Case 3

Lim, 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 Features

• 38 y/o pregnant diabetic female• G3P3 • Delivered big baby thru caesarean• Non-ambulatory • With indwelling catheter• Post-op wound was clean• On 3rd day of H.D.: fever and chills• CBC: leukocytosis (↑neutrophils)• Urinalysis: Pyuria

1. WHAT IS YOUR DIAGNOSIS?

Diagnosis

• Urinary Tract Infection

Urinary tract infection (UTI)

• Characterized by BACTERIURIA and PYURIA

• May be symptomatic or asymptomatic

• May affect the kidneys (pyelonephritis) or the bladder (cystitis)

Etiology

• More than 85% - caused by Gram (-) bacilli that are normal inhabitants of the intestinal tract

• Most common: Escherichia coli• Other causes: Proteus

Klebsiella

Enterobacter

Streptococcus faecalis

2. WHAT ARE THE FACTORS THAT PREDISPOSED THIS PATIENT TO THIS INFECTION?

Risk factors

• Indwelling catheterization– The daily risk of bacteriuria with catheterization is

3% to 10%, approaching 100% after 30 days

• Other risk factors: female sex, diabetes mellitus, older age, impaired immunity, and lack of antimicrobial exposure

2 ROUTES

• HEMATOGENOUS

- through the bloodstream

• ASCENDING

- from the lower urinary tract

PATHOGENESIS

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 INFECTION

1. Colonization of the distal urethra and introitus

( in the female) by coliforms

2. From the urethra to the bladder –urethral catheterization

3. Urinary tract obstruction and stasis of urine

4. Vesicoureteral reflux

5. Intrarenal reflux

PATHOGENESIS

3. HOW DO YOU CLASSIFY THESE INFECTIONS ACQUIRED WITHIN THE INSTITUTIONS?

Nosocomial infections

• Infections 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 Infections

• Four most common types of nosocomial infections are:1. UTI2. SSI3. Nosocomial Pneumonia4. Nosocomial Bacteremia

Urinary Tract Infection

• 80% associated with the use of indwelling catheters

• Associated with less morbidity– Gram-negative enterics, 50%– Fungi, 25%– Enterococci, 10%

Surgical Site Infection• Are 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 Pneumonia

• About 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 factors

– mechanical ventilation (high risk), – elderly,– neonates, – severe underlying disease, – immunodeficiency, – depressed sensorium, – cardiopulmonary disease, – recent thoraco-abdominal surgery

Pathogens infecting the Respiratory tract

• Bacterial pneumonia• Legionnaires' disease• Pulmonary aspergillosis• Mycobacterium tuberculosis• Viral pneumonias

– Respiratory Syncytial Virus (RSV)– Influenza

Nosocomial Bacteremia• About 5% of nosocomial infections• may occur at the entry site of the intravascular

device• sources of infection-causing microorganism for these

infections are endogenous– Coagulase-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?

Prevention

• Place 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 any thing while emptying the bag

6. WHAT ARE OTHER ORGANISMS THAT CAUSE PULMONARY, GASTROINTESTINAL AND POST SURGICAL WOUND INFECTIONS?

Microorganism Infections caused

Staphylococcus aureus, Coagulase negative Staphylococci, Enterococci

Surgical wound infections, Pneumonia, Septicemia, Urinary Tract Infections

Escherichia coli, Pseudomonas aeruginosa, Enterobacter spp. And Klebsiella Pnemoniae

Pneumonia and surgical wound infections

Clostridium difficile Causes nearly half of nosocomial diarrhea

Candida Albicans Urinary tract infections and Septicemia

Acinetobacter, Citrobacter, Haemophilus

Urinary tract infections and surgical wound infections

Hospital acquired: Pulmonary

Pseudomonas aeruginosa – most common MDR Gram-negative bacterium

causing Ventilator-associated pneumonia

Methicillin-resistant Staphylococcus aureus– is an increasing cause of VAP

Hospital acquired: Gastrointestinal

Clostridium difficile– Causes pseudomembranous colitis

• offensive-smelling diarrhea, fever, and abdominal pain• life-threatening complications can develop

– Ex: Toxic megacolon

– Clindamycin• causes the alteration of the normal bacterial flora of

the bowel

Hospital acquired: Surgical wound

Most common causes of surgical site infection:• Staphylococcus aureus - wounds and incisions• Staphylococcus epidermidis - nosocomial

bacteremia• Bacteroides fragilis - anaerobic isolate from

surgical infection

THANK YOU!