Case 3 Lim, Mary Lim, Phoebe Lim, Syndel Lipana, Kirk Liu, Johanna
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Case 3Lim, MaryLim, PhoebeLim, SyndelLipana, KirkLiu, Johanna
A 38 y/o G3P3 diabetic delivered by Caesarian section due to a big baby. She was non-ambulatory and on indwelling catheter on the first 24 hours post operation. On the 3rd H.D she experienced fever and chills. Post operative wound was clean. CBC revealed leucocytosis with predominance of neutrophils and urinalysis with marked pyuria.
Salient Features38 y/o pregnant diabetic femaleG3P3 Delivered big baby thru caesareanNon-ambulatory With indwelling catheterPost-op wound was cleanOn 3rd day of H.D.: fever and chillsCBC: leukocytosis (neutrophils)Urinalysis: Pyuria
1. WHAT IS YOUR DIAGNOSIS?
DiagnosisUrinary Tract Infection
Urinary tract infection (UTI)Characterized by BACTERIURIA and PYURIAMay be symptomatic or asymptomaticMay affect the kidneys (pyelonephritis) or the bladder (cystitis)
EtiologyMore than 85% - caused by Gram (-) bacilli that are normal inhabitants of the intestinal tractMost common: Escherichia coliOther causes: Proteus Klebsiella Enterobacter Streptococcus faecalis
2. WHAT ARE THE FACTORS THAT PREDISPOSED THIS PATIENT TO THIS INFECTION?
Risk factorsIndwelling catheterizationThe daily risk of bacteriuria with catheterization is 3% to 10%, approaching 100% after 30 daysOther risk factors: female sex, diabetes mellitus, older age, impaired immunity, and lack of antimicrobial exposure
2 ROUTES HEMATOGENOUS - through the bloodstreamASCENDING - from the lower urinary tractPATHOGENESIS
PATHOGENESIS HEMATOGENOUS INFECTION- less common- results from seeding of the kidneys by bacteria from distant foci in the course of septicemia or infective endocarditis
ASCENDING INFECTIONColonization of the distal urethra and introitus ( in the female) by coliformsFrom the urethra to the bladder urethral catheterizationUrinary tract obstruction and stasis of urineVesicoureteral refluxIntrarenal refluxPATHOGENESIS
3. HOW DO YOU CLASSIFY THESE INFECTIONS ACQUIRED WITHIN THE INSTITUTIONS?
Nosocomial infectionsInfections which are a result of treatment in a hospital but not secondary to the patient's original condition. Appear 48 hours or more after hospital admission or within 30 days after discharge
4. DIFFERENTIATE THESE TYPE OF INFECTIONS.
Nosocomial InfectionsFour most common types of nosocomial infections are:UTISSINosocomial PneumoniaNosocomial Bacteremia
Urinary Tract Infection80% associated with the use of indwelling catheters
Associated with less morbidityGram-negative enterics, 50%Fungi, 25%Enterococci, 10%
Surgical Site InfectionAre also frequent 15%
Presence of purulent discharge around the wound or the insertion site of a drain or
Presence of cellulites which is emanating from the wound
Patients acquire infection either endogenously or exogenously
Contamination varies with the length of the procedure and the health condition of the patient
Staphylococcus aureus, 20%Pseudomonads, 16%
Nosocomial PneumoniaAbout 3% of patients on ventilators acquire pneumonia
The source is often endogenous but may also be exogenous with transfer of an organism from the respiratory equipment
Risk factorsmechanical ventilation (high risk), elderly, neonates, severe underlying disease, immunodeficiency, depressed sensorium, cardiopulmonary disease, recent thoraco-abdominal surgery
Pathogens infecting the Respiratory tractBacterial pneumoniaLegionnaires' diseasePulmonary aspergillosisMycobacterium tuberculosisViral pneumoniasRespiratory Syncytial Virus (RSV)Influenza
Nosocomial BacteremiaAbout 5% of nosocomial infectionsmay occur at the entry site of the intravascular devicesources of infection-causing microorganism for these infections are endogenousCoagulase-negative staphylococci, 40%Enterococci, 11.2%Fungi, 9.65%Staphylococcus aureus, 9.3%Enterobacter species, 6.2%Pseudomonads, 4.9%
5. WHAT ARE THE RECOMMENDED PREVENTIVE MEASURES?
PreventionPlace bladder catheters only when absolutely needed (e.g. to relieve obstruction).Use aseptic technique.Minimize manipulation or opening of drainage systems.Remove bladder catheters as soon as is feasible.Healthcare providers clean their hands by washing them with soap and water or using an alcohol-based hand rub before and after touching the catheter. Avoid disconnecting the catheter and drain tube. This helps to prevent germs from getting into the catheter tube.
The catheter is secured to the leg to prevent pulling on the catheter. Avoid twisting or kinking the catheter. Keep the bag lower than the bladder to prevent urine from backflowing to the bladder. Empty the bag regularly. The drainage spout should not touch anything while emptying the bag
6. WHAT ARE OTHER ORGANISMS THAT CAUSE PULMONARY, GASTROINTESTINAL AND POST SURGICAL WOUND INFECTIONS?
MicroorganismInfections causedStaphylococcus aureus, Coagulase negative Staphylococci, EnterococciSurgical wound infections, Pneumonia, Septicemia, Urinary Tract Infections Escherichia coli, Pseudomonas aeruginosa, Enterobacter spp. And Klebsiella PnemoniaePneumonia and surgical wound infectionsClostridium difficileCauses nearly half of nosocomial diarrheaCandida AlbicansUrinary tract infections and SepticemiaAcinetobacter, Citrobacter, HaemophilusUrinary tract infections and surgical wound infections
Hospital acquired: PulmonaryPseudomonas aeruginosa most common MDR Gram-negative bacterium causing Ventilator-associated pneumoniaMethicillin-resistant Staphylococcus aureus is an increasing cause of VAP
Hospital acquired: GastrointestinalClostridium difficileCauses pseudomembranous colitisoffensive-smelling diarrhea, fever, and abdominal painlife-threatening complications can developEx: Toxic megacolon Clindamycincauses the alteration of the normal bacterial flora of the bowel
Hospital acquired: Surgical woundMost common causes of surgical site infection:Staphylococcus aureus - wounds and incisions Staphylococcus epidermidis - nosocomial bacteremiaBacteroides fragilis - anaerobic isolate from surgical infection
**Ventilator-associated pneumoniapeople who are onmechanical ventilationthrough anendotrachealor tracheostomy
*Example: Surgical site infectionThose that occur as a result of a surgical procedure or those that require surgical intervention as part of their treatment
S. Aureus because it is the most common normal flora of the skinB. Fragilis because it is a common normal flora of the gi