Download Case 3

Case 3
Lim, Mary
Lim, Phoebe
Lim, Syndel
Lipana, Kirk
Liu, Johanna
• A 38 y/o G3P3 diabetic delivered by Caesarian
section due to a big baby. She was nonambulatory 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
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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
PATHOGENESIS
2 ROUTES
• HEMATOGENOUS
- through the bloodstream
• ASCENDING
- from the lower urinary tract
PATHOGENESIS
• HEMATOGENOUS INFECTION
- less common
- results from seeding of the kidneys by
bacteria from distant foci in the course
of septicemia or infective endocarditis
PATHOGENESIS
•
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
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.
2.
3.
4.
UTI
SSI
Nosocomial Pneumonia
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
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mechanical ventilation (high risk),
elderly,
neonates,
severe underlying disease,
immunodeficiency,
depressed sensorium,
cardiopulmonary disease,
recent thoraco-abdominal surgery
Pathogens infecting the
Respiratory tract
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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 anything 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!