InstituteInstitute for for Microbiology Medical Faculty of Masaryk University Microbiology Medical Faculty of Masaryk University and St Anna Faculty Hospitaland St Anna Faculty Hospital in Brno in Brno

Miroslav VotavaMiroslav Votava

Agents of Agents of nosocomialnosocomial (hospital-(hospital-acquired) acquired) infections infections

The last lThe last lecture for 3rd-year studentsecture for 3rd-year students1414thth December 20 December 201212

Congenital and neonatal infections Congenital and neonatal infections ddefinitionsefinitions ndash revision ndash revision

bull CongenitalCongenital infections infections === intrauterine = intrauterine infections =infections == prenatal = prenatal infectionsinfections

perinatalperinatal infections (closely infections (closely before andbefore and during during thethe delivery)delivery) bull NeonatalNeonatal infectionsinfections postnatalpostnatal infections (up infections (up to to 4 4 weeks of life)weeks of life)

bull Congenital and neonatal infections are caused by Congenital and neonatal infections are caused by agents agents unusual unusual in older children in older children

A little bit A little bit oof immunologyf immunology ndash ndash revision revision

Fetus = an immunological paradoxFetus = an immunological paradoxFetus and mother = two immune systemsFetus and mother = two immune systemsTo be able to get on well both must be To be able to get on well both must be

modulatedmodulated

bdquobdquoFetal immunodeficiencyldquoFetal immunodeficiencyldquo11 Inability to produce Inability to produce cytokinescytokines22 Defects in intracellular Defects in intracellular killingkilling33 Immature production of Immature production of antibodiesantibodies

The protection of the fetusThe protection of the fetus ndash ndash revision revision

bull Placenta and amnionPlacenta and amnionbull MaternalMaternal IgGIgG (halftime = 20 days) (halftime = 20 days)

ndash actively transported through the placentaactively transported through the placentandash IgG against capsular polysaccharides are IgG against capsular polysaccharides are

active only up to circa 3 months after active only up to circa 3 months after deliverydelivery

ndash IgG against viruses are effective even up IgG against viruses are effective even up to 12-15 months to 12-15 months

bull Colostral IgAColostral IgA

PrenatalPrenatal infections ndash infections ndash revision revision

AgentAgentTrimesterTrimester

Congenital Congenital defectsdefects

Postnatal Postnatal persistencepersistence11 22 33

Treponema pallidumTreponema pallidum -- ++ ++ ++ ++List monocytogenesList monocytogenes -- -- ++ -- --Rubella virus Rubella virus ++++ ++ -- ++ ++CMVCMV ++ ++ ++ ++ ++Parvovirus B19Parvovirus B19 plusmnplusmn ++ plusmnplusmn -- --VZVVZV ++ -- ++ plusmnplusmn ++HSVHSV ++ ++ ++ -- ++HIVHIV -- ++Toxoplasma gondiiToxoplasma gondii plusmnplusmn ++ ++++ ++ ++

DiagnosticsDiagnostics of prenatal infection of prenatal infection ndash revision ndash revision

Examination of Examination of mothermother ndash ndash immensely important in immensely important in syphilissyphilis (obligatory in (obligatory in

most countries) and in most countries) and in toxoplasmosistoxoplasmosis

Examination ofExamination of the the newbornnewbornndash ndash above all the detection of its above all the detection of its IgMIgM (IgM (IgM

antibodies antibodies cannot be of maternal origincannot be of maternal origin ndash ndash they donrsquot they donrsquot passpass through the placenta) through the placenta)

ndash ndash sometimes the sometimes the directdirect detection (eg CMV in detection (eg CMV in urine)urine)

Treatment Treatment ampamp prevention of prevention of prenatal infectionprenatal infection ndash revision ndash revision

TreatmentTreatment (of the mother) (of the mother)PNCPNC in syphilis in syphilisspiramycinspiramycin in toxoplasmosis in toxoplasmosis

PreventionPreventionhealthy motherhealthy mother (examined for syphilis (examined for syphilis possibly for toxoplasmosis)possibly for toxoplasmosis)

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Congenital and neonatal infections Congenital and neonatal infections ddefinitionsefinitions ndash revision ndash revision

bull CongenitalCongenital infections infections === intrauterine = intrauterine infections =infections == prenatal = prenatal infectionsinfections

perinatalperinatal infections (closely infections (closely before andbefore and during during thethe delivery)delivery) bull NeonatalNeonatal infectionsinfections postnatalpostnatal infections (up infections (up to to 4 4 weeks of life)weeks of life)

bull Congenital and neonatal infections are caused by Congenital and neonatal infections are caused by agents agents unusual unusual in older children in older children

A little bit A little bit oof immunologyf immunology ndash ndash revision revision

Fetus = an immunological paradoxFetus = an immunological paradoxFetus and mother = two immune systemsFetus and mother = two immune systemsTo be able to get on well both must be To be able to get on well both must be

modulatedmodulated

bdquobdquoFetal immunodeficiencyldquoFetal immunodeficiencyldquo11 Inability to produce Inability to produce cytokinescytokines22 Defects in intracellular Defects in intracellular killingkilling33 Immature production of Immature production of antibodiesantibodies

The protection of the fetusThe protection of the fetus ndash ndash revision revision

bull Placenta and amnionPlacenta and amnionbull MaternalMaternal IgGIgG (halftime = 20 days) (halftime = 20 days)

ndash actively transported through the placentaactively transported through the placentandash IgG against capsular polysaccharides are IgG against capsular polysaccharides are

active only up to circa 3 months after active only up to circa 3 months after deliverydelivery

ndash IgG against viruses are effective even up IgG against viruses are effective even up to 12-15 months to 12-15 months

bull Colostral IgAColostral IgA

PrenatalPrenatal infections ndash infections ndash revision revision

AgentAgentTrimesterTrimester

Congenital Congenital defectsdefects

Postnatal Postnatal persistencepersistence11 22 33

Treponema pallidumTreponema pallidum -- ++ ++ ++ ++List monocytogenesList monocytogenes -- -- ++ -- --Rubella virus Rubella virus ++++ ++ -- ++ ++CMVCMV ++ ++ ++ ++ ++Parvovirus B19Parvovirus B19 plusmnplusmn ++ plusmnplusmn -- --VZVVZV ++ -- ++ plusmnplusmn ++HSVHSV ++ ++ ++ -- ++HIVHIV -- ++Toxoplasma gondiiToxoplasma gondii plusmnplusmn ++ ++++ ++ ++

DiagnosticsDiagnostics of prenatal infection of prenatal infection ndash revision ndash revision

Examination of Examination of mothermother ndash ndash immensely important in immensely important in syphilissyphilis (obligatory in (obligatory in

most countries) and in most countries) and in toxoplasmosistoxoplasmosis

Examination ofExamination of the the newbornnewbornndash ndash above all the detection of its above all the detection of its IgMIgM (IgM (IgM

antibodies antibodies cannot be of maternal origincannot be of maternal origin ndash ndash they donrsquot they donrsquot passpass through the placenta) through the placenta)

ndash ndash sometimes the sometimes the directdirect detection (eg CMV in detection (eg CMV in urine)urine)

Treatment Treatment ampamp prevention of prevention of prenatal infectionprenatal infection ndash revision ndash revision

TreatmentTreatment (of the mother) (of the mother)PNCPNC in syphilis in syphilisspiramycinspiramycin in toxoplasmosis in toxoplasmosis

PreventionPreventionhealthy motherhealthy mother (examined for syphilis (examined for syphilis possibly for toxoplasmosis)possibly for toxoplasmosis)

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

A little bit A little bit oof immunologyf immunology ndash ndash revision revision

Fetus = an immunological paradoxFetus = an immunological paradoxFetus and mother = two immune systemsFetus and mother = two immune systemsTo be able to get on well both must be To be able to get on well both must be

modulatedmodulated

bdquobdquoFetal immunodeficiencyldquoFetal immunodeficiencyldquo11 Inability to produce Inability to produce cytokinescytokines22 Defects in intracellular Defects in intracellular killingkilling33 Immature production of Immature production of antibodiesantibodies

The protection of the fetusThe protection of the fetus ndash ndash revision revision

bull Placenta and amnionPlacenta and amnionbull MaternalMaternal IgGIgG (halftime = 20 days) (halftime = 20 days)

ndash actively transported through the placentaactively transported through the placentandash IgG against capsular polysaccharides are IgG against capsular polysaccharides are

active only up to circa 3 months after active only up to circa 3 months after deliverydelivery

ndash IgG against viruses are effective even up IgG against viruses are effective even up to 12-15 months to 12-15 months

bull Colostral IgAColostral IgA

PrenatalPrenatal infections ndash infections ndash revision revision

AgentAgentTrimesterTrimester

Congenital Congenital defectsdefects

Postnatal Postnatal persistencepersistence11 22 33

Treponema pallidumTreponema pallidum -- ++ ++ ++ ++List monocytogenesList monocytogenes -- -- ++ -- --Rubella virus Rubella virus ++++ ++ -- ++ ++CMVCMV ++ ++ ++ ++ ++Parvovirus B19Parvovirus B19 plusmnplusmn ++ plusmnplusmn -- --VZVVZV ++ -- ++ plusmnplusmn ++HSVHSV ++ ++ ++ -- ++HIVHIV -- ++Toxoplasma gondiiToxoplasma gondii plusmnplusmn ++ ++++ ++ ++

DiagnosticsDiagnostics of prenatal infection of prenatal infection ndash revision ndash revision

Examination of Examination of mothermother ndash ndash immensely important in immensely important in syphilissyphilis (obligatory in (obligatory in

most countries) and in most countries) and in toxoplasmosistoxoplasmosis

Examination ofExamination of the the newbornnewbornndash ndash above all the detection of its above all the detection of its IgMIgM (IgM (IgM

antibodies antibodies cannot be of maternal origincannot be of maternal origin ndash ndash they donrsquot they donrsquot passpass through the placenta) through the placenta)

ndash ndash sometimes the sometimes the directdirect detection (eg CMV in detection (eg CMV in urine)urine)

Treatment Treatment ampamp prevention of prevention of prenatal infectionprenatal infection ndash revision ndash revision

TreatmentTreatment (of the mother) (of the mother)PNCPNC in syphilis in syphilisspiramycinspiramycin in toxoplasmosis in toxoplasmosis

PreventionPreventionhealthy motherhealthy mother (examined for syphilis (examined for syphilis possibly for toxoplasmosis)possibly for toxoplasmosis)

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

The protection of the fetusThe protection of the fetus ndash ndash revision revision

bull Placenta and amnionPlacenta and amnionbull MaternalMaternal IgGIgG (halftime = 20 days) (halftime = 20 days)

ndash actively transported through the placentaactively transported through the placentandash IgG against capsular polysaccharides are IgG against capsular polysaccharides are

active only up to circa 3 months after active only up to circa 3 months after deliverydelivery

ndash IgG against viruses are effective even up IgG against viruses are effective even up to 12-15 months to 12-15 months

bull Colostral IgAColostral IgA

PrenatalPrenatal infections ndash infections ndash revision revision

AgentAgentTrimesterTrimester

Congenital Congenital defectsdefects

Postnatal Postnatal persistencepersistence11 22 33

Treponema pallidumTreponema pallidum -- ++ ++ ++ ++List monocytogenesList monocytogenes -- -- ++ -- --Rubella virus Rubella virus ++++ ++ -- ++ ++CMVCMV ++ ++ ++ ++ ++Parvovirus B19Parvovirus B19 plusmnplusmn ++ plusmnplusmn -- --VZVVZV ++ -- ++ plusmnplusmn ++HSVHSV ++ ++ ++ -- ++HIVHIV -- ++Toxoplasma gondiiToxoplasma gondii plusmnplusmn ++ ++++ ++ ++

DiagnosticsDiagnostics of prenatal infection of prenatal infection ndash revision ndash revision

Examination of Examination of mothermother ndash ndash immensely important in immensely important in syphilissyphilis (obligatory in (obligatory in

most countries) and in most countries) and in toxoplasmosistoxoplasmosis

Examination ofExamination of the the newbornnewbornndash ndash above all the detection of its above all the detection of its IgMIgM (IgM (IgM

antibodies antibodies cannot be of maternal origincannot be of maternal origin ndash ndash they donrsquot they donrsquot passpass through the placenta) through the placenta)

ndash ndash sometimes the sometimes the directdirect detection (eg CMV in detection (eg CMV in urine)urine)

Treatment Treatment ampamp prevention of prevention of prenatal infectionprenatal infection ndash revision ndash revision

TreatmentTreatment (of the mother) (of the mother)PNCPNC in syphilis in syphilisspiramycinspiramycin in toxoplasmosis in toxoplasmosis

PreventionPreventionhealthy motherhealthy mother (examined for syphilis (examined for syphilis possibly for toxoplasmosis)possibly for toxoplasmosis)

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

PrenatalPrenatal infections ndash infections ndash revision revision

AgentAgentTrimesterTrimester

Congenital Congenital defectsdefects

Postnatal Postnatal persistencepersistence11 22 33

Treponema pallidumTreponema pallidum -- ++ ++ ++ ++List monocytogenesList monocytogenes -- -- ++ -- --Rubella virus Rubella virus ++++ ++ -- ++ ++CMVCMV ++ ++ ++ ++ ++Parvovirus B19Parvovirus B19 plusmnplusmn ++ plusmnplusmn -- --VZVVZV ++ -- ++ plusmnplusmn ++HSVHSV ++ ++ ++ -- ++HIVHIV -- ++Toxoplasma gondiiToxoplasma gondii plusmnplusmn ++ ++++ ++ ++

DiagnosticsDiagnostics of prenatal infection of prenatal infection ndash revision ndash revision

Examination of Examination of mothermother ndash ndash immensely important in immensely important in syphilissyphilis (obligatory in (obligatory in

most countries) and in most countries) and in toxoplasmosistoxoplasmosis

Examination ofExamination of the the newbornnewbornndash ndash above all the detection of its above all the detection of its IgMIgM (IgM (IgM

antibodies antibodies cannot be of maternal origincannot be of maternal origin ndash ndash they donrsquot they donrsquot passpass through the placenta) through the placenta)

ndash ndash sometimes the sometimes the directdirect detection (eg CMV in detection (eg CMV in urine)urine)

Treatment Treatment ampamp prevention of prevention of prenatal infectionprenatal infection ndash revision ndash revision

TreatmentTreatment (of the mother) (of the mother)PNCPNC in syphilis in syphilisspiramycinspiramycin in toxoplasmosis in toxoplasmosis

PreventionPreventionhealthy motherhealthy mother (examined for syphilis (examined for syphilis possibly for toxoplasmosis)possibly for toxoplasmosis)

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

DiagnosticsDiagnostics of prenatal infection of prenatal infection ndash revision ndash revision

Examination of Examination of mothermother ndash ndash immensely important in immensely important in syphilissyphilis (obligatory in (obligatory in

most countries) and in most countries) and in toxoplasmosistoxoplasmosis

Examination ofExamination of the the newbornnewbornndash ndash above all the detection of its above all the detection of its IgMIgM (IgM (IgM

antibodies antibodies cannot be of maternal origincannot be of maternal origin ndash ndash they donrsquot they donrsquot passpass through the placenta) through the placenta)

ndash ndash sometimes the sometimes the directdirect detection (eg CMV in detection (eg CMV in urine)urine)

Treatment Treatment ampamp prevention of prevention of prenatal infectionprenatal infection ndash revision ndash revision

TreatmentTreatment (of the mother) (of the mother)PNCPNC in syphilis in syphilisspiramycinspiramycin in toxoplasmosis in toxoplasmosis

PreventionPreventionhealthy motherhealthy mother (examined for syphilis (examined for syphilis possibly for toxoplasmosis)possibly for toxoplasmosis)

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Treatment Treatment ampamp prevention of prevention of prenatal infectionprenatal infection ndash revision ndash revision

TreatmentTreatment (of the mother) (of the mother)PNCPNC in syphilis in syphilisspiramycinspiramycin in toxoplasmosis in toxoplasmosis

PreventionPreventionhealthy motherhealthy mother (examined for syphilis (examined for syphilis possibly for toxoplasmosis)possibly for toxoplasmosis)

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Infections proceeding Infections proceeding moremore severely in pregnancyseverely in pregnancy ndash revision ndash revision

Malaria Malaria ndashndash because of lower cellular immunity because of lower cellular immunityVirus hepatitis Virus hepatitis ndash especially VHE ndash especially VHE InfluenzaInfluenza ndash during pandemics ndash during pandemics PoliomyelitisPoliomyelitis ndash more frequent paralysis ndash more frequent paralysisUrinary tract infections Urinary tract infections ndash pressure on the ndash pressure on the

ureter atonia of urinary bladderureter atonia of urinary bladderCandidosis Candidosis ndash vulvovaginitis ndash vulvovaginitis Listeriosis Listeriosis ndash beware of cheesendash beware of cheese

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

PerinatalPerinatal infections infections ndash revision ndash revision bdquobdquoImmunologic immaturity and naivety of the Immunologic immaturity and naivety of the

newbornldquonewbornldquoInability to produce antibodies against Inability to produce antibodies against

polysaccharidespolysaccharidesLow level of complement and few NK cellsLow level of complement and few NK cellsSmall supply of neutrophilsSmall supply of neutrophilsInsufficient function of neutrophilsInsufficient function of neutrophilsLow level of IgA (particularly in premature infants)Low level of IgA (particularly in premature infants)Low mucosal immunityLow mucosal immunity(Satisfactory cellular immunity)(Satisfactory cellular immunity)

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Agents transmissibleAgents transmissible during during deliverydelivery ndash revision ndash revision

bull Agents originating Agents originating in vagina cervix and rectumin vagina cervix and rectumGGBSBS ndash sepsis and meningitis (early and late one) ndash sepsis and meningitis (early and late one)CChlhl trachomatis trachomatis D ndash KD ndash K ndash inclusion conjunctivitisndash inclusion conjunctivitisE coliE coli amp otheramp other enteric rods enteric rods ndash ndash sepsis and meningitis sepsis and meningitis NNeisseriaeisseria gonorrhoeae gonorrhoeae ndash ndash purulent conjunctivitispurulent conjunctivitisLListeriaisteria monocytogenes monocytogenes ndash meningitis and sepsisndash meningitis and sepsisHHaemophilusaemophilus influenzae influenzae ndash meningitis and sepsisndash meningitis and sepsisMMycoplasmaycoplasma hominis hominis ndash ndash pneumoniapneumoniaCCandidaandida albicans albicans ndash ndash soor (thrush)soor (thrush)HSV-2HSV-2 ndash generalized herpes ndash generalized herpes

bull Agents originating Agents originating in bloodin bloodHBV HIVHBV HIV

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Agents transmissible Agents transmissible postnatallypostnatally ndash revision ndash revision

bull From the motherFrom the motherggroup B streptococciroup B streptococci ndash sepsis and meningitisndash sepsis and meningitisStaphylococcus aureus Staphylococcus aureus ndash ndash pyodermia even sepsis pyodermia even sepsisMycobacterium tuberculosis Mycobacterium tuberculosis ndash tuberculosis ndash tuberculosis CMVCMV ndash ndash HIVHIV ndash AIDS ndash AIDS

bull From theFrom the surrounding surrounding environmentenvironmententerobacteriaenterobacteriaee incl salmonellae incl salmonellae ndash diarrhoea and sepsis ndash diarrhoea and sepsis Pseudomonas aeruginosa Pseudomonas aeruginosa ndash ndash serious diarrhoeaserious diarrhoeaStaphylococcus aureusStaphylococcus aureus ndash pyodermia even sepsisndash pyodermia even sepsisrrespiratory syncytial virus (RSV)espiratory syncytial virus (RSV) ndash bronchiolitis ndash bronchiolitis

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

DiagnosticsDiagnostics of perinatal and of perinatal and postnatal infectionspostnatal infections ndash revision ndash revision The The most rapid methodsmost rapid methods are essentialare essential

ndash ndash therefore therefore directdirect detection only detection onlyMicroscopy Microscopy ndash invaluable in CSF (Cocci or ndash invaluable in CSF (Cocci or

rods G+ or Gndash In clumps chainsrods G+ or Gndash In clumps chains or or in in pairs) pairs)

Detection of antigens Detection of antigens ndash CSF again GBS ndash CSF again GBS HIB pneumococci meningococci HIB pneumococci meningococci (group B (group B ~~ E coli E coli K1)K1)

PCR PCR ndash not yet standardizedndash not yet standardized

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

PreventionPrevention of perinatal and postnatal of perinatal and postnatal infectionsinfections ndash revision ndash revision

Screening of the mother Screening of the mother (examination of vaginal (examination of vaginal and rectal swab for GBS)and rectal swab for GBS)

Prevention of premature laboPrevention of premature labouur r (because of (because of immune immaturity of the newborn)immune immaturity of the newborn)

Leading the delivery lege artis Leading the delivery lege artis (examination per (examination per rectum induction of laborectum induction of labouur after the rupture of r after the rupture of membranes etc)membranes etc)

Clean and tidyClean and tidy delivery room and the newborn delivery room and the newborn wardward

helliphellip

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Definition of NIDefinition of NINosocomial infections =Nosocomial infections =

= infections originated in connection with the = infections originated in connection with the stay in hospital stay in hospital (as distinct from infections (as distinct from infections originated in the community)originated in the community)

At least 5 patients are afflicted by NI but At least 5 patients are afflicted by NI but probably moreprobably more

Exogenic NIExogenic NIsource = source = other patientsother patients staff staff environmentenvironmentvector = in most cases vector = in most cases the staffrsquos unthe staffrsquos unwashed washed handshands

Endogenic NIEndogenic NIsource = source = the patient himselfthe patient himself

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Consequences of NIConsequences of NIIncreased Increased mortalitymortality ( (daggerdagger) ndash up to 40 (rough ) ndash up to 40 (rough

estimate in this country amounts to hundreds estimate in this country amounts to hundreds deaths per year)deaths per year)

ProlongedProlonged hospitalizationhospitalization (by weeks) and (by weeks) and increasincreased ed costcost (by tens (by tens of of thousands or more thousands or more Czech crowns per case)Czech crowns per case)

EconomicEconomic loss loss circa 15 miliiard CZC per yearcirca 15 miliiard CZC per yearAdditional Additional ATBATB therapy (both therapy (both costcost and toxicity) and toxicity)Patients = the Patients = the source of infectionsource of infection for others for others

And the same time And the same time gtgt13 NI 13 NI can becan be preventepreventedd

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Main kinds of NIMain kinds of NI11 Urinary infections Urinary infections ofof catetherized catetherized patients ndash up patients ndash up

to 40 of all NIto 40 of all NI22 Respiratory infections Respiratory infections ndash about 20 ndash about 20

ndash Early ventilator pneumoniaEarly ventilator pneumoniandash Late ventilator pneumoniaLate ventilator pneumoniandash Aspiration pneumoniaAspiration pneumoniandash Other respiratory infectionsOther respiratory infections

3 Suppurative infections of surgical wounds 3 Suppurative infections of surgical wounds ndash ndash about 20 about 20

4 Bloodstream Infections 4 Bloodstream Infections (sepsis (sepsis fromfrom inserted inserted intravenous catheters) ndash at least 15 intravenous catheters) ndash at least 15

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Etiology of urinary NIEtiology of urinary NIEscherichia coli Escherichia coli 25 25 other enterobacteriaeother enterobacteriae 20 20 enterococcienterococci 15 15 Pseudomonas aeruginosa Pseudomonas aeruginosa 10 10 other Gndash non-fermenting rods 10 other Gndash non-fermenting rods 10 candidae candidae 5 5

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Etiology of respiratory NI ndash I Etiology of respiratory NI ndash I Early Early ventilator pneumoniaventilator pneumonia

Staphylococcus aureus Staphylococcus aureus 25 25 Streptococcus pneumoniae Streptococcus pneumoniae 20 20 Haemophilus influenzae Haemophilus influenzae 15 15 enterobacteriae 10 enterobacteriae 10 other aerobically growing bacteriae 5 other aerobically growing bacteriae 5 anaerobesanaerobes 1 1 (monomicrobial etiology agent originates (monomicrobial etiology agent originates

from the communityfrom the community) )

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Etiology of respiratory NI ndash II Etiology of respiratory NI ndash II Late Late ventilator pneumoniaventilator pneumonia

Gndash non-fermenting rodsGndash non-fermenting rods 40 40 ((P aeruginosa Acinetob baumanniiP aeruginosa Acinetob baumannii))

enterobacteriaeenterobacteriae 30 30 (klebsiellae (klebsiellae E coliE coli enterobacters) enterobacters)

staphylococcistaphylococci20 (above all 20 (above all S aureusS aureus))

yeasts yeasts 5 5 (some cases have polymicrobial etiology(some cases have polymicrobial etiology

agents are of agents are of hospitalhospital origin) origin)

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Etiology of respiratory NI ndash III Etiology of respiratory NI ndash III AspirationAspiration nosocomial pneumonia nosocomial pneumonia

Older works Older works emphasizedemphasized anaerobesanaerobesNewer studies trace the same etiology as in ventilator Newer studies trace the same etiology as in ventilator

pneumonias and pneumonias and emphasizedemphasized GGramram--negativenegative rodsrods (non-fermenting ones rather than enterobacteriae)(non-fermenting ones rather than enterobacteriae)

Affliction of lungs in Affliction of lungs in febrile neutropeniafebrile neutropeniaFirst days 2First days 2timestimes more more often often G+ cocciG+ cocci (staphylococci (staphylococci

pneumococci) thpneumococci) thaan n Gndash rodsGndash rods (enterobacteriae and (enterobacteriae and pseudomonads)pseudomonads)

Later on darr G+ cocci uarr Later on darr G+ cocci uarr candidae and aspergillscandidae and aspergillsAfter an allogenic transplantation of bone marrow mainly After an allogenic transplantation of bone marrow mainly

CMVCMV

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Etiology of suEtiology of surrgical wounds gical wounds suppuration suppuration

(It depends on the terrain in which the (It depends on the terrain in which the surgery took place)surgery took place)

Staphylococcus aureusStaphylococcus aureuscoagulase-negative staphylococcicoagulase-negative staphylococciStreptococcus pyogenesStreptococcus pyogenesenterobacteriaeenterobacteriaebacteroids prevotellae peptostreptococcibacteroids prevotellae peptostreptococcigramnegative non-fermenting rodsgramnegative non-fermenting rodsClostridium perfringensClostridium perfringens

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Etiology of sepsis Etiology of sepsis fromfrom iv iv catheters catheters

Coagulase-negative staphylococci Coagulase-negative staphylococci ((gtgt50 ) 50 ) ndash because of the biofilm productionndash because of the biofilm production

enterococcienterococciStaphylococcus aureusStaphylococcus aureusenterobacteriae (enterobacteriae (E coliE coli klebsiellae) klebsiellae)Pseudomonas aeruginosaPseudomonas aeruginosaAcinetobacter Acinetobacter sppsppCandida Candida sppspp

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Etiology of nosocomial viroses Etiology of nosocomial viroses

Influenza v Influenza v ndash esp infants and older patientsndash esp infants and older patientsRSVRSV ndash newborns and suckling infants ndash newborns and suckling infantsadenovirusesadenoviruses ndash eye departments ndash eye departmentsOther respiratory virusesOther respiratory virusesCMVCMV ndash after the cytotoxic therapy ndash after the cytotoxic therapyrotavirusesrotaviruses ndash esp children ndash esp childrenHBVHBV ndash ndash higher risk with prologed stayhigher risk with prologed stayHIV ndash fortunately not in this countryHIV ndash fortunately not in this country

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Predispozition to NI Predispozition to NI AgeAge ndash both extremes of the age ndash both extremes of the ageTherapyTherapy ndash cytotoxic ndash cytotoxic therapytherapy steroids steroids antibioticsantibioticsBasic illnessBasic illness

affliction of the liveraffliction of the liverdiabetes mellitusdiabetes mellitustumorstumorsaffliction of the kidneys and bladderaffliction of the kidneys and bladderskin lesionsskin lesions

TraumaTrauma ndash incl surgical wounds and iv catheters ndash incl surgical wounds and iv catheters

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Prevention of NI ndash I Prevention of NI ndash I Four main strategiesFour main strategies

11 Elimination of sources of infection Elimination of sources of infection from the from the hospital environment hospital environment

22 Breaking Breaking the epidemic chain ( the epidemic chain (the way of the way of spreading the infectionspreading the infection from the source to from the source to the hostthe host))

3 Strengthening the resistance 3 Strengthening the resistance of the host to of the host to the infectionthe infection

4 Investigating4 Investigating the causes of NI the causes of NI

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Prevention of NI ndash II Prevention of NI ndash II 11 Elimination of sources of infection Elimination of sources of infection

from the hospital environmentfrom the hospital environment

bull Sterile Sterile instruments dressings medicines instruments dressings medicines fluids for infusions duly examined blood for fluids for infusions duly examined blood for transfusions clean linen noncontaminated transfusions clean linen noncontaminated foodfood

bull Prevention of contact with infected Prevention of contact with infected staffstaff ndash ndash anan acutely ill or a carrier of pathogens acutely ill or a carrier of pathogens

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Prevention of NI ndash III Prevention of NI ndash III 2 Breaking 2 Breaking the epidemic chain the epidemic chain

bull EquipmentEquipmentndash ventilation (air conditioning and legionellae building ventilation (air conditioning and legionellae building

works and aspergills)works and aspergills)ndash water (legionellae)water (legionellae)ndash Patientlsquos isolationPatientlsquos isolation

bull For hisher protection For hisher protection bull For the vicinity protectionFor the vicinity protection

bull PeoplePeoplendash Support of aseptic behavior of Support of aseptic behavior of staffstaffndash The most important is The most important is effective hand washingeffective hand washing

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Prevention of NI ndash IV Prevention of NI ndash IV 3 Strengthening the host resistance3 Strengthening the host resistance

bull ImmunizationImmunizationndash influenza (older patients)influenza (older patients)ndash pneumococcal infections (before transplantation pneumococcal infections (before transplantation

before splenectomy)before splenectomy)ndash VHB (in seronegative persons beforVHB (in seronegative persons beforee dialysis) dialysis)ndash VZV infections (specific Ig in immunocompromiVZV infections (specific Ig in immunocompromissed)ed)

bull ATB prophylaxisATB prophylaxisndash In In ldquodirtyrdquo surgeryldquodirtyrdquo surgeryndash inin ort orthhopopaaediedicscs ccardioardiosurgerysurgery neuro neurosurgerysurgery

bull Lowering the risk ofLowering the risk of infecinfectiontionndash Proper techniqueProper techniquendash Meticulous care of invasive aidsMeticulous care of invasive aids a andnd infu infusionssionsndash PrevenPrevention of decubitestion of decubites

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

PrevenPrevention of tion of NNII ndash V ndash V 4 4 Investigating the causes of NI Investigating the causes of NI

bull Surveillance Surveillance (= (= detailed monitoringdetailed monitoring) ndash ) ndash records changes in numbers or types records changes in numbers or types of NIof NI

bull Examination ofExamination of individual cases of NIindividual cases of NI espesp if they have anif they have an epidemic chara epidemic characcterter

bull FormulaFormulation of antition of antiepidemicepidemic principles principles aand monitoring how they are nd monitoring how they are observedobserved

helliphellip

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Homework Homework 1212

Austrian artistAustrian artist Ivo Ivo Saliger (1894ndashSaliger (1894ndash

1987)1987)The Physician The Physician

StrugglingStrugglingwith the Death for with the Death for

a Young Girl a Young Girl (1920)(1920)

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Homework Homework 112 2

Successful homework 1Successful homework 122 solver solver

NoneNone

(but thanks for the effort)(but thanks for the effort)

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

HomeworkHomework 1313

The gouache of a The gouache of a Czech artist is Czech artist is a a part of the cycle part of the cycle named after an named after an infectious disease infectious disease ndash which onendash which one

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination

Answer and questionsAnswer and questions

The solution of the homework and possible The solution of the homework and possible questions please mail questions please mail (on Monday 630 am (on Monday 630 am

at the latest) at the latest) to the addressto the address

mvotavamedmunicz

Thank you for your attentionThank you for your attention

Good luck at the examinationGood luck at the examination