Big five of your hospital

Transcription

1 Big five of your hospital

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Faculty/ Presenter Disclosure Yazdan Mirzanejad, MD,FRCPC Relationship with Commercial interests: -- Grant /research support: Sanofi Pasteur for C. diff vaccine multi Centers clinical trials -- Speakers Bureau/ Honoraria : Merck, Pfizer, Optimer, Triton, UBC CPD, Nova Clinical Services, Gilead -- Consulting Fees : none -- Other : none

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6 Health Care associated Line sepsis

7 Catheter related Urinary tract infection

8 VENTILATOR ASSOCIATED PNEUMONIA

9 CDAD

10 Nosocomial Aspiration pneumonia

11 In their 70 s present with:

12 Couple of weeks ago Fever, chills, runny nose Updated influenza & Pneumovax BP; 100/ 50, tachycardia, afebrile, Bilateral crackles Seen FP, BIAXIN X 1 week Co morbidities; DM, HTN, high cholesterol, hypothyroidism, obese morbidities, COPD Shortness of breath

13 WHAT WOULD you LIKE TO DO NOW? CBC: 8.5, lymphopenia Hyponatremia Hyperosmolar urine TNI o.4 BNP : 2400 EKG WNL SPUTUM NO GROWTH BLOOD CULTURE NEGATIVE Diagnosis of CHF & PNEUMONIA made without any real evidence! Lasix NITROPATCH MEROPENEM FOLEY CATHETER IN-OUT MONITORED BED

14 4 DAYS LATER, CLINICAL STABILITY BREATHING MUCH IMPROVED on aggressive diuresis Bedside nurse based on their outdated protocol sent CATHETERIZED URINE FOR C+S without UA because urine looked cloudy! patient was asymptomatic! Result came back for Stenotrophomona 50 cfu/ml Pharmacist recommended to attending Physician to start intravenous levofloxacin and discontinue Meropenem Urinary Catheter not replaced or d/c at this point!

15 During admission, experienced angina and arranged for angio Stented but developed diarrhea with fever! DIAGNOSED WITH CDAD WBC : BORDERLINE BP ABDOMINAL PAIN BLOOD & MUCUS IN STOOL POSITIVE FECAL LEUKOCYTES C. diff PCR positive TREATED FOR 10 DAYS WITH METRONIDAZOLE DIARRHEA IMPROVED BUT EXPERIECED SEVERE NAUSEA & A BOUT OF MASSIVE VOMITING AT NIGHT.

16 5 DAYS LATER DEVELOPED S.O.B ABG, PaO2 OF 55 PH OF 7.2 Pa CO2 50 NEW FEVER OF 38.9 WBC COPIOUS EXPECTORATION OF PURULENT SPUTUM TRANSFERRED TO ICU & intubated WHAT IS YOUR DIAGNOSIS?

17 NOSOCOMIAL ASPIRATION THE COURSE OF TREATMENT BECAME PROLONGED VENTILATOR ASSOCIATED PNEUMONIAE REQUIRED LONGER COURSE OF ANTIBIOTICS THERAPY CENTRAL LINE INSERTION PNEUMONIAE PATIENT WAS INTUBATED

18 PATIENT WAS TRANSFERRED TO THE MEDICAL FLOOR A FEW DAYS LATER DIAGNOSED WITH FEVER DECLINE IN LOC CXR NORMAL ANTIFUGAL ADDED TO OTHER PREVIOUS CT OF HEAD NORMAL CT OF ABDOMEN NORMAL WBC WITH LEFT SHIFT UA/ C+S NEGATIVE BLOOD CULTURE PENDING ANTIBIOTICS LINE WAS REPLACED

19 CANDIDIASIS, BLOOD GREW CANDIDA ALBICANS

20 PATIENT SURVIVED THE LAST CATHETER RELATED SEPSIS. NOW NOTICED TO HAVE THE HEEL PRESSURE ULCER DEBRIDED BY PLASTICS INTRAVENOUS ANTIBIOTICS THERAPY BONE SCAN SHOWED OSTEOMYELITIS PROBE TEST WAS POSITIVE PRESSURE POINTS WERE RELIEVED TOOK 8 WEEKS UNTIL COMPLETELY HEALED LENGTH OF STAY 112 DAYS

21 5 DAYS LATER EXPERIENCED PLEURITIC CHEST PAIN! FEVER+ LEUKOCYTOSIS

22 Echocardiogram TRATED WITH 6 WEEKS OF FLUCANAZOLE

23 AGAIN IMPROVED initially! However : NOW 164 DAYS The ID service was consulted for the first time to see the patient with severe diarrhea, abdominal pain, but in the next 24 hours developed decreased LOC followed by abdominal distention, hypotension WBC of CRP of 350 Ilieus ensued IV flagyl followed by oral Vancomycin, rectal enema ID recommended CT scan Asked general surgery to see Patient worsen after initial improvement. IV Ig, Unfortunately developed toxic mega-colon, anuric Expired!

24 Complicated C.diff

25 1) Was the management of catheterized urine evidence based?

26 Prevent Transmission Practice hand hygiene Fact: Hand hygiene is the single most important infection control measure for preventing the spread of antimicrobial resistant organisms.

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28 Severe CDAD Cathete r related UTI Health care associated Pneumoni a Catheter related sepsis SYNDROM E Ventilator associated Pneumoni a

29 ASYMPTOMATIC BACTERIURIA For not d/c catheter Increased length of stay and relapse of fatal C.diff associated Colitis & Death Unnecessary Antibiotics therapy Nosocomial ASPIRATION pneumonia, Catheter related candidemia More antibiotics CDAD

30 Improved Patient Outcomes associated with Proper Hand Hygiene Chlorinated lime hand antisepsis Ignaz Philipp Semmelweise ( )

31 Link to: NNIS Online at CDC Prevent Infection Get the catheters out Fact: Indwelling catheters are the single most important factor contributing to bacteremia in hemodialysis patients.

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39 Using a Criteria-based Reminder to Reduce Use of Indwelling Urinary Catheters and Decrease Urinary Tract Infections Yin-Yin Chen, RN, PhD, Mei-Man Chi, RN, MS, Yu-Chih Chen, RN, PhD, Yu-Jiun Chan, MD, PhD, Shin-Shang Chou, RN, PhD, Fu-Der Wang, MD Disclosures Am J Crit Care. 2013;22(2):

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41 Results A total of 278 patients were recruited. 1-Utilization rate of indwelling urinary catheters was decreased by 22% in the intervention group compared with the control group (relative risk, 0.78; 95% CI, ; P <.001). 2-The intervention significantly shortened the median duration of catheterization (7 days vs 11 days for the control group; P <.001). 3- The success rate for removing the catheters in the intervention group by day 7 was 88%. 4- The reminder intervention reduced the incidence of catheterassociated infections by 48% (relative risk, 0.52; 95% CI, ; P =.009) in the intervention group compared with the control group. 5-Conclusions Use of a criteria-based reminder to remove indwelling urinary catheters can diminish the use of urinary catheterization and reduce the likelihood of catheter-associated urinary infections. its use should be strongly considered as a way to enhance the safety of patients and HAI s in general as the chain of events!

42 ASYMPTOMATIC BACTERIURIA d/c Catheter Reduced length of stay and relapse of fatal C.diff associated Colitis & Death Reduced rate s of Unnecessary Antibiotics therapy Nosocomial ASPIRATION pneumonia, Catheter related candidemia Less antibiotics Reduced rate s of Active CDAD

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44 What are practical steps in Take home messages?: What are the facts about asymptomatic bacteriuria in Catheterized patients? 1) Negative predictive value for a negative urinalysis is 100% 1) 2) Positive predictive value for a positive urine culture is < 50% 2) 3) UTI as a cause of fever investigation in Elderly is < 10% 3) 4) If you treat asymptomatic bacteriuria the chance of C.diff is 8.5 times more than in untreated group 4) 5) If patient with asymptomatic bacteriuria be treated with antibiotics, the chance of symptomatic bacteriuria higher than untreated patient in the subsequent months with ARO s. 5) 6) The rate of catheter related nosocomial infection is 40% of all infections in hospital

45 Use Antimicrobials Wisely Treat infection, not contamination or colonization Fact: A major cause of antimicrobial overuse is treatment of contamination or colonization.

46 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings To control Antimicrobial Resistance: Prevent Transmission Antimicrobial Resistance Optimize Use Antimicrobial-Resistant Susceptible Pathogen Pathogen Pathogen Antimicrobial Use Prevent Infection Infection Effective Diagnosis & Treatment

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48 What are the 3 major risks for HAI? Unnecessary catheterization Treating colonization vs source control Increased length of stay! 48

49 Barriers to change 1-Not updating policies 2-Complacency 3-Ordering UA BY non-medical 4- Ordering antibiotics by phone 5-Not differentiating colonization versus true infection