Why are nosocomial infections increasing

The CDC has released these example questions for patients to raise to their nurses and doctors to protect themselves from Healthcare-associated Infections. This checklist should be used to systematically assess key elements and actions to ensure optimal antibiotic prescribing and limit overuse and misuse of antibiotics in hospitals.

Click here for checklist. Who's At Risk? Of these infections: 32 percent of all healthcare-acquired infection are urinary tract infections 22 percent are surgical site infections 15 percent are pneumonia lung infections 14 percent are bloodstream infections What's at Stake? Recommendations include: healthcare providers cleaning their hands with soap and water or an alcohol-based hand rub before and after caring for every patient; catheters being used only when necessary and removed as soon as possible; cleaning the skin where the catheter is being inserted or the surgical site, and providers wearing hair covers, masks, gowns and gloves when appropriate.

The effort — involving an assessment of potential problems, increased staff education, use of proven best practices, leadership buy-in and more — resulted in a dramatic reduction in urinary tra Behzadifar, S. Azari et al.

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Nikfar, S. Latifi, and F. View at: Google Scholar B. Upon inspection, their urine can be cloudy and foul-smelling. Neonates on the other hand usually do not present with any of the above findings and may have very subtle and nonspecific signs of infection. Fever may or may not be present. Laboratory investigations should be guided by the results of a detailed physical examination and review of systems. Caution should be taken when interpreting laboratory results because not all bacterial or fungal growth on a culture are pathogenic.

Growth on cultures may reflect simple microbial colonization. Consider the following:. The process by which the specimen was obtained e. The presence of other supporting evidence of infection e.

Among the different methods used to establish the catheter as the source of bloodstream infections catheter-associated bloodstream infection , the differential time to positivity of paired blood cultures is the simplest. The other methods include quantitative cultures of blood obtained from the catheter and peripheral vein and also, quantitative culture of catheter segment.

Unfortunately, quantitative culture is not readily available in most laboratories and culture of the catheter requires pulling out the device. Multiple blood cultures over 24 h and appropriate volume of blood sample may increase the yield in cases of intermittent or low-inoculum bacteremia. Fungal cultures should be obtained if fungal infection is suspected. The laboratory should incubate cultures longer for fungus detection than for other pathogens.

Imaging studies such as echocardiography should be considered if thrombosis or vegetations is a concern. Candidate patients include those who have prolonged or persistent bacteremia or fungemia despite antimicrobial therapy or in patients with a new-onset murmur.

In immunocompromised patients, special studies are occasionally requested, such as cultures for nocardia and atypical mycobacteria, cytomegalovirus, and cytomegalovirus antigenemia detection Special imaging techniques e. We have witnessed a cyclical parade of pathogens in hospitals. In Semmelweis's era, Group A streptococci created most nosocomial problems. For the next 50 to 60 years, grampositive cocci, particularly streptococci and Staphylococcus aureus , were the hospital pathogens of major concern.

These problems culminated in the pandemic of to , when S. In the s, gram-negative bacilli, particularly Pseudomonas aeruginosa and Enterobacteriaceae , became synonymous with nosocomial infection. By the late s and early s, several different classes of antimicrobial drugs effective against gram-negative bacilli provided a brief respite.

During this time, methicillin-resistant S. For example, the average postoperative stay of approximately 5 days now is usually shorter than the 5- to 7-day incubation period for S. Acquired antimicrobial resistance is the major anticipated problem in hospitals.

Devices have more bloodstream infections due to coagulase-negative staphylococci. In fact, most cases of occult bacteremia in ICU patients are probably due to vascular access-related infections. Fungal urinary tract infections have also increased in ICU patients, presumably because of extensive exposure to broad-spectrum antibiotics. In the National nosocomial infections Surveillance system, Candida spp. Appropriate use of antibiotics is important. Up to 30 of ventilator associated pneumonias are treated inadequately.

There is increasing evidence to suggest that the use of appropriate and early antibiotics improves morbidity and mortality. Antibiotics should be administered at the right dose and for the appropriate duration. Antibiotic-resistant bacteria prolong hospitalization, increase the risk of death, and require treatment with toxic and expensive antibiotics. Empirical use of antibiotic is often necessary as laboratory results are often not available for 48 h after the samples are sent to the laboratory for culture.

Appropriate specimens include blood, urine, sputum, bronchoalveolar lavage, pus and wound swabs. Blood cultures are only positive for pathogen in a third of cases. Once the antibiotic profile is available, a narrow-spectrum antibiotic can be commenced. Indicators of response to treatment include temperature, leucocytes count and C- reactive protein CRP levels. Procalcitonin is secreted by macrophages in response to septic shock and is an early and a more specific marker of bacterial infection than CRP.

De-escalation involves early initiation of broad-spectrum antibiotic therapy in patients with suspected sepsis without the availability of microbiology results. The increase in antibiotic resistant pathogens such as MRSA has led some investigators to suggest broader antibiotic coverage by adding a glycopeptide to carbapenem as the initial empirical therapy. This aggressive empirical regimen is continued for 24—48 h by which time laboratory tests have confirmed the causative organisms and sensitivities.

This allows for de-escalation of antibiotic therapy. This regimen should be reserved for selected patients on ICU who are seriously ill, with an extended antibiotic history and evidence of colonization by multi-resistant organisms.

Unnecessary continuation of this regime will increase the risk of colonization with resistant bacteria. Rotational antibiotic therapy is a strategy to reduce antibiotic resistance by withdrawing an antibiotic, or class of antibiotics, from ICU for a short period, to allow resistance rates to decrease or remain stable.

The persistent use of one class of antibiotics leads to the emergence of resistant strains of bacteria; this is known as selective pressure. Rotational regimens are thought to reduce this selective pressure. There is growing support for this regimen. Kollef and colleagues 10 demonstrated a statistical decrease in nosocomial pneumonia in a large ICU after the introduction of an antibiotic rotation policy. Restrictive antibiotic policies are less flexible and, to a certain extent binding, with respect to prescribing.

They require the prescriber to give written justification for any deviation from the policy. Automatic stop orders restrict prolonged antibiotic administration.

In the general hospital setting, these measures have had some success with significant reductions in antibiotic resistance.

However, the overall survival in ICU was unchanged. The concept that commensals within the bowel may provide a protective role against more virulent organisms is called colonization resistance.

Translocation of Gram-negative bacteria across the intestinal wall is thought to be a major cause of nosocomial infections. SDD aims to eliminate Gram-negative aerobic bacteria by decontamination of the oral cavity and intestinal tract.

There are several variations of the SDD regimen. One such regimen is non-absorbable polymyxin E, tobramycin, and amphotericin B for gastrointestinal decontamination and cefotaxime for systemic prophylaxis.

Cephalosporins are usually given as prophylaxis as they act on commensal respiratory flora such as Streptococcus pneumoniae , Hemophilus influenza and S. Meta-analysis has demonstrated that SDD regimens decrease the incidence of nosocomial pneumonia but overall survival or duration of intensive care treatment is unchanged.

The cost effectiveness of SDD has not been evaluated. Healthcare-associated infections are most commonly caused by viral, bacterial, and fungal pathogens. These pathogens should be investigated in all febrile patients who are admitted for a noufebrile illness or those who develop clinical deterioration unexplained by the initial diagnosis. Most patients who have healthcare-associated infections caused by bacterial and fungal pathogens have a predisposition to infection caused by invasive supportive measures such as endotracheal intubation and the placement of intravascular lines and urinary catheters.

Ninety-one of bloodstream infections were in patients with central intravenous lines CVL, 95 of pneumonia cases were in patients undergoing mechanical ventilation and 77 of urinary tract infections were in patients with urinary tract catheters.

Candida spp are increasingly important pathogens in the NICU.