Field of Pharmacy Sciences

Bachelor of pharmacy Pharm-D program (Clinical Pharmacy)

Pharmacy Seminars I
PPP519
Fall semester 2024-2025

Date : Month 2024

Nosocomial Infections
 Outline

•Definitions
•Incidence
Epidemiology
•Risk Factors
General Infection Control Measures
•Hand Hygiene
•Isolation Precautions for Communicable Infections
Nosocomial Infections and Specific Infection Control Measures
•Intravascular Device–Related Bloodstream Infection
•Ventilator-Associated Pneumonia (VAP)
•Catheter-Associated Urinary Tract Infection (CAUTI)
•Control of Antibiotic Resistance
 Definitions

Also called “hospital acquired infection” can be defined as: An

infection acquired in hospital by a patient who was admitted for a
reason other than that infection.

Also can be define: the infection occurring in a patient in a hospital

or other health care facility in whom the infection was not present
or incubating at the time of admission. This includes infections
acquired in the hospital but appearing after discharge, and also
occupational infections among staff of the facility.
 Incidence

• 5-10% of patients admitted to acute care hospitals

acquire infections
• 2 million patients/year
• 1/4 of nosocomial infections occur in ICUs
• 90,000 deaths/year
• majority are endemic
• can result from diagnostic or therapeutic procedures
 Risk Factors

Immunocompromised State: Patients with weakened immune systems (e.g., those with cancer,diabetes,
HIV/AIDS, or organ transplant recipients) are more susceptible to infections.

Invasive Devices: Use of medical devices such as catheters, ventilators, and intravenous linescan introduce
pathogens directly into the body, increasing infection risk.

Surgical Procedures: Surgeries, especially those that involve major organs or open wounds, canprovide a
pathway for pathogens to enter the body.

Antibiotic Use: Broad-spectrum antibiotics can disrupt normal microbiota, making patients morevulnerable to
opportunistic infections, including Clostridium difficile

Length of Hospital Stay: The longer a patient is hospitalized, the higher their risk of encounteringhospital-
associated pathogens.

Age: Both the very young and elderly populations are more at risk due to weaker immuneresponses and
possible chronic conditions.
 Risk Factors

Chronic Medical Conditions: Conditions such as diabetes, cardiovascular diseases, and chronic
respiratory conditions may increase susceptibility to infections.

Poor Hand Hygiene Practices: Inadequate handwashing or lack of proper infection control
practices by healthcare workers can facilitate the spread of infections.

Presence of Multi-drug Resistant Organisms (MDROs): Exposure to these resistant organisms,

often found in healthcare settings, can increase the likelihood of infections that are harder to treat.

Malnutrition: Malnourished individuals often have impaired immune responses, making them more
susceptible to infections.

Environmental Factors: Poor sanitation, overcrowded facilities, or inadequate disinfection

practices in the hospital can contribute to the spread of infections
 General Infection Control Measures

1-Hand Hygiene: is the single most effective intervention to reduce the cross
transmission of nosocomial infections

General Guidelines:
Use soap and water for handwashing when hands are visibly dirty or contaminated with fluids.
Use alcohol-based hand rubs or antimicrobial soap when hands are not visibly soiled.

Specific Scenarios for Hand Hygiene:

•Before patient contact, especially during high-risk procedures (e.g., inserting catheters).
•After exposure to bodily fluids, contaminated surfaces, or patient-adjacent objects.
•Always after restroom use, regardless of visible contamination.

Preferred Products:
•Alcohol-based hand rubs are effective and convenient for most situations.
•Antimicrobial wipes are not substitutes for proper hand hygiene.
General Infection Control Measures
 General Infection Control Measures

2-Isolation Precautions for Communicable Infections

1. Source or protective Isolation

-Source - isolation of infected patientmainly to prevent airborne transmission via respiratory droplets
respiratory MRSA, pulmonary tuberculosis.
-Protective - isolation of immune-suppressed patient

2. Standard Precautions:
Basic practices applied to all patients, regardless of their infection status.
•Components:
•Hand hygiene (e.g., washing hands or using hand sanitizer).
•Use of personal protective equipment (PPE), such as gloves, gowns, and masks, as needed.
•Proper cleaning and disinfection of equipment and surfaces.
•Respiratory hygiene (e.g., covering coughs and sneezes).
 General Infection Control Measures

3.Transmission-Based Precautions
Used in addition to standard precautions when dealing with known or suspected infectious diseases that
require extra control measures. These include:
•Contact Precautions:
• For infections spread by direct contact (e.g., MRSA, C. difficile).
• Requires gloves and gowns for contact with the patient or their environment.
• Private rooms patients.
•Droplet Precautions:
• For infections transmitted by large respiratory droplets (e.g., influenza, meningitis).
• Requires surgical masks when within 3-6 feet of the patient.
• Patient placement in a private room is preferred.
•Airborne Precautions:
• For infections transmitted by small airborne particles (e.g., tuberculosis, measles, chickenpox).
• Requires a negative-pressure room and the use of N95 respirators or higher-level respirators.
 SITES OF NOSOCOMIAL INFECTIONS

• Urinary tract 40%

• Pneumonia 20%
• Surgical site 17%
• Bloodstream (IV) 8%
Nosocomial Infections and Specific Infection Control Measures

1-Intravascular Device–Related Bloodstream

Infection
2-Ventilator-Associated Pneumonia (VAP)
3-Catheter-Associated Urinary Tract
Infection (CAUTI)
4-Control of Antibiotic Resistance
1-Intravascular Device–Related Bloodstream
Infection
 1-Intravascular Device–Related Bloodstream Infection

Catheter-Related Bloodstream Infection (CRBSI):

- 4th most frequent site of NI
- Attributable mortality 20%
-A BSI caused by an intravascular catheter, confirmed through specific microbiologic
tests like quantitative culture of the catheter tip or differences in microbial growth
between catheter-drawn and peripheral blood samples.
 PATHOGENESIS

1-Entry Points for Infection:

A-Skin Exit Site: Infections can originate from the catheter’s skin entry point,
spreading along the catheter’s external surface to the bloodstream.
Prevention: Tunneling the catheter under the skin or fully implanting it
increases the distance between the skin and the bloodstream, reducing risk.

B-Catheter Hub: Contamination of the catheter hub can lead to internal

(intraluminal) infection and subsequent bloodstream infection.

2-Contaminated Infusates: Rarely, infusates (fluids administered via the

catheter) can carry pathogens.

3-Hematogenous Seeding: Infection can spread from other infected body

sites to the catheter through the bloodstream.
RISK FACTORS
 RISK FACTORS

Age < 1 year > 60 years

• Granulocytopenia
• Immunosuppression
• Loss of skin integrity (e.g. burns, psoriasis)
• Presence of distant infection
• Type of catheter: plastic > steel - Location: central > periphera
• Contamination of the catheter hub
 Prevention

1.Limit Insertions to Trained Personnel: Only trained and skilled healthcare

workers should insert central venous catheters to minimize errors and
complications.
2.Avoid Femoral Vein Use: The femoral vein has a higher risk of infection and
complications.
3.Prefer Subclavian Veins: Use the subclavian vein
4.Hand Hygiene: Perform thorough hand hygiene before catheter insertion,
assessment, or dressing changes to reduce contamination risk.
5.Skin Preparation: Clean the insertion site with >0.5% chlorhexidine with
alcohol before catheter insertion.
 Prevention

6.Sterile Techniques: Use maximum sterile barrier precautions during insertion, including a
mask, sterile gloves, gown, and full-body drape.
7.Catheter Maintenance:
-Avoid systemic antibiotics for routine prophylaxis.
-Do not replace catheters routinely; only do so if necessary or if aseptic technique was
compromised during insertion.
8.Timely Removal: Remove intravascular catheters as soon as they are no longer required
for patient care to reduce infection risk.
 Treatment

1. Empiric Antibiotic Therapy:

•Initiate broad-spectrum antibiotic therapy immediately after collecting blood cultures.
•Once the pathogen is identified via culture and sensitivity testing, narrow down the antibiotic
to one specifically effective against the causative organism.
3. Monitoring and Supportive Care:
•Monitor the patient closely for systemic signs of infection, such as fever, hypotension, or
tachycardia.
4. Duration of Therapy:
•Uncomplicated bloodstream infections: 7–14 days of antibiotic therapy.
•Complicated infections (e.g., endocarditis, osteomyelitis): Extended antibiotic courses of 4–6
weeks may be necessary.
 Treatment

•Start Empirical Therapy:

•Gram-Positive Coverage:
•Vancomycin: Preferred for empiric therapy, especially when Staphylococcus
aureus (including MRSA) or coagulase-negative staphylococci are suspected.
•Daptomycin: Alternative for patients with vancomycin intolerance or resistance.
•Gram-Negative Coverage:
•Consider cefepime, piperacillin-tazobactam, or a carbapenem in cases of
neutropenia, immunosuppression, or suspected gram-negative infection.
•If Fungemia is Suspected:
•Consider amphotericin B or IV fluconazole, depending on the patient’s condition.
•Switch to Targeted Therapy:
•Once blood culture results and susceptibilities are available, adjust antibiotics accordingly.
2-Ventilator-Associated Pneumonia (VAP)
 Definitions

Ventilator-Associated Pneumonia (VAP) is a type of pneumonia that occurs 48

hours or more after endotracheal intubation and mechanical ventilation. It is a
serious complication of critical illness, with increased morbidity, mortality, and
healthcare costs.
 Pathogenesis

In healthy individuals, multiple defense mechanisms (e.g., airway barriers, cough

reflex, mucociliary clearance, immune cells, and antibodies) keep the lower
respiratory tract sterile despite frequent aspiration of bacteria from the upper
airways.

In mechanically ventilated patients, these defenses are compromised due to:

1.Endotracheal Intubation: Disrupts the cough reflex, damages airway surfaces,
and provides a pathway for bacteria to enter the lungs.
2.Subglottic Secretion Pooling: Secretions collect above the cuff of the tube and
leak into the lower airways, carrying pathogens.
3.Critical Illness: Weakens the immune system, increasing vulnerability to
infections.
 Pathogenesis

Pathogens reach the lower respiratory tract through:

1.Aspiration of secretions from the oropharynx or
stomach.
2.Inhalation of contaminated air or aerosols.
3.Spread from nearby infections (e.g., pleural space).
4.Bloodborne infections from remote sites
 Risk Factors

1. Mechanical Ventilation
•Prolonged ventilation (>24 hours or >7 days).
•Reintubation or emergent intubation.
2. Oropharyngeal and Gastric Colonization
•Poor dental hygiene (increased bacterial load).
•High gastric pH (e.g., due to antacids or H₂-blockers).
3. Host Factors
•Advanced age.
•High illness severity (e.g., trauma, neurosurgical ICU).
•Postsurgical state.
•Poor nutritional status.
•Oversedation.
•Transfusion therapy.
•Exposure to broad-spectrum antibiotics.
 Prevention

1. Nonpharmacologic Measures
•Avoid prolonged intubation: Use noninvasive ventilation when possible.
•Reduce mechanical ventilation duration.
•Head elevation: Keep the bed at 30–45° to minimize aspiration.
•Oral care:
• Brush teeth daily.
• Perform oral cleansing every 2–4 hours.
• Apply antiseptic solutions periodically.
•Subglottic secretion drainage: Use modified endotracheal tubes when
feasible.
•Education and adherence to infection control protocols.
•Hand hygiene and proper disinfection of respiratory equipment.
 Treatment

•Start Empirical Therapy:

•Based on factors like intubation duration, hospitalization length, previous antibiotics, disease
severity, and local pathogen resistance patterns.
•Use broad-spectrum antibiotics to cover:
•Gram-negative bacilli (e.g., Pseudomonas aeruginosa).(Use one of the following:
Piperacillin/tazobactam or Cefepime or Levofloxacin)
•Methicillin-resistant S. aureus (if suspected).
•(Use one of the following: Piperacillin/tazobactam or Cefepime or Levofloxacin)
•Add vancomycin or linezolid to the regimen.
•Narrow Therapy:
•Adjust antibiotics based on culture results, clinical improvement, and imaging findings.
•Treatment Duration:
•Uncomplicated cases (adults): 7–10 days.
•Complicated cases (e.g., necrotizing pneumonia): At least 14 days.
•Children with tracheitis (no pneumonia): Less than 7 days may be enough.
3-Catheter-Associated Urinary Tract Infection
(CAUTI)
3-Catheter-Associated Urinary Tract Infection (CAUTI)

-A UTI in a patient who had an indwelling urinary catheter is in

place at the time of or within 48 hours prior to infection onset.

-25% of hospitalized patients will have a urinary catheter

for part of their stay
-Most common site of NI (40%)
 Pathogenesis

•Primary Sources of Infection:

•Microorganisms often originate from the patient's colonic and perineal flora or the hands of healthcare
workers during catheter insertion or handling.

.Common pathogens of CAUTI.

Escherichia coli

Klebsiella pneumonia Bacteria

Pseudomonas aeruginosa

Candida albicans Fungi

 Pathogenesis

•Modes of Infection:
•Extraluminal Route: Microbes ascend along the external catheter surface through capillary action,
particularly during or after insertion.
•Intraluminal Route: Contamination occurs through the catheter's lumen due to failures in closed drainage
 Risk Factors

1. Female gender
2. Diabetes mellitus
3. Duration of catheterization
4. Lower professional training of inserter
5. Old age
6. Immunocompromised patients
7. Retrograde flow of urine from drainage bag
 Prevention

1.Avoid Unnecessary Catheterization: Only use catheters when essential.

2.Consider Alternatives:
•Use condom catheters for males.
3.Ensure Proper Insertion: Trained professionals should insert catheters with aseptic technique.
4.Timely Removal: Remove catheters as soon as they are no longer needed.
5.Maintain Closed Drainage: Ensure the system remains tightly sealed to prevent contamination.
6.Maintain free urine flow: Keep the urine bag below bladder level to facilitate flow and avoid
backflow.
 Prevention

7.Use Advanced Catheters:

•Anti-infective impregnated catheters (e.g.,
nitrofurazone, minocycline-rifampin) may reduce
infections.

•Silver-alloy catheters have shown moderate

effectiveness compared to standard catheters.
 treatment

1.Antimicrobial Therapy:
•Start with empiric broad-spectrum antibiotics based on local resistance patterns.
•Adjust the antibiotic regimen according to the results of urine culture and sensitivity
testing.
•Uncomplicated CAUTI: Treat with antibiotics for 7–10 days.
•Complicated CAUTI or delayed response: Treatment may extend to 10–14 days.
Antibiotic Choices (General Guidelines):
•Empiric Therapy: Use broad-spectrum antibiotics to cover:
•Gram-negative bacilli (e.g., Pseudomonas aeruginosa).(Use one of the following:
Piperacillin/tazobactam or Cefepime or Levofloxacin)
•Targeted Therapy: Based on urine culture and susceptibility testing.

2. Symptom Management:
•Address symptoms like fever, dysuria, or flank pain with appropriate supportive care.
•Encourage adequate hydration unless contraindicated.
4-Control of Antibiotic Resistance
 4-Control of Antibiotic Resistance

•Education:
•Train healthcare workers on resistance and best practices.
•Use clinical guidelines tailored to local resistance trends.

•Antibiotic Prescription Management:

•Clear guidelines help reduce the overuse of antibiotics.
•daily reviews of prescriptions improve usage practices.

•Antibiotic Cycling (Rotation):

•Rotating the antibiotics used in intensive care units (ICUs) can help reduce the
emergence of resistance
 4-Control of Antibiotic Resistance

•Active Surveillance:
•Regularly monitor for resistant bacteria in ICUs.
•Obtain cultures before starting antibiotics.

•Hand Hygiene:
•Emphasize consistent handwashing.
•Use alcohol-based rubs to limit bacterial spread.

•Use of Gloves:
•Gloves provide an additional layer of protection to limit bacterial spread.
 4-Control of Antibiotic Resistance

•Rapid Diagnostics:
•Implement technologies for quick identification of pathogens to adjust therapy
promptly.

•De-escalation of Therapy:
•Switch to narrow-spectrum antibiotics based on culture results to minimize resistance.

•Infection Control:
•Isolate patients with resistant bacteria to limit cross-infection.
•Prevent cross-infection through strict hygiene.
 sources

Centers for Disease Control and Prevention (CDC)

World Health Organization (WHO)
PubMed

Chapter:
Nosocomial Infection in the Intensive
Care Unit
ANY QUESTIONS ?