections

Hospital acquired: Pulmonary Pseudomonas aeruginosa most common MDR Gram-negative bacterium causing Ventilator-associated pneumonia Methicillin-resistant Staphylococcus aureus is an increasing cause of VAP Ventilator-associated pneumonia  people who are on mechanical ventilation through an endotracheal or tracheostomy

Hospital acquired: Gastrointestinal Clostridium difficile Causes pseudomembranous colitis offensive-smelling diarrhea, fever, and abdominal pain life-threatening complications can develop Ex: Toxic megacolon Clindamycin causes the alteration of the normal bacterial flora of the bowel

Hospital acquired: Surgical wound Most common causes of surgical site infection: Staphylococcus aureus - wounds and incisions Staphylococcus epidermidis - nosocomial bacteremia Bacteroides fragilis - anaerobic isolate from surgical infection Example: Surgical site infection Those that occur as a result of a surgical procedure or those that require surgical intervention as part of their treatment S. Aureus because it is the most common normal flora of the skin B. Fragilis because it is a common normal flora of the gi

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