Healthcare Associated Infections. Stephanie M. Podolski, MPH, MSPA, PA-C Hospitalist PA Maine General Medical Center

Transcription

1 Healthcare Associated Infections Stephanie M. Podolski, MPH, MSPA, PA-C Hospitalist PA Maine General Medical Center

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3 Disclosures No financial or business related disclosures to report

4 Overview Pneumonia (HAP and VAP) Gastrointestinal Illness Urinary Tract Infections Primary Bloodstream Infections Surgical site infections (inpatient surgery) Line infections (PICC, Midline or Central Line Associated Infections) Antibiotic Resistant Infections

5 Healthcare-Associated Infections (HAIs) Infections acquired while patient s receive medical treatment in a health care facility Threat to patient safety Often preventable Surveillance and data collections through the National Healthcare Safety Network and the Emerging Infections Program

6 Healthcare-Associated Infections (HAIs) 1 in 25 hospitalized patients will acquire a healthcare-associated infection each day The CDC s annual National and State Healthcare-Associated Infections Progress Report found: 50% decrease in central line-associated blood stream infections between 2008 and 2014 No change in the rate of catheter-associated UTIs between 2009 and % decrease in surgical site infections in specifically tracked procedures 8% decrease in hospital onset C. difficile infections between 2011 and % decrease in hospital onset MRSA bacteremia between 2011 and 2014

7 Types of Infections

8 Central Line Associated Blood Stream Infections (CLABSIs) Central line is a catheter that is placed in a large major vein in the neck, chest (often close to groin) or groin Strict protocol for insertion, followed by strict infection control prevention practices Provide patient with education regarding proper maintenance and monitoring Remove central line as soon as no longer needed CLABSI: when bacteria or viruses enter the bloodstream through the central line Results in thousands of deaths per year Adds billions of dollars in added U.S. healthcare costs Entirely preventable

9 Surgical Site Infection (SSI) SSI: an infection that occurs in the part of the body where the surgery took place Superficial involving skin only Tissues under the skin, organs or implanted material Symptoms: redness, pain, fever, chills, purulent drainage Treatment: Antibiotics usually start broad spectrum and tailor toward appropriate organism based on culture

10 SSI Prevention Patient education Medical providers, nurses, and staff must follow CDC surgical infection prevention guidelines Clean hands and arms up to elbows with antiseptic prior to surgery Clean hands with soap and water or alcohol based hand rub before and after caring for each patient. Shave patient as indicated (area where procedure will occur) Wear hair covers, masks, gowns, and gloves during surgery and maintain sterile technique When indicated, give antibiotics 60 minutes pre-op and stop within 24 hours post-op Use appropriate antiseptic on skin prior to operation

11 Catheter Associated UTI (CAUTI) UTI: infection related to urethra, bladder, ureters or kidneys. HA UTI: Approximately 75% are associated with a urinary catheter (15-20% of patients have catheters during hospitalization) CAUTI: infection related to use of urinary catheter. prolonged use is highest risk factor Should only be used for appropriate clinical indications

12 CDC Guidelines: Appropriate Use

13 CDC Guidelines: Inappropriate Use

14 CDC: Alternative Recommendations

15 CAUTI Prevention Is Key Ensure Proper Urinary Catheter Placement Techniques with Nursing Staff Ensure Proper Urinary Catheter Maintenance Techniques and Protocols are Followed Know if your hospital has a Quality Improvement Program PAs need to continue surveillance and monitoring inpatient and outpatient Long term catheters change every 30 days Consider Urology Involvement

16 Pneumonia: Definitions Health Care Associated Pneumonia (HCAP) Hospitalized within 90 days of infection Reside in nursing home or long term care facility Received parenteral antimicrobial therapy, chemotherapy or wound care within 30 days Ventilator Acquired Pneumonia (VAP): pneumonia during mechanical ventilation or sustained immediately after Community Acquire Pneumonia No contact to medical institutions. Common organisms S. Pneumonia, H. influenza, M. catarrhalis Less common atypical bacteria (Chlamydia pneumonia, Mycoplasma pneumonia, Legionella)

17 Pneumonia in Hospitalized Patients Community Acquired Pneumonia (CAP) Usual treatment is macrolide and cephalosporin. If risk for pseudomonas or aspiration, then consider Fluoroquinolone or broad spectrum antibiotic, such as Zosyn. CURB-65 score is a Pneumonia Severity Score» Confusion» BUN >19 mg/dl» Respiratory Rate >30» Systolic BP 90 or Diastolic BP 60» Age 65 For severe pneumonia (CURB-65 score >=3), steroid (oral) could improve mortality, reduce risk for ARDS, shorten length of stay. Routine coverage for atypical pneumonia is probably not necessary Duration of therapy for CAP 5-7 days are adequate for mild to moderate cases.

18 Pneumonia in Hospitalized Patients HCAP (Health Care Associated Pneumonia) term used to include VAP and HAP. Concept of "HCAP" is removed by 2016 Clinical Practice Guidelines by the Infectious Disease Society of America and the American Thoracic Society because Most patients with HCAP do not have antibiotic resistant pathogens Broad spectrum prescribing should be based on a narrow set of risk factors that better predict the presence of resistant pathogens HAP (hospital acquired pneumonia) and VAP (ventilator-associated pneumonia) are still treated with broader spectrum antibiotic than CAP.

19 Ventilator Associated Pneumonia (VAP) VAP: lung infection that develops in a person who is on a ventilator by means of tracheostomy or endotracheal tube (intubation) Treatment: Broad spectrum IV antibiotics Prevention while in the hospital Elevate head of bed degrees unless other medical conditions prevent this Monitor patient s ability to breathe on their own daily Proper hand hygiene from staff and family/friends Adequate oral hygiene

20 Pneumonia follow-up If the patient has COPD, re-order PFT s after completion of antibiotic and steroid course Always reassess for possibility of aspiration or other risk factors, immunosuppression, environmental factors, etc. Ensure that the patient has had PCV13 and PPSV23 May require outpatient Pulmonary consult

21 Clostridium Difficile Colitis Clostridium difficile is a spore forming, Gram positive anaerobic bacillus that produces two exotoxins (A and B) Accounts for 15-25% of antibiotic associated diarrhea Fluoroquinolones, penicillins, cephalosporins, clindamycin Doxycycline has the smallest risk PPIs increase the risk of C.diff by 65% First line treatment: Oral vancomycin (125 mg QID) for days OR metronidazole 500 mg TID for days Probiotics while on antibiotics

22 Clostridium Difficile Colitis Diseases resulting from C. Difficile: Pseudomembranous colitis Toxic megacolin Perforations of the colon Sepsis Death (rarely)

23 Bacteremia Bacteremia describes the presence of viable bacteria in the blood. Two Types: Transient or sustained bacteremia. Transient: usually 2 10 minutes. Common e.g. after toothbrushing, various procedures, such as organ biopsies. Sustained: a bacteremia lasting over minutes and often days to weeks. **Important to find source of Bacteremia

24 How does bacteremia occur? Bacteria enter the circulatory and lymphatic systems through acute infections or breaches of the skin barrier or mucosa. Breaches occur common means teeth brushing, insect bites or small wounds Usually our immune system will prevent microscopic bacteremia below threshold of detection Once threshold is broken, bacteremia can lead to septicemia with dangerous complications such as toxemia, sepsis, and septic shock. FUN FACT: Once symptomatic, the immune response to the infection results in the clinical signs and symptoms rather than exposure to the microbes themselves.

25 Bacteremia KEY POINT: In the patient with bacteremia, it is important to determine if the patient has transient vs. sustained bacteremia. How do you do this? Can you tell if a patient has bacteremia by Hx and P.E.?

26 Blood Cultures Blood Culture Rule of Thumb: In suspected bacteremic patients, obtain at least two blood cultures BEFORE any Antibiotics! Collection of samples can be done back to back. The previous common practice of separating each culture by minutes can increase time to antibiotic administration. Make sure skin prep and procedure in which blood cultures are drawn is accurate in order to avoid contamination (RN or Lab) Positive blood cultures: R/o skin contaminants Remember staph coagulase (-) and (+) are commonly on the skin Define etiology and Identify pathogens Two or more spaced blood cultures allow the determination of transient vs. sustained bacteremia. Sustained bacteremias are more worrisome. Allow for bacterial susceptibilities to Antibiotics to be done. Goal will be to narrow the spectrum of antibiotic treatment ASAP

27 Organisms Involved in HAIs Actinetobacter Burkholderia cepacia Clostridium difficile Clostridium Sordellii Carbapenem-resistant Enterobacteriaceae (CRE Gram-negative Bacteria Hepatitis HIV Klebsiella MRSA Mycobacterium acscessus Norovirus Pseudomonas aeruginosa Staphylococcus aureus Tuberculosis VISA/VRSA Vancomycin-resistant Enterococci (VRE)

28 HAI Progress Report

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30 Why Do We Care? Often times HAI require broad spectrum antibiotic treatment, and if provided to patients over an extended period of time, then this can increase population resistance. Important note: Know your states antibiotic resistance by population we want to be stewards of appropriate antibiotic prescribing.

31 CDC Antibiotic Resistance Patient Safety Atlas Data collected from U.S. Healthcare facilities that reported at least one HAI to CDC NHSN Dates collected: , with updates in 12/2015 Reported events; CLABSI, CAUTI, and SSI Reported pathogens: MRSA Carbapenem-resistant Enterobacteriaceae (CRE) Multidrug-resistance Pseudomonas aeruginosa

32 National Average for Antibiotic Resistance?

33 New England Antibiotic Resistance by State

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35 Preventing HAIs Targeted Assessment for Prevention (protocols and proper procedures for nursing and medical provider insertion and maintenance of catheters, etc.) Infection Control and Prevention Plans Patient Information Packets Outpatient follow-up care guides

36 Systemic Inflammatory Response Syndrome (SIRS) and Sepsis

37 SIRS Systemic Inflammatory Response Syndrome (SIRS) SIRS is an appropriate response to infection or any other stimulus that activates physiological inflammatory response. New Data from New England Journal suggests we stop screening people for SIRS There is potential that every hospitalized person will meet SIRS criteria at least once during a hospital stay

38 History of SIRS Systemic inflammatory response system (SIRS) has been a term used clinically for more than 20 years. SIRS is considered present when two of more of the acute findings of tachycardia, leukocytosis or leukopenia, fever or hypothermia or tachypnea (elevated respiratory rate) were present If a source of infection was found and documented and SIRS criteria was indeed met, then patients were said to have sepsis. PROBLEM: Sepsis became a commonly used clinical term. After reassessing this concept, in 2012, a consensus of experts concluded that SIRS was a potentially misleading term and this nomenclature was discarded. The 2012 consensus group defined sepsis as a systemic, deleterious host response to infection leading to severe sepsis (acute organ dysfunction secondary to documented or suspected infection) and septic shock (severe sepsis plus hypotension not reversed by fluid resuscitation). The term septic patient was still embraced by the 2012 consensus group but a more fluid definition was acceptable. Then the Sepsis 2015 Guidelines came Along and everything changed

39 Sepsis Redefinition Sepsis is not simply infection + two or more SIRS criteria Why was it changed? Too many variables Definition for severe sepsis is confusing 4 different ways to classify sepsis in the U.S. Different criteria caused different mortality measurements Mortality for Septic Shock United States % Australia 22% Germany 60.5% The Netherlands 60%

40 Sepsis New Definition Sepsis is life threatening organ dysfunction caused by a dysregulated host response to infection

41 Septic Shock Septic shock is a subset of sepsis in which profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Definition of sepsis with: Cellular/metabolic abnormalities lactate elevation High risk for mortality

42 Sepsis and Septic Shock Pathophysiology At low concentrations, pro-inflammatory cytokines such as interleukin 1 (IL-1) and tumor necrosis factor-α (TNF-α) play important roles in the host s immune defenses. Large circulating amounts of pro-inflammatory cytokines can result in a life threatening immune response. IL-1 induces vasodilation (widening of blood vessels) and reduces the tight junctions between vascular endothelial cells, leading to widespread edema. As fluids move out of circulation into tissues, blood pressure begins to drop (hypotension). Without proper monitoring, the blood pressure can fall below the level necessary to maintain proper kidney and respiratory functions leading to septic shock. Also note: excessive release of cytokines during the inflammatory response can lead to the formation of blood clots. Hypotension and blood clot formation can lead to multiple organ failure and death.

43 Sequential Organ Failure Assessment (SOFA) A score, used primarily in the ICU, of 2 points or more is associated with an in-hospital mortality of greater than 10%. Septic shock is a subset of sepsis Clinically identified as having vasopressor requirement to maintain a mean arterial pressure (MAP) of 65 mmhg or greater and serum lactate level greater than 2 mml/l in the absence of hypovolemia. Associated with hospital mortality rates of 40%

44 Quick SOFA (qsofa) To be used to identify patients showing signs of possible sepsis Screening tool used in acute care setting Must have two of the following: Respiratory rate of 22/min or greater Altered mentation Systolic BP 100 mmhg or less

45 What causes sepsis? Bacteria are the most common pathogens associated with the development of sepsis, and septic shock. gram-positive and gram-negative pathogens The most common infection associated with sepsis is bacterial pneumonia, accounting for about half of all cases, followed by intra-abdominal infections and urinary tract infections. Additional sources for bacterial infections: superficial wounds surgical wounds animal bites indwelling catheters (urinary, central lines, PICC/mid-lines, dialysis, etc.) NOTE: fungus and viruses can also cause Sepsis

46 Case Study #1 35 year old paraplegic female with history of Type 1 Diabetes, ESRD, neurogenic bladder with chronic indwelling Foley Catheter, chronic wheel chair bound status, chronic ischial decubitis ulcers (followed by wound care) and immobility who presented to the hospital with diarrhea, flank pain, elevated blood sugars, fever, chills, fatigue, worsening wounds Vital Signs: Temp BP 89/53, HR 111 RR 20, SPO2 98% on RA Labs: WBC 22,000 hemoglobin 12.8, hematocrit 30, platelets 235. UC: growing Gram negative rod Lactic acid: 3.1 Bilateral ischial decubitis wounds, (status post surgery and recent surgical debridement): necrotic appearing borders with foul smelling discharge

47 Case Study #1 What type of infection(s) are you worried about in this patient scenario? What other labs or tests do you want? Who should we consult?

48 Diagnoses 1. Recurrent catheter associated urinary tract infection (UTI) with UC growing Enterobacter cloacae, pseudomonas 2 morphotypes. 2. Bilateral chronic ischial decubitus ulcer/osteomyelitis. Repeat wound cultures showing polymicrobial infection. Primary culture growing at this point in time Streptococcus viridans and enterococcus species, additional mixed pathogens. 3. Sepsis, multifactorial secondary to CAUTI and infected ischial decubitus ulcer with underlying osteomyelitis currently on vacuumassisted closure (VAC) therapy. 4. Clostridium difficile colitis treated and resolved.

49 Case Study #2 72 year old male with a history of bronchiectasis and severe pulmonary fibrosis. History of acute hypoxic respiratory failure in June 2017, requiring intubation and ventilator support. Identified to have pneumonia post initiation of ventilator while hospitalized. Stabilized and then extubated.

50 Case Study #2 What type of infection(s) are you worried about in this patient scenario? What labs and tests do you want? Who do you want to consult?

51 Case Study #2 Sputum culture collected post extubation in June 2017 growing Mycobacterium Avium Complex and Pseudomonas Aeruginosa (initially only resistant to Cipro) Treated with IV Cefepime per ID In August 2017 Repeat Sputum Culture performed showing Pseudomonas pneumonia persists and now organism is resistant to Cipro and Cefepime Treatment changed to Zosyn and meropenem per ID In September 2017 Repeat Sputum Culture performed showing Pseudomonas infection continues and now organism is PAN RESISTANT Started on IV Zerbaxa (ceftolozane/tazobactam), eventually transitioned to IV Colistin per ID Patient died suddenly one morning without warning at the end of September (with some signs of clinical stability and improvement)

52 Case Study #3 67 year old male presented to the ER with chief complaint of SOB. He has a history of COPD, not O2 or steroid dependent, previous pneumonia, hypertension, and hyperlipidemia. Patient is encephalopathic. Vital Signs: Temp HR 101, RR 24, SPO2 82% on room air BP: 136/82 Lactic Acid level 2.1 Daughter found him confused at home and called

53 Case Study #3 What criteria does he meet at time of admission? What other information do you want?

54 Case Study #3 CXR: Right lower lobe pneumonia WBC: 20,000 H and H stable Platelet Count stable BUN 20, Cr 1.4 (baseline is usually normal for him) Given a Albuterol Neb in ER and started on oxygen via nasal cannula, SPO2 now 90. ABG not done Sputum culture pending Blood cultures are growing strep pneumoniae Repeat Labs in morning pending UC is pending.

55 Case Study #3 Diagnosis Sepsis, present on admission, secondary to Right lower lobe pneumonia Strep pneumonia bacteremia, secondary to above Acute on chronic hypoxic respiratory failure Acute on chronic COPD exacerbation Acute Kidney Injury Treatment Admit to Hospital IV azithromycin and IV ceftriaxone, q6 hour nebulizers (changed to DuoNebs), lite IV fluid hydration, oxygen to maintain SPO2 above 92% Monitor oxygen needs and ensure he has 48 hours IV antibiotics without fever before switching to oral

56 Resources f_faqs_hcp.html

57 Questions??