Nosocomial Infections Flashcards
(28 cards)
Types of nosocomial infections
- pneumonia
- urinary catheter associated infection
- venous access associated bacteremia
- soft tissue infection: sx site or pressure ulcers
- C diff
Non infective causes of nosocomial fever
- bleeding
- thrombosis
- drug fever
- cancer
- central fever
- atelectasis
- tissue damage
- polyarticular gout
Nosocomial pneumonia
- RF
- Diagnosis
RF: cannot protect airways - stroke, dementia, post sx, mechanical ventilation
Diag: clinical
- fever
- leukocytosis
- purulent sputum
- desaturation
- new or progressive infiltrates
Nosocomial pneumonia
- bugs
- tx
Bugs
- pseudomonas
- MRSA
- less common: klebsiella, acinetobacter baumannii
Empiric abx
- anti pseudomonas: ceftazidime, cefepime, tazocin, meropenem, imipenem, amikacin, gentamicin, ciprofloxacin, levofloxacin, aztreonam, polymyxin B
- anti MRSA: vancomycin, linezolid
culture directed abx if culture +ve for 7days
Cause of non response to initial abx
- wrong organism
- complication
- wrong diagnosis
What to tx for ventilator associated pneumonia
MRSA, pseudomonas aeruginosa
- pip-taco and vancomycin
risk factors for CAUTI
prolonged catheterisation > 6 days
Female gender
Acceptable indications for indwelling urinary catheter use
- clinically significant urinary retention
- urinary incontinence: e.g. comfort in terminally ill patient
- accurate urine output monitoring required: e.g. in critically ill patients
- patient unable or unwilling to collect urine: operation/ procedures
How to diagnose CAUTI
gold standard is urine culture
- dipstick and other non culture tests not reliable
What are the complications of pyelonephritis
- renal or perinephric abscess
- emphysematous pyelonephritis
- renal papillary necrosis
- recurrent infection: xanthogranulomatous pyelonephritis
What are RF for complicated pyelonephritis
- urolithiasis
- structural abnormality
- ureter catheter/ stents
- urinary tract instrumentation
- long term catheterisation
- immunocompromised host
How to diagnose pyelonephritis
Clinical - fever >38 with chills, flank pain, n&v - costovertebral angle tenderness Laboratory - urine culture/ UFEME: WBC>10^5 - blood cultures
When to image pyelonephritis
- severely ill
- persistently febrile despite 48-72 hours of appropriate antibiotics
- suspicion for urinary tract obstruction (worsening renal function or decreasing urine output) or other complications (e.g. abscess)
What is the criteria for admitting someone with pyelonephritis
- male
- underlying DM
- persistent n&v
- fever > 38
empiric tx for pyelonephritis
- IV cefazolin
- IV gentamicin stat
empiric tx for nosocomial urinary infection
IV cefepime, IV amikacin stat
empiric tx for cystitis
PO co-trimoxazole
else
PO augmentin
what is fulminant CDI
- tx
- hypotension
- shock
- ileus
- megacolon
tx:
- po vancomycin
- rectal vancomycin
- IV metronidazole
sx:
- subtotal colectomy with preservation of rectum
- diverting loop ileostomy with colonic lavage with antegrade vancomycin flushes
what to do for recurrent C diff recurrence
- PO vancomycin in pulsed and tapered regimen
- PO vancomycin 125mg Q6h x10d then rifaximin 400mg TDS 20 d
- Fidaxomicin 200mg BD 10day
- Fecal microbiota transplant
Definition of HCAP vs HAP
pneumonia acquired in healthcare facilities (nursing home, hemodialysis centers, outpatient clinics, hospitalisation) within last 3 months
HAP: pneumonia acquired after 72 hours of hospitalisation
how to prevent VAP
- use non invasive positive pressure ventilation in selected populations
- manage patients without sedation wherever possible
- interrupt sedation daily
- assess readiness to extubate daily
- perform spontaneous breathing trials with sedatives turned off
- facilitate early mobility
- utilise endotracheal tubes with subglottic secretion drainage ports for patients expected to require greater than 48-72 hours of mechanical ventilation
- change ventilator circuit only if visibly soiled/ malfunctioning
- elevate head of bed to 30-45deg
- hand hygiene
- glove and gown compliance
- oral care with chlorhexidine
- maintain ETT cuff pressure > 20mmhg
- orogastric rather than nasogastric feeding tubes
- avoiding gastric overdistension
- eliminating non essential tracheal suctioning
Common VAP bugs
can be polymicrobial
gram neg bacilli: e coli, klebsiella, stenotrophomonas, pseudomonas, acinetobacter
gram pos: S aureus (MRSA). streptococcus
virus and fungi uncommon in immunocompetent hosts
What are the drugs useful against pseudomonas
BETA LACTAMS - cephalosporin: ceftazidime, cefepime - carbapenems: imipenem, meropenem - monobactam: aztreonam NON BETA LACTAMS - fluroquinolones: ciprofloxacin, levofloxacin - aminoglycosides: amikacin, gentamicin - polymyxin B
how do I prevent nosocomial pneumonia
General: hand hygiene, contact precaution
Mech ventilation:
- non invasive ventilation, avoid intubation
- continuous suction of subglottic secretions
- endotracheal tube
- contaminated condensate emptied and prevented from entering ETT
Prevent aspiration
- 30-40deg
- enteral nutrition
colonisation
- daily interruption of sedation and avoid paralytic agents
stress bleeding prophylaxis: H2 antagonist/ sucralfate
