Device associated hospital acquired infection (da hai)

DA-HAI usually are seen in ICU of healthcare system. This ppt focusses on pathogenesis, diagnosis and preventive measures of such infection.

1. DEVICE ASSOCIATED HOSPITAL ACQUIRED INFECTIONS (DA-HAI) DIAGNOSIS AND PREVENTION Maj Shilpi Gupta MD (Microbiology)

2. TYPES OF HOSPITAL ACQURIED INFECTION

3. INTRODUCTION A device-associated infection is an infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection Ventilator Associated Pneumonia (VAP) Catheter Associated Urinary Tract Infection (CAUTI) Central Line Associated Blood Stream Infection (CLABSI)

4. IMPORTANCE http://www.who.int/csr/bioriskreduction/infection_control/en/index.html HCAI Developed countries Developing countries Hospitalized patients 3.5%-12% 5.7%-19.1% ICU settings Upto 51% 7.8%-88.9%

5. ESTIMATES OF PREVENTABLE INFECTIONS, DEATHS AND COSTS

6. INDIAN STUDIES Study period Place of study HAI incidence VAP CAUTI CLABSI Reference 2004-2005 New Delhi 34.1% 31.4 11.2 3.4 Habibi et al 2006-2007 Puducherry NA 30.6 NA NA Joseph et al 2010-2011 Chandigarh 29.1% 6.0 9.08 13.8 Datta P et al 2009-2010 Pune 17.6% 32 9 16 Singh et al 2010-2011 Vellore NA 40.1 NA NA Mathai et al 2011-2013 Puducherry 50.2% 72.5 12.4 3.9 Bammi et al 2015-2016 New Delhi NA 16.7 7.3 10.3 Bineeta et al

7. DA-HAI Definition Pathogenesis Etiology Risk factors Diagnosis Prevention

8. Ventilator Associated Pneumonia (VAP)

9. VAP Type of hospital acquired pneumonia developing > 48 hours after mechanical intubation In India VAP is most common DAHAI with overall rate ranging from 6.0-72.5 per 1000 ventilator days . The key risk factor to the development of VAP is a cuffed endotracheal tube or tracheostomy, both of which interfere with the normal anatomy and physiology of the respiratory tract. The average time taken to develop VAP from the initiation of MV is around 5 to 7 days Mortality rate quoted as between 24% and 76% ATOTW 382 — Ventilator-Associated Pneumonia (27 June 2018)

10. PATHOPHYSIOLOGY

11. Biofilm image

12. TYPES OF VAP EARLY ONSET VAP LATE ONSET VAP During first 96 hours of MV More 5 days of MV Less severe More severe Better prognosis Increased morbidity & mortality Antibiotic sensitive bacteria Multidrug resistant (MDR) bacteria

13. RISK FACTORS Host related Device related Extremes of age Re-intubation/prolonged intubation Lung disease/ARDS Ventilator circuit Immunosuppression Orogastric and nasogastric tube Unconsciousness Body position Antibiotic exposure Chest surgery

14. DIAGNOSIS (Clinical Pulmonary Infection Score) PARAMETER RESULT SCORE Temperature (°C) 36.5-38.4 38.5-38.9 < 36 or > 39 1 2 Oxygenation status (PaO2:FiO2 ratio) > 240 or acute respiratory distress syndrome (ARDS) < 240 and absence of ARDS 2 Tracheal secretions None Mild/ non-purulent Purulent 1 2 Radiographic findings on chest X-ray No infiltrates Diffuse/patchy infiltrates Localised infiltrate 1 2 Leukocytes (cells/mm³) 4,000-11 000 < 4,000 or >11,000 > 500 band cells 1 2 Culture results (respiratory samples) No/mild growth Moderate/florid growth Florid growth and pathogen consistent with Gram stain 1 2 VAP = CPIS score > 6

15. PREVENTION

16. CARE BUNDLES A care bundle is a collection of preventive interventions that are evidence based such that the application of all the interventions is consistent for all the patients at all times to prevent DA-HAI

17. Dr.T.V.Rao MD 20

18. CATHETER ASSOCIATED URINARY TRACT INFECTIONS (CAUTI)

19. CAUTI 2 nd most common DA-HAI CAUTI occurs at a rate of 3% to 10% per day Incidence approaches 100% within 30 days Approximately 3% of all patients with a catheter will develop bacteremia Each year more than 13,000 deaths are associated with UTIs Increases hospital length of stay by 1-3 days http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf

20. 66% of CAUTI acquired by the extraluminal route Staph, Enterococcus, E.coli 34% acquired by intraluminal route: Gram negatives

21. PATHOGENESIS Extraluminal Intraluminal –Outside the Catheter -Inside the catheter –Biofilm –Biofilm –Organism migration –Disconnection of Catheter / Drainage System – Fecal Incontinence –Contamination at Sample Port and outlet tube -Associated with endogenous organisms, i.e., bacteria that colonize the patient’s own perineum -Associated with exogenous organisms and result from cross-contamination from the hands of healthcare workers

22. Risk Factors Host related Device related Female sex Prolonged catheterization Old age Disconnection of drainage system Orthopaedic /neurology Meatal colonization Impaired immunity Incontinence Renal dysfunction

23. DIAGNOSIS Patient must meet 1, 2 and 3 below: Patient has indwelling urinary catheter for more than 48 hours, and 2. Has at least one of the following signs/symptoms Fever (>38°C) Suprapubic tenderness Costovertebral angle pain or tenderness Urinary urgency, frequency, dysuria and 3. Urine culture positive (>10⁵ cfu /ml) Fever + positive urine culture + Foley catheter > 2 days = CAUTI www.cdc.gov/hicpac/cauti/001_cauti.html

24. PREVENTION HICPAC guidelines at: http://www.cdc.gov/hicpac/cauti/001_cauti.html

25. Strategies NOT recommended for CAUTI prevention Changing catheters or drainage bags at routine -(Indications for removal include infection, obstruction, or compromise of closed system) Routine antimicrobial prophylaxis Cleaning of periurethral area with antiseptics while catheter is in place (use routine hygiene) Irrigation of bladder with antimicrobials Instillation of antiseptic or antimicrobial solutions into drainage bags Urinary incontinence is not an accepted indication for urinary catheterization http://www.cdc.gov/hicpac/cauti/001_cauti.html

26. CAUTI BUNDLE Hand hygiene Avoid unnecessary urinary catheters Insert catheter using aseptic technique Review catheter necessity daily

27. CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS (CLABSI)

28. CLABSI Defined as a laboratory-confirmed bloodstream infection (LC BSI) not related to an infection at another site that develops within 48 hours of a central line placement Defines a central line in terms of tip position; "the device must terminate in one of the great vessels ... or in or near the heart to qualify as a central line“ Of all the healthcare-associated infections, CLABSIs are the most costly

29. Comparison of the Major Types of Central Venous Catheters (CVCs) Catheter Type Entry Site Duration of Use Advantages Disadvantages Comments Non tunneled CVCs Percutaneously into central veins (internal jugular, subclavian, or femoral vein) Short term Percutaneous insertion Relatively safe and inexpensive May be inserted in the OR Dressing required over site Risk of infection ■ Account for the majority of CLABSIs ■ More commonly used than long term CVCs Tunneled CVCs Implanted into internal jugular, subclavian, or femoral vein Long term Dressing not needed after healed ■ Require surgical insertion ■ Require local or general anesthesia ■ Increased cost ■ Lower rate of infection than non tunneled ■ Dacron cuff inhibits migration of organisms Implantable ports Inserted in the subclavian or internal jugular vein. Tunneled beneath the skin; Long term ■ Patient comfort ■ Local catheter site care and dressing not needed ■ Require surgical insertion and removal ■ Require general anesthesia ■ Increased cost ■ Lowest risk for CLABSI Peripherally inserted central catheter (PICC) Inserted percutaneously into basilic, brachial, or cephalic vein and enters the superior vena cava Usually short to intermediate ■ Ease of insertion, usually at the bedside ■ Relatively inexpensive and safe ■ Can be difficult to position in central vein ■ Potential for occlusion ■ Lower rate of infection than non tunneled CVCs

30. Sources of intravascular catheter infection Skin Vein Intraluminal from contamination of tubes and hubs beyond 10 days from a HCWs contaminated hands Haematogen from distant sites from a contaminated infusate . Extraluminal from skin within 7- 10 days

31. ETIOLOGY Gram-positive organisms Coagulase-negative staphylococci   Enterococci Staphylococcus aureus  34.1% 16% 9.9% Gram negative organisms Klebsiella Enterobacter Pseudomonas  E.coli  Acinetobacter 5.8% 3.9% 3.1%; 2.7% 2.2% Candida species  11.8% Others 10.5%

32. RISK FACTORS Host related Device related Extremes of age Catheter type Chronic illnesses ( hemodialysis , malignancy, gastrointestinal tract disorders, pulmonary hypertension) Catheter location ( femoral line has the highest, followed by internal jugular, then subclavian) Immunosuppression Conditions of insertion (emergent versus elective, use of full barrier precautions versus limited), Malnutrition Catheter site care Total parenteral nutrition (TPN) Loss of skin integrity (burns)

33. DIAGNOSIS Patient must meet 1, 2 and 3 below: Patient is for more than 48 hours of a central line placement Patient has at least one of the following signs or symptoms: fever (>38°C) chills, or hypotension AND 3. Patient has a pathogen cultured from 1 or more blood cultures AND Organism cultured from blood is not related to an infection at another site www.cdc.gov/hicpac/clabsii/001_cauti.html

34. Focus of prevention of infections Skin Vein Insertion site Hubs Tubes Catheters

35. PREVENTION

36. MAXIMAL STERILE BARRIER (MSB) The operator should dress up surgically: Surgical mask Head cover Eye protection  Sterile gown Sterile gloves Full-size sterile drape around the insertion site

37. CLABSI BUNDLE Hand hygiene Skin antisepsis with chlorhexidine Avoid femoral access Insertion with maximal sterile barrier (MSB) precautions Review need of CVC necessity daily

38. Summary DA-HAI DA-HAI Essential criteria Clinical criteria Lab criteria Management CAUTI Device for more than 48 hour -Raised temp -TLC -Other -Urine sample collected from sampling port of catheter after disinfecting with a sterile syringe - Catheter tip is unacceptable - > 10 5 CFU /ml - Change catheter - A/b according to culture report CLABSI -Raised or decreased temp -TLC -Hypotension -Paired blood samples taken from central line and peripheral site -Central line tip along with peripherally collected blood sample -Change central line -A/b according to culture report VAP -Fever -TLC -Purulent secretion -Radiological -Gram stain (pus cells) - BAL > 10 4 CFU/ml ET aspirate > 10 6 CFU /ml ET tube is unacceptable - Change ventilator - A/b according to culture report.

39. DA-HAI Indicators To calculate VAP , data to be collected include: No. of patients developed VAP X 1000 Total no. of Ventilator days To calculate CAUTI , data to be collected include: No. of patients developed CRUTI X 1000 Total no. of urinary catheter days To calculate CLABSI , data to be collected include: No. of patients developed CLABSI X 1000 Total no. of catheter days

40. CONCLUSION The cost of prevention is only a miniscule compared to treatment of these infections