1. Health Care Associated Infections
Prof. Dr. A. Çağrı Büke
Yeditepe University Medical Faculty
Infectious Diseases and Clinical Microbiology

2. Health care associated infections
Ç. BÜKE HCAI / NI
Health care associated infections
Health care-associated infections, or infections acquired in health-care settings are the most frequent adverse event in health-care delivery worldwide
Hundreds of millions of patients are affected by health care-associated infections worldwide each year, leading to significant mortality and financial losses for health systems

3. Ç. BÜKE HCAI / NI
HCAIs
Of every 100 hospitalized patients at any given time, 7 in developed (7%) and 10 (10%) in developing countries will acquire at least one health care-associated infection
While urinary tract infection is the most frequent health care-associated infection in high-income countries,
Surgical site infection is the leading infection in settings with limited resources, affecting up to one-third of operated patients
This is up to nine times higher than in developed countries

4. Ç. BÜKE HCAI / NI
HCAIs
In high-income countries, approximately 30% of patients in intensive care units (ICU) are affected by at least one health care-associated infection
In low- and middle-income countries the frequency of ICU-acquired infection is at least 2─3 fold higher than in high-income countries
Newborns are at higher risk of acquiring HCAIs

5. Epidemiology Ç. BÜKE HCAI / NI
Studies indicate that each year, hundreds of millions of patients are affected by HCAIs around the world
The European Centre for Disease Prevention and Control reports an average prevalence of 7.1% in European countries
The estimated incidence rate in the United States of America (USA) was 4.5%

6. Definition of HCAIs Ç. BÜKE HCAI / NI
Health care-associated infections, or “nosocomial” and “hospital” infections, affect patients in a hospital or other health-care facility, and are not present or incubating at the time of admission
That appear more than 48 h after admission
They also include infections acquired by patients in the hospital or facility but appearing after discharge
10 days – 1 month – 1 year

7. Risk factors for HCAIs Ç. BÜKE HCAI / NI
Prolonged and inappropriate use of invasive devices and antibiotics
immuno-suppression and other severe underlying patient conditions;
Insufficient application of standard and
isolation precautions
Urinary tract infection
Ventilator associated infection
CVC related blood stream infection
Surgical site infection

8. Determinants of HCAIs Ç. BÜKE HCAI / NI
Inadequate environmental hygienic conditions and waste disposal;
Poor infrastructure;
Insufficient equipment;
Understaffing;
Overcrowding;
Poor knowledge and application of basic infection control measures;
Lack of procedure;
Lack of knowledge of injection and blood transfusion safety;
Absence of local and national guidelines and policies.

9. Magnitude of HCAIs Ç. BÜKE HCAI / NI
Health care-associated infections create additional suffering and come at a high cost for patients and their families
Infections prolong hospital stays, create long-term disability, increase resistance to antimicrobials, represent a massive additional financial burden for health systems and cause unnecessary deaths
Such infections annually account for attributable deaths in Europe and potentially many more that could be related, and they account for deaths in the USA

10. Economic impact of HCAIs
Ç. BÜKE HCAI / NI
Economic impact of HCAIs
Annual financial losses due to health care-associated infections are also significant:
They are estimated at approximately €7 billion in Europe, including direct costs only
and reflecting 16 million extra days of hospital stay, and at about US$ 6.5 billion in the USA.

11. Ç. BÜKE HCAI / NI
Sources of HCAIs

12. Surgical site infections
Ç. BÜKE HCAI / NI
Surgical site infections
Most common nosocomial infection among surgical patients (38%)
2/3 incisional
1/3 organs or spaces accessed during surgery
Clinical signs generally occur
Systemic and local signs of inflammation
Bacterial counts ≥ 105 cfu/mL
Purulent versus non-purulent leakage
Surgical chemoprophylaxis is important for prevention

13. Ç. BÜKE HCAI / NI
Staphylococcus aureus, Enterococci, CNS, E.coli, K.pneumoniae, A. baumannii, P.aeruginosa
SSI
Superficial SSI; involves only skin or subcutaneous tissue of the incision
Infection occurs within 30 days after the operation
Deep incisional SSI; involves the deep soft tissue (e.g., fascia and muscle layers)
Infection occurs within 30 days after the operation without implant, within 1 year with implant
Organ/space SSI; involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation

14. Risk factors for SSI Ç. BÜKE HCAI / NI Duration of surgical scrub
Maintain body temp
Skin antisepsis
Preoperative shaving
Duration of operation
Antimicrobial prophylaxis
Operating room ventilation
Inadequate sterilization of instruments
Surgical drains
Surgical technique
Poor hemostasis
Age
Diabetes
HbA1C and SSI
Glucose > 200 mg/dL postoperative period (<48 hours)
Nicotine use: delays primary wound healing
Steroid use: controversial
Malnutrition: no epidemiological association
Obesity: 20% over ideal body weight

15. SSI wound classification
Ç. BÜKE HCAI / NI
SSI wound classification
Class 1 = Clean
Operative wound clean, non-traumatic, with no inflammation encountered, no break in technique
Gastrointestinal, respiratory and genitourinary tracts not entered
Neurological procedures
Endocrine procedures
Eye surgery
Orthopedic procedures
Penile prosthesis
Vascular procedures
Skin (mastectomy, lumpectomy, lesions,
lipoma, cosmetic
Exploratory Lap (no bowel involvement II)
Expected rate of infection: %

16. SSI wound classification
Ç. BÜKE HCAI / NI
SSI wound classification
Class 2 = Clean contaminated
Non-traumatic wound with minor break in technic
Gastrointestinal, respiratory and genitourinary tracts entered without significant spillage. Thoracic procedure (except mediatinoscopy I)
GI procedures (including: laparoscopy, colonoscopy, gastroscopy), (it is III)
GU procedures (infected III)
Ear surgery (infected III)
Nose/Oropharynx procedures
GYN procedures (oophorectomy I, inflammed III, infective IV, Histerectomy)
Expected rate of infection: %

17. SSI wound classification
Ç. BÜKE HCAI / NI
SSI wound classification
Class 3 = Contaminated
Operative wound contaminated
Fresh traumatic wound from clean source
Operative wound with a major break in techique
Gross spillage from the gastrointestinal tract
Incision encountering acute non-purulent inflamation
Expected rate of infection: %

18. SSI wound classification
Ç. BÜKE HCAI / NI
SSI wound classification
Class 4 = Dirty infected
Operative wound dirty
Traumatic wound from dirty source
Fecal contamination
Foreign body
Retained devitialized tissue
Operative wound with acute bacterial
Operative wound where clean tissue is transected to gain access to a collection of pus
Infected
Abscess
Wound debridement
Expected rate of infection: %

19. Organisms responsible for SSI
Ç. BÜKE HCAI / NI
Organisms responsible for SSI
Staphylococcus aureus
Enterococci
CNS
E.coli
K.pneumoniae
A. baumannii
P.aeruginosa

20. Prevention of SSIs Ç. BÜKE HCAI / NI Proper hair removal
Take a bath with chlorhexidine containing shampoo
Antisepsis of surgical area with 2% chlorgexidine
Appropriate prophylactic antibiotic chosen
Antibiotic given within 1 hour before incision
Discontinuation of antibiotic within 24 hours of surgery
Glucose control
Normothermia in colorectal surgery patients

21. Urinary tract infection
Ç. BÜKE HCAI / NI
Urinary tract infection
Associated with urinary catheter and invasive urological procedures
Catheter-associated (CA) bacteriuria is the most common HCAI infection worldwide
The rate of widespread andinappropriate use is high

22. Diagnosis of CA-UTI Ç. BÜKE HCAI / NI
Patient has at least 2 of the following signs or symptoms with no other recognized cause:
Fever (38.8C),
Urgency, frequency, dysuria, or suprapubic tenderness
and at least 1 of the following
Positive dipstick for leukocyte esterase and/ or nitrate
Pyuria
Organisms seen on Gram’s stain of unspun urine and
Isolation the uropathogen with >102-3 cfu/ml in non voided specimen

23. Prevention of CA-UTI x Ç. BÜKE HCAI / NI
Closed system integrity should not be impaired
The most effective way to reduce the incidence of CA-UTI is to reduce the use of urinary catheterization by restricting its use to patients who have clear indications and by removing the catheter as soon as it is no longer needed x

24. Catheter associated bloodstream infection
Ç. BÜKE HCAI / NI
Catheter associated bloodstream infection
Risk factors
Heavy skin colonization at the insertion site
Internal jugular or femoral vein sites
Duration of placement
Contamination of the catheter hub
12-25% attributable mortality

25. Catheter associated bloodstream infection
Ç. BÜKE HCAI / NI
Catheter associated bloodstream infection
Risk for bloodstream infection:
BSI per 1,000 catheter/days
Subclavian or internal jugular CVC
5-7
Hickman/Broviac (cuffed, tunneled) 1
PICC

26. Epidemiology of CA-BSI
Ç. BÜKE HCAI / NI
Epidemiology of CA-BSI

27. Prevention of CA-BSI Ç. BÜKE HCAI / NI
Limit duration of use of intravascular catheters
No advantage to changing catheters routinely (except for Staphylococcus spp. and Candida spp.)
Change PICCs every 72 hours
Maximal barrier precautions for insertion
Sterile gloves, gown, mask, cap, full-size drape
Chlorhexidine prep for catheter insertion
Maximal barrier precautions
Daily review of line necessity

28. Nosocomia pneumonia Ç. BÜKE HCAI / NI
Nosocomial pneumonia is the 2nd most common hospital-acquired infections after UTI.
Accounting for 31 % of all nosocomial infections
Nosocomial pneumonia is the leading cause of death from hospital-acquired infections %
The incidence of nosocomial pneumonia is highest in ICU, especially due to invasive mechanical ventilation (Ventilator associated pneumonia). 10-fold higher than non-ventilated patients

29. Definition of NP Early-onset nosocomial pneumonia:
Ç. BÜKE HCAI / NI
Definition of NP
Early-onset nosocomial pneumonia:
Occurs during the first 4 days
Usually is due to S. pneumoniae, MSSA, H. Influenza,
or anaerobes.
Late-onset nosocomial pneumonia:
More than 4 days
More commonly by G(-) organisms, esp. P. aeruginosa,
Acinetobacter, Enterobacteriaceae (Klebsiella spp., E.coli,
Enterobacter, Serratia) or MRSA.
Anaerobes are common in patients predisposed to aspiration
Legionella spp.

30. Ventilator associated pneumonia
Ç. BÜKE HCAI / NI
Ventilator associated pneumonia
Ventilator-associated pneumonia (VAP) is pneumonia that develops 48 hours or longer after mechanical ventilation is given by means of an endotracheal tube or tracheostomy
Results from the invasion of the lower respiratory tract and lung parenchyma by microorganisms
Intubation compromises the integrity of the oropharynx and trachea and allows oral and gastric secretions to enter the lower airways

31. Diagnosis of VAP Ç. BÜKE HCAI / NI
New or progressive radiographic consolidation or infiltrate
In addition, at least 2 of the following:
Temperature > 38 °C
Leukocytosis (white blood cell count ≥  12,000 cells/ mm3 or leukopenia (white blood cell count <  4,000 cells/mm3)
Presence of purulent secretions

32. Prevention of HCAIs Ç. BÜKE HCAI / NI Transmission of HCAIs
By direct contact with patients
By droplets
By airborn

33. Prevention of HCAIs Ç. BÜKE HCAI / NI Goals; Protect the patients
Patients to patients transmission by HCWs
Protect the health care workers
By contact, airborne and droplets
Needle stick injury

34. Hand hygiene Prevention of HCAIs Ç. BÜKE HCAI / NI Gloves
Standard precautions
Isolation
Contact isolation
Airborn isolation
Droplet isolation
Gloves
Mask
Eyeglasse
Hand hygiene
Gown

35. Dressing and undressing of protective equipment
Ç. BÜKE HCAI / NI
Dressing and undressing of protective equipment
Perform hand hygiene
Place the gown
over the scrubs
Put on a mask
Put on eyeglasse or a face shield
Put on gloves
Remove gloves
Remove gown
Perform hand hygiene
Remove eyeglasse or a face shield
Remove mask

36. Ç. BÜKE HCAI / NI
Hand hygiene

37. Hand hygiene Ç. BÜKE HCAI / NI
40–60 second by washing with soap and water

38. Hand hygiene Ç. BÜKE HCAI / NI
20–30 second by handrubbing with antiseptics