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Causes of Surgical Site Infections (SSI)

Studies have been done to make a more uniformed preventative evidence based guideline for preventing SSI. These evidence based guidelines help reduce the causes of SSI. 

In a study done on disease control measures to prevent surgical infections; it showed that of 799 patients that were operated on 29% did not shower the night before, the surgical staff did not used the correct hand and forearm scrubbing techniques, excessive hair removal was done using razors, the operating room doors were left open in 36.3 % of cases, or wounds were not dressed, drained and accessed well, in the appropriate amount of time to prevent SSI.  

Graf, K., & Vonberg, R.-P. (2014). Chapter 1 Infection Control Measures for the prevention of Surgical Site Infections. In Microbiology for Surgical Infections (pp. 1–15). Academic Press. doi: https://doi.org/10.1016/B978-0-12-411629-0.00001-5

Submitted by Dionisia P.

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Causes of  Urinary Tract Infection

Biofilms from bacteria can colonize on the inside of indwelling urinary catheters. Placement of the catheters is the main cause of infection. long term use of catheters can also cause an accumulation of microorganisms that can cause infections usually more than seven days. 

Djeribi, R., Bouchloukh, W., Jouenne, T., & Menaa, B. (2012). Characterization of bacterial biofilms formed on urinary catheters. American Journal of Infection Control, 26(4), 854–859. Retrieved from https://reader.elsevier.com/reader/sd/pii/S0196655311012636?token=F2D43068F07A20D1037B597FCEB2C78BDC5BDA4E3C87C4368DE07CDB44E735881EB9B88B3EBDF9825036F26A5DC1A0EA

Submitted by Dionisia P.

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Causes of Hospital Pneumonia

At a veterans Affairs Medical center during 2011-12, a study was done with all patients who had acquired pneumonia from being admitted in the hospital.  Of 259 patients, 17% were uninfected prior to being admitted to the hospital. 217 had a bacterial infection, 7% had bacterial and vial confections. 

Musher, D. M., Abers, M. S., & Bartlett, J. G. (2017). Evolving Understanding of the Causes of Pneumonia in Adults, With Special Attention to the Role of Pneumococcus. Clinical Infectious Diseases, 65(10), 1736–1744. doi: https://doi.org/10.1093/cid/cix549

submitted by Dionisia P.

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Catheter-associated urinary tract infection

What Causes a CAUTI?

Bacteria or fungi may enter your urinary tract via the catheter. There they can multiply, causing an infection.

There are a number of ways infection can occur during catheterization. For example:

the catheter may become contaminated upon insertion

the drainage bag may not be emptied often enough

bacteria from a bowel movement may get on the catheter

urine in the catheter bag may flow backward into the     bladder

the catheter may not be regularly cleaned

Clean insertion and removal techniques can help lower the risk of a CAUTI. Daily catheter care is required as well. Catheters shouldn’t be left in longer than needed, as longer use is associated with a higher risk of infection.

Referrence

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Catheter-associated urinary tract infection

Preventing urinary tract infections in patients with indwelling catheters

An indwelling urethral catheter increases the risk of urinary tract infection (UTI) by compromising urinary tract defenses, irritating the urethral and bladder mucosa, and promoting growth of a bacterial biofilm. Roughly 25% of patients in acute-care hospitals have indwelling catheters at some point. Of the more than 1 million hospital-acquired UTIs occurring in the United States each year, 80% are linked to indwelling catheters.

Catheter-associated UTIs increase morbidity and mortality, lengthen hospital stays by 1 to 3 days, and add approximately $675 per patient to overall costs, with an additional $3,800 if bacteremia occurs. Research confirms that most of these UTIs result from pathogens that ascend the urethra and that the urethral meatus, drainage bag, and connections are potential bacterial reservoirs in catheterized patients.

In October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for costs associated with hospital-acquired conditions (HACs) that were absent at admission and could have been reasonably prevented had appropriate guidelines been followed. UTI is one of these HACs. The Joint Commission’s 2012 National Patient Safety Goals include a new goal for preventing catheter-urinary tract infections caused by catheters.

Caregivers have been using traditional catheter practices for years, although some of these practices have been proven to be ineffective or even potentially harmful. Studies suggest that one of them—prophylactic systemic antibiotic therapy—may merely delay a catheter-related UTI and might even contribute to emergence of antibiotic-resistant bacteria. Generally, organisms deep within the matrix of the urinary tract’s bacterial biofilm are unaffected by antibiotics.

Referrence

Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 2000; 160:678.

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Catheter-associated urinary tract infection

Treatment

Antibiotics

Asymptomatic, low-risk patients are not treated. Symptomatic and high-risk patients are treated using antibiotics and supportive measures. The catheter should be replaced when treatment begins. Choice of empiric antibiotic is as for acute pyelonephritis. Sometimes vancomycin is added to the regimen. Subsequently, antibiotics with the narrowest spectrum of activity, based on culture and sensitivity testing, should be used. Optimal duration is not well established but 7 to 14 days is reasonable in patients who had a satisfactory clinical response, including resolution of systemic manifestations.

Asymptomatic women and men with recent catheter removal who have UTI diagnosed by urine culture should be treated based on the culture results. Optimal duration of treatment is not known.

Referrence

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Catheter-associated urinary tract infection

Diagnosis

·         Urinalysis and urine culture for patients with symptoms or at high risk of sepsis

Testing is done only in patients who might require treatment, including those who have symptoms and those at high risk of developing sepsis, such as

·         Patients with granulocytopenia

·         Organ transplant patients taking immunosuppressants

·         Pregnant women

·         Patients undergoing urologic surgery

Diagnostic testing includes urinalysis and urine culture. If bacteremia is suspected, blood cultures are done. Urine cultures should be done, preferably after replacing the catheter (to avoid culturing colonizing bacteria), then by a direct needle stick of the catheter, all done with aseptic technique, so that contamination of the specimen is minimized.

In women who have had a catheter removed, urine culture within 48 h is recommended regardless of whether symptoms occur.

Referrence

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Signs and symptoms of central- line associated bloodstream infection:

Signs and symptoms of central- line associated bloodstream infection:

 A central line being inserted

Central-line associated bloodstream infection

Symptoms of local infection site include:

Pain, soreness

Redness, warmth, swelling

Yellow or green drainage

Systemic infection symptoms include:

Fever

Hypotension

Tachycardia

Respiratory distress

Chills/rigors

Diaphoresis

Altered cognitive state

CE(2017). Central Line- Associated Bloodstream Infections(CLABSI). Retrieved from

https://www.ausmed.com/cpd/articles/central-line-associated-bloodstream-infections

Submitted by: H. Nguyen

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Signs and symptoms of Vancomycin- Resistant Enterococci(VRE) infections

Signs and symptoms of Vancomycin- Resistant Enterococci(VRE) infections

Symptoms may depend on where the infection is. 

Fever, chills, body aches, stiff neck

Fatigue,weakness, dizziness, headache, confusion

Urinating more often than usual or pain when you urinate

Urine that smells bad, or blood in your urine

Pain or pressure in your abdomen

Red, warm skin around a wound, or soreness, swelling, and drainage from a wound

Fast heart rate

Reeja Tharu(2014). Vancomycin- Resistant Enterococci(VRE). Retrieved from https://www.medindia.net/patients/patientinfo/vancomycin-resistant-enterococci.htm

Drug.com(2019). Vancomycin Resistant Enterococcus. Retrieved from https://www.drugs.com/cg/vancomycin-resistant-enterococcus.html

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Signs and symptoms of surgical site infections

Signs and symptoms of surgical site infections:

Surgical site infection may cause redness, tenderness, warmth, swelling, fever, and pain. It may have pus from the wound site or drainage from the site that is cloudy, green, or foul smelling. Surgical site infection may also cause delayed healing.

Wound Infection Images. Retriever from https://www.shutterstock.com/search/wound+infection

Watson(2018).How to Tell If You Have an Infection Following Surgery. Retrieved from

https://www.healthline.com/health/signs-of-infection-after-surgery

Submitted by: H. Nguyen

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Treatment for Central Line Associated Bloodstream Infection

According to MSIC an estimated 250,000-500,000 CLABSI occur in U.S. Hospitals each year, I find  this alarming. Echinocandins are the preferred treatment in central line-associated bloodstream infections. Patients who cannot tolerate echinocandins, Providers may use  liposomal amphotericin B as  an alternative. Other medication such as  Fluconazole can be recommended if patients are not severely ill and if they have no recent exposure to azoles. Blood test or a culture of your central line will show which germ may be causing the infection. Intravenous fluid and oxygen can also be used to treat CLABSI if it is required by the Provider.

Khadian H.G.

References

https://www.ausmed.com/cpd/articles/central-line-associated-bloodstream-infections

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Treatment for Surgical Site Infection

Most Surgical Site Infection can be treated with Antibiotics, medications. The medication used will help to decrease pain or swelling that may occur. A procedure may be used is to clean the wound, and the  drainage from the wound is tested to determine which antibiotics is best to use.  Surgery can also be used to treat some Surgical Site Infections. Washing hands is very important when visiting anyone who is in recovery before and after you enter their room.

Khadian H.G.

https://www.slideshare.net/maythamalshimmary/wound-infection-15818962References

https://www.nice.org.uk/guidance/ng125/resources/surgical-site-infections-prevention-and-treatment-pdf-66141660564421

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Treatment for UTI

Antibiotics Drugs are usually  the first used  for UTIs which include:

Trimethoprim/sulfamethoxazole (Bactrim, Septra, others)

Fosfomycin (Monurol)

Nitrofurantoin (Macrodantin, Macrobid)

Cephalexin (Keflex)

Ceftriaxone

When symptoms are gone  within a few days of treatment, you may need to continue antibiotics for a week or more. Take the entire course of antibiotics as prescribed if your Provider advises.

If you have  an uncomplicated UTI your doctor may advise a shorter treatment, such as taking an antibiotic for one to three days. The  short course of treatment depends on your specific symptoms and your medical history. Drink plenty of water. because it  helps to dilute your urine and flush out bacteria.    Avoiding  drinks that may irritate your bladder.coffee, alcohol, and soft drinks containing citrus juices or caffeine until your infection has cleared is also recommended. They can irritate your bladder and tend to aggravate your frequent or urgent need to urinate.  In some instances   use of  a heating pad by applying  a warm, but not hot, heating pad to your abdomen to minimize bladder pressure or discomfort  that you may experience with a UTI.

Khadian H.G

Reference

https://www.healthline.com/health/womens-wellness-uti-antibiotics

https://www.top10homeremedies.com/home-remedies/home-remedies-for-urinary-tract-infection.html

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Risk Factors for CA-UTI

The risk of introducing bacteria into the urine after a single catheterization is 1% to 5%. Some CA-UTIs are similar to uncomplicated UTIs in that the bacteria are associated with the individual's own intestinal or skin flora. These organisms are introduced into the urinary tract with catheter insertion. Thus, catheterization should be limited. Since the incidence of bacteriuria associated with indwelling catheterization is between 3% and 8% per day, it is essential to limit the duration of catheterization. Once catheter placement has occurred, contamination from external sources offers another possible mechanism for infection. External contamination can occur when health care providers use improper techniques to empty the catheter bag. Improper emptying can result in the backup of urine into the tubing.Also, the external environment can cross-contaminate the catheter. Contamination may occur in the bag, as well as in the exterior or interior of the tubing. Contamination of the exterior of the tubing is more common.Furthermore, some bacterial pathogens can produce a biofilm, which is an adherent layer of accumulated microorganisms and their extracellular products. The biofilm protects the organism against both host defenses and antibiotic therapy. Migration to the bladder can occur within 1 to 3 days.Biofilms also contribute to an increased risk of antimicrobial resistance, as the microorganisms are able to share genetic material at a faster rate. Additionally, some bacterial biofilms have the ability to alter the urine pH, facilitating the development of catheter encrustations. These encrustations obstruct urine flow and increase the risk of CA-UTI.

The duration of catheterization is also a risk factor. Nearly all patients who are catheterized for more than 30 days (long-term catheterization) will experience bacteriuria. These severely ill patients also are at risk for upper-UT inflammation, which increases the risk of bacteremia. Long-term catheterization infections are often polymicrobial, which requires a broader treatment spectrum. Additionally, not only does catheterization increase the risk of bacteremia, it also increases the risk of other complications, like deep venous thrombosis, as a result of limited mobility. These complications result in extended stays and increased costs.

General CA-UTI risk factors include nonuse of systemic antibiotics; female sex (likely anatomical); catheter insertion outside the operating room, or deviation from the optimal sterile environment; absence of a catheter chamber clip; rapidly fatal underlying illness; older age; diabetes; and elevated serum creatinine at the time of diagnosis. These last several events are associated with breaches in or decreased response to the host's defense mechanisms, which also increases the risk of infection. Even after the catheter is removed, the patient remains at risk for bacteriuria for at least 24 hours.

Reference  

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Management of Catheter-Associated Urinary Tract Infections

Urinary tract infections (UTIs) are the most common nosocomial acquired infection in the United States in both the hospital and the long-term care setting. In most hospitals, catheter-associated (CA) bacteriuria accounts for approximately 40% of all nosocomial acquired infections annually. Although multiple risk factors exist, 80% of nosocomial infections are CA. This is not implausible considering that 20% to 25% of patients admitted to an acute-care hospital receive catheterization at some point during their stay. UTIs also account for 15% of nosocomial bacteremia. These infections have been estimated to cost from $600 to more than $2,800 per event, and most are largely avoidable with preventive practices. In 2008, the Centers for Medicare and Medicaid Services initiated the practice of denying compensation for such events. This action has likely contributed to the recent updating of existing guidelines to focus on the prevention, diagnosis, and management of CA-UTIs. This article will review key guideline initiatives.

Identification of Infection

Distinguishing between a bacterial presence (or colonization) and a symptomatic infectious process is the basis for treatment decisions. The 2009 Infectious Diseases Society of America (IDSA) guidelines define CA-UTI as “the presence of symptoms or signs compatible with UTI with no other identified source of infection along with ≥103 colony-forming units (cfu)/mL of ≥1 bacterial species” from a catheterized or previously catheterized (≤48 hours) urine sample.4 The CDC's definition of CA-UTI is comparable, but it requires a positive urinalysis if the culture is between 103 cfu/mL and 105 cfu/mL

Common symptoms associated with CA-UTIs may include fever, flank pain, costovertebral tenderness, hematuria (no menstrual), and new-onset delirium. There also may be increased frequency or tenderness upon urination after the catheter is removed. In patients with spinal cord injuries, the signs and symptoms of CA-UTI may include discomfort or pain over the kidney or bladder or during urination; new-onset incontinence; fever; increased spasticity or hyperreflexia; malaise; lethargy; or a sense of unease, according to the National Institute on Disability and Rehabilitation Research Consensus Statement.

The IDSA has classified the absence of symptoms in the presence of bacteria (≥105 cfu/mL of ≥1 bacterial species in the catheterized patient) as asymptomatic CA bacteriuria (CA-ASB). In most CA-ASB studies, treatment resulted in only a temporary sterilization of the urine, not eradication of the bacteria. Moreover, once the catheter was removed, 33% to 50% of patients with bacteriuria cleared on their own. Thus, treatment of CA-ASB increases the risk of development of drug resistance or adverse events associated with an unnecessary therapeutic agent. Therefore, urine samples from asymptomatic catheterized patients should not be screened for infection. Exceptions include pregnant women; patients undergoing urologic surgery, with or without a prosthesis; attempts to control an extremely resistant nosocomial bacterial strain within a patient care unit; and immunosuppressed patients in whom infection could be related to a serious complication, such as bacteremia.

Reference

Haley RW, Hooton TM, Culver DH, et al. Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequency by selected characteristics of patients. Am J Med 1981; 70:947.  

By Isa Junior Khalid 

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Catheter-associated Urinary Tract Infections (CAUTI)

INTRODUCTION

Urinary catheters are placed for a number of reasons, including diagnostic and therapeutic reasons, as well as for convenience. The presence of a catheter increases the risk of bacteriuria, which can be clinically benign or progress to serious infection. There is an overall lack of consensus about the optimal approach to catheter-associated urinary tract infections (UTIs), apart from removing catheters when no longer necessary.

Issues related to symptomatic UTI and asymptomatic bacteriuria in patients with indwelling bladder catheters will be reviewed in this topic.

Issues related to asymptomatic bacteriuria and cystitis in other circumstances, and the indications for placement, methods of catheterization, and management and complications of bladder catheters are discussed separately. (See "Asymptomatic bacteriuria in adults" and "Acute simple cystitis in women" and "Acute simple cystitis in men" and "Placement and management of urinary bladder catheters in adults" and "Complications of urinary bladder catheters and preventive strategies" and "Acute complicated urinary tract infection (including pyelonephritis) in adults".)

DEFINITIONS

Because the presence of bacteria in a urine sample may represent contamination by bacteria colonizing the periurethral area in addition to bladder bacteriuria, thresholds for bacterial growth from a urine sample that is likely to represent true bladder bacteriuria in specific contexts have been suggested by various expert groups. The Infectious Diseases Society of America (IDSA) guidelines define catheter-associated bacteriuria as follows [1]:

●Symptomatic bacteriuria (urinary tract infection [UTI]) – Culture growth of ≥103 colony forming units (cfu)/mL of uropathogenic bacteria in the presence of symptoms or signs compatible with UTI without other identifiable source in a patient with indwelling urethral, indwelling suprapubic, or intermittent catheterization. Compatible symptoms include fever, suprapubic or costovertebral angle tenderness, and otherwise unexplained systemic symptoms such as altered mental status, hypotension, or evidence of a systemic inflammatory response syndrome.

A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN).  Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.  Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay.  The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter.  Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed         

                               From Isa Junior Khalid

         1.      Bardossy AC, Jayaprakash R, Alangaden AC, et al. Impact and Limitations of the 2015 National Health and Safety Network Case Definition on Catheter-Associated Urinary Tract Infection Rates. Infect Control Hosp Epidemiol 2017; 38:239.

2.      Warren JW, Platt R, Thomas RJ, et al. Antibiotic irrigation and catheter-associated urinary-tract infections. N Engl J Med 1978; 299:570.

3.      Haley RW, Hooton TM, Culver DH, et al. Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequency by selected characteristics of patients. Am J Med 1981; 70:947.

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Treatment of Urinary Tract Infection

If you find yourself with a UTI the first choice to treat is antibiotics, they assist in fighting the infection. Treatment depends on the type of organism causing the infection and how severe it is. In addition you must do the following

Complete the prescribed course of antibiotics

Drink plenty of water to flush out the germs Cranberry juice is recommended

Use heating pads to get relief from back pain

Khadian H.G