Hospital Acquired Infections Nursing CE Course

3.0 ANCC Contact Hours AACN Category B

Syllabus

Upon completion of this activity, participants should be able to:

1. Discuss the causes, prevention, treatment, and nursing care of patients with infections caused by Clostridium difficile.

2. Describe the causes, prevention, treatment, and nursing care of patients with infections caused by methicillin-resistant Staphylococcus aureus.

3. Explain the causes, prevention, treatment, and nursing care of patients with infections caused by vancomycin-resistant Enterococcus.

4. Discuss the causes, prevention, treatment, and nursing care of patients with central line-associated bloodstream infections.

5. Describe the causes, prevention, treatment, and nursing care of patients with catheter-associated urinary tract infections.

6. Explain the causes, prevention, treatment, and nursing care of patients with ventilator-associated pneumonia.

Hospital-acquired infections (HAI’s) are an ongoing issue in hospitals and healthcare organizations, in spite of ongoing efforts to prevent infections and reduce infection rates. On any given day, 1 in 31 hospitalized patients will have at least one healthcare-associated infection (Centers for Disease Control and Prevention [CDC], 2019d). The Society for Healthcare Epidemiology of America (SHEA, 2014), the Association for Practitioners in Infection Control and Epidemiology (APIC, 2016), and the CDC (2015b) advocate for consistent, facility-wide adoption of up-to-date, evidence-based guidelines and tools for infection prevention and control.

Hand hygiene is the most crucial overall strategy to prevent hospital-acquired infections (CDC, 2019d). According to the CDC, healthcare workers wash their hands or perform hand hygiene less than 50% of the time. Monitoring hand hygiene compliance is one key component of a hospital’s infection prevention program. The Joint Commission Center for Transforming Healthcare developed a hand hygiene-targeted surveillance tool. Shabot et al. (2016) described a project that implemented the Joint Commission Targeted Solutions Tool® over four years in 150 inpatient units at 12 hospitals within Memorial Hermann Health Systems. Their study concluded that 

“procedure-specific processes to reduce infections related to devices such as central lines or ventilators or others, such as urinary catheters, may not achieve extremely low rates of infection unless they are accompanied by high rates of hand hygiene compliance” (p. 15). 

In addition to hand hygiene the use of standard precautions and transmission-based precautions is critical to the prevention of hospital acquired infections. Standard precautions are used in the care of all patients in the healthcare setting. Transmission based precautions are the second tier of basic infection control precautions and are used in addition to standard precautions to prevent the transmission of communicable diseases in the healthcare setting (Siegel, Rhinehart, Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2019).

The purpose of this course is to provide nurses with information on the causes of and current evidence-based best practices for the prevention and treatment of hospital-acquired infections.

Clostridium Difficile Infection

Epidemiology and Pathophysiology

Clostridium difficile (C. diff), now termed Clostridioides difficile by the CDC (2018), is a Gram-positive, spore-forming anaerobic bacterium that causes C. diff infection by producing toxin A and toxin B.  A third toxin, called binary toxin, has been identified in about 5% of C. diff isolates. The ability of the organism to form spores allows C. diff to survive for months in the hospital environment. C. diff infection is bacterial diarrhea that occurs in patients who have recently taken antibiotics (usually within two months). Pseudomembranous colitis is a more severe form of C. Diff infection where pseudomembranous plaques are visualized by colonoscopy on the surface of the colon. C. diff is the most known cause of infectious diarrhea in healthcare settings. Rates of C. diff infection in the United States have tripled since 2000 (Bowling, 2018; McDonald et al., 2018).

CDC (2019b) data indicate that C. diff infections cause almost 500,000 illnesses in the United States each year, and 1 in 5 patients diagnosed with C. diff infection will have a recurrence. According to the Infectious Disease Society of America (IDSA), surveillance for hospital-acquired C. diff infections should be conducted in all inpatient facilities to screen for elevated rates or outbreaks (McDonald et al., 2018).

Risk factors and Protective factors

Acute care facilities are considered a high-risk environment for C. diff infection due to two factors: high antimicrobial use and the hospital environment being heavily contaminated with C. diff spores. Poor antibiotic prescribing practices, such as prescribing an unnecessary or inappropriate antibiotic, put patients at increased risk for C. diff infections (CDC, 2019a). According to the CDC (2017)

“Studies indicate that 30 to 50 percent of antibiotics prescribed in hospitals are inappropriate or unnecessary…overprescribing and misprescribing is contributing to the growing challenges posed by Clostridium difficile and antibiotic-resistant bacteria. Studies indicate that improving prescribing practices in hospitals can help reduce rates of Clostridium difficile infection and antibiotic resistance.” (para. 1).

The most critical modifiable risk factor for C. diff infection is exposure to antibiotics. The IDSA addresses the essential role of antibiotic stewardship in controlling C. diff infection rates. Antibiotic stewardship is the use of current evidence-based recommendations to guide providers in prescribing antibiotics. The disruption of the healthy intestinal microbiota by antibiotics is long-lasting, and the risk of developing a C. diff infection increases during antibiotic therapy and up to three months following the end of antibiotic treatment. IDSA recommends that providers minimize the number of antibiotics that are prescribed, targeting antibiotics based on local epidemiology, and considering the restriction of fluoroquinolones, clindamycin (Cleocin), and cephalosporins, except for surgical antibiotic prophylaxis. In addition to the hospital environment itself, and poor antibiotic prescribing practices, risk factors for C. diff infection also include age 65 or older, duration of hospitalization, cancer chemotherapy, and prescribed proton pump inhibitors (CDC, 2017, 2019b; McDonald et al., 2018).

Protective factors for C. diff infection include hand hygiene for patients and healthcare providers, scrupulous environmental cleaning, and instituting contact precautions when caring for patients who have three or more diarrhea stools. Hospitalized patients who experience three or more unformed, watery stools in 24 hours with a history of antibiotic exposure, without any other identified cause or diagnosis, should be placed on contact precautions in a private room with a dedicated toilet. If necessary, they may be placed in a semiprivate room with another patient who has C. diff infection. (CDC, 2019b; IDSA, 2018).

Signs and Symptoms

C. diff infection is characterized by three to more than 20 watery or unformed stools per day. The stools may exhibit a characteristic odor. Patients with C. diff infection may also have abdominal cramping, anorexia, nausea, fever, and leukocytosis. In addition, 28% of patients with C. diff infection have occult fecal blood (Bowling, 2018; CDC, 2019b). 

Diagnosis

    According to the IDSA (2018) laboratory testing for C. diff should not be performed on patients who have received a laxative within the previous 48 hours (McDonald et al., 2018, p. e16). Diagnostic testing should be done for symptomatic patients.  Diagnostic tests for C. diff infection include:

  • Stool culture which has high specificity and low sensitivity for C. diff. This test has a 7-day turnaround time
  • Enzyme immunoassays for toxins A and B which use monoclonal antibodies to detect toxin A and polyclonal antibodies to detect toxin B. These are rapid tests with high specificity and low sensitivity
  • Latex test or immunoassay for C. diff antigen which detects glutamine dehydrogenase (GDH). The GDH immunoassay test is used in a two-step testing algorithm to identify C. diff infection. 
  • Colon endoscopy used to detect the more severe form of C. diff infection, pseudomembranous colitis.
  • Nucleic acid amplification tests (NAATs) that use two different methods: a polymerase chain reaction and loop-mediated amplification of DNA to detect toxic genes for C. diff in stool samples. NAATs have a high sensitivity and specificity along with a turnaround time of several hours; for these reasons, they are the principal diagnostic tests used for C. diff infection in the United States (Bowling, 2018, para. 19-24; CDC, 2019b, para. 6)

The IDSA (2018) recommends the best approach to laboratory diagnostic testing for C. diff infection is careful screening for clinical symptoms and a NAAT alone, a GDH plus toxin, a GDH plus toxin along with a NAAT, or a NAAT plus toxin (McDonald et al., 2018, p. e3).

A question that often arises in caring for patients diagnosed with C. diff infection is repeat testing. According to the IDSA, repeat testing should be done when there is a recurrence of symptoms of C. diff infection following a successful course of treatment. However, there is no clinical value in repeat testing to establish a cure (McDonald et al., 2018, p. e22).

Prevention

When caring for patients with a suspected or confirmed C diff infection it is critical to prevent transmission. Hospitalized patients who have three or more diarrhea stools in 24 hours, in the absence of another cause for that diarrhea, should be placed on contact isolation and tested for C. diff infection. In addition to prompt initiation of contact precautions, nurses need to remember that patients with suspected C. diff infection need to be placed in a private room with a dedicated toilet, or they can be placed in a semiprivate room cohort with another patient with C. diff. Because patients with C. diff infection continue to shed the organism, contact precautions should be maintained for several days after diarrhea stools have resolved. When a patient with C. diff infection transfers to a new facility, the nurse must notify the receiving facility that the patient has a C. diff infection. Hand hygiene is another critical prevention strategy. In routine situations, healthcare workers should perform hand hygiene before and after removing gloves following contact with patients who have suspected or confirmed C. diff infection with either soap and water or alcohol-based hand hygiene products. Handwashing with soap and water is necessary when there has been direct contact with feces or the patient’s perineal region, as alcohol-based products do not kill C. diff. For this reason, handwashing with soap and water is the preferred method of hand hygiene in C. diff infection outbreak situations. Disposable patient care equipment should be used whenever possible. Reusable equipment requires thorough cleaning with a sporicidal disinfectant (CDC, 2019b; McDonald et al., 2018).

Treatment and Management

The first step in the treatment and management of C. diff infection is for the provider to discontinue the provoking antibiotic therapy. Symptoms will resolve in 20 to 25% of patients by stopping the prescribed antibiotic. A ten-day course of oral vancomycin (Vancocin) or fidaxomicin (Dificid) is recommended for an initial episode of C. diff infection.  Fidaxomicin (Dificid) is more expensive than vancomycin (Vancocin). In situations where there is limited availability of vancomycin (Vancocin) or fidaxomicin (Dificid), a ten-day course of metronidazole (Flagyl) may be prescribed. For a repeat episode of C. diff infection, another course of oral vancomycin (Vancocin) or fidaxomicin (Dificid) is indicated. Fecal microbiota transplantation is recommended for patients with multiple recurrences of C. diff infection that have not responded to antibiotics. Fecal microbiota transplantation is based on the concept that recurrent C. diff infection persists because of the altered colonic microbiota in the bowel due to prior antibiotic therapy. Fecal microbiota transplantation reestablishes the normal fecal microbiota by infusion of healthy donor feces (Bowling, 2018; McDonald et al., 2018).

Nursing Care and Nursing Implications

Nursing care for patients with suspected or confirmed C. diff infection begins with scrupulous hand hygiene, along with prompt initiation of contact precautions. An important consideration when placing C. diff patients in isolation is the requirement for patients with C. diff need to be placed in a private room with a dedicated toilet. In situations where a private room is unavailable, patients may be placed in a semiprivate room with another patient who has confirmed or suspected C. diff infection (McDonald et al., 2018; Bowling, 2018).

In addition to initiating and maintaining appropriate isolation precautions for the duration of the C. diff infection, nurses are responsible for monitoring for and reporting the occurrence of three or more diarrhea stools in 24 hours, monitoring the patient’s lab work for C. diff test results, and administration of prescribed antibiotic therapy. Nurses also need to be sure that appropriate cleaning and disinfection of the patient’s room occurs, including the daily use of a sporicidal agent or a 1:10 bleach solution in areas where C. diff infection rates are high. In addition, some hospitals have added terminal disinfection with UV radiation or hydrogen peroxide vapor to their cleaning regimen. Currently, there is limited data available to support the use of UV radiation or hydrogen peroxide vapor as an effective terminal cleaning method (CDC, 2019b; McDonald et al., 2018).

Future Research and Trends

Srinivasa et al. (2019) studied the role of the environmental spread of C diff infection within hospital rooms in a 495-bed academic medical center. Bed tracing was conducted to analyze the movement of patients with confirmed C. diff within the hospital and identify rooms that had a high occupancy of positive patients throughout 2016. High-occupancy rooms were defined as those with nine or more C. diff positive patients during the year. Environmental cultures were then performed in the identified high-occupancy rooms. Their results indicate that the floors of the patient rooms may be reservoirs for C. diff, contributing to the spread of C. diff infection within hospitals. They noted that sporicidal floor disinfectant is effective in eliminating C. diff and recommended its use to thoroughly clean floors (Srinivasa et al., 2019).

C. diff infections have changed. A more virulent epidemic strain, ribotype 027, formerly called NAP1/BI/027, emerged in the mid-2000s. This strain produced toxin A, toxin B, and binary toxin. The prevalence of ribotype 027 has decreased worldwide, although it remains the major ribotype in the United States. A new strain, ribotype 78, has recently emerged in the Netherlands (CDC, 2019b).

Methicillin-Resistant Staphylococcus Aureus Infection

Epidemiology and Pathophysiology

 Staphylococcus is part of the human bacterial flora or microbiota. Methicillin was the drug of choice to treat infections caused by beta-lactamase-producing penicillin-resistant Staphylococcus aureus (S. aureus) beginning in October of 1960. However, within six months, strains resistant to methicillin emerged. Methicillin-resistant S. aureus (MRSA) is the term used to describe S. aureus strains that are resistant to beta-lactam antibiotics: penicillins, cephalosporins, and carbapenems. MRSA is a frequent pathogen in healthcare-associated infections and has been associated with significant morbidity, mortality, and increased hospital length of stay. The higher morbidity and mortality rates related to MRSA are not due to the MRSA itself but other factors such as delays in initiation of appropriate antibiotic therapy, less effective antibiotic therapy, or the increased severity of underlying illness for hospitalized patients with infections caused by MRSA (Becker & Kock, 2014; SHEA, 2014; Siddiqui & Koirala, 2018). 

Risk factors and Protective factors

Risk factors for hospital-acquired MRSA infection include prolonged hospitalization, compromised immune system, the presence of invasive devices such as central venous catheters, antibiotic treatment or being near individuals who are infected with or colonized with MRSA (Harris 2019; SHEA, 2014; Siddiqui & Koirala, 2018). 

Protective factors for hospital-acquired MRSA infection include hand hygiene for patients and healthcare providers, meticulous environmental cleaning, and instituting contact precautions when caring for patients colonized with MRSA as well as patients diagnosed with an active MRSA infection. Contact precautions when caring for a patient with respiratory infection or pneumonia caused by MRSA, would require the nurse to use a mask and goggles, in addition to gloves and gowns.  A mask and goggles are required personal protective equipment (PPE) because contact with the patient’s respiratory secretions is anticipated. Healthcare workers’ hands can become a vehicle for MRSA transmission from contact with the patient’s skin, wounds, dressings, secretions, equipment or environmental surfaces in the hospital room that is contaminated with MRSA (Harris, 2019; CDC, 2019e; Siegel, et al., 2019).

Signs and Symptoms

MRSA can cause several different types of infection: pneumonia, ventilator-associated pneumonia (VAP), endocarditis, catheter-associated urinary tract infection (CAUTI), bloodstream infection (including central line-associated bloodstream infection [CLABSI]), soft tissue infection and/or wound infection (including surgical site infection). MRSA symptoms vary depending upon the site of the infection. Patients with a soft tissue, wound, or surgical site infection may have redness, tenderness, and/or drainage from the site. Patients with a bloodstream infection, CBLASI, pneumonia, VAP, and/or CAUTI will have fatigue, fever, as well as pain or swelling at the site of the infection (Harris, 2019).

Diagnosis and Treatment

MRSA is diagnosed based on culture results. The culture and sensitivity will guide the healthcare provider’s selection of the most appropriate antibiotic to treat the infection. Other diagnostic tests that may be ordered by the provider include complete blood count, urinalysis with urine culture, chest x-ray, and/or CT scan (Harris, 2019).

Vancomycin (Vancocin) IV is the antibiotic of choice for the treatment of most hospital-acquired MRSA infections. The vancomycin (Vancocin) dose is adjusted based on the patient’s serum trough level and renal function. Daptomycin (Cubicin) IV is an appropriate antibiotic when vancomycin (Vancocin) is not available or is not well-tolerated (Becker & Kock, 2014; Siddiqui & Koirala, 2018).

According to the CDC (2019a), antibiotic stewardship in acute care hospitals is crucial to reducing hospital-acquired infections, including MRSA. The Core Elements of Hospital Antibiotic Stewardship Programs include:

  • Leadership Commitment: Dedicating necessary human, financial, and information technology resources.
  • Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs shows that a physician leader is effective.
  • Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use.
  • Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment needs after a set period of initial treatment (i.e., “antibiotic time out” after 48 hours).
  • Tracking: Monitoring antibiotic prescribing and resistance patterns.
  • Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses, and relevant staff.
  • Education: Educating clinicians about resistance and optimal prescribing (CDC, 2019a. para. 5).

Siddiqui and Koirala (2018) also emphasize the critical importance of antibiotic stewardship and teamwork in managing and preventing hospital-acquired MRSA infections.

Prevention

The reservoir for MRSA in hospitals includes colonized or infected patients or healthcare providers as well as contaminated objects/surfaces in the patient care environment. Thorough cleaning of the hospital environment and reusable patient care equipment is also critical to preventing MRSA transmission. According to SHEA (2014), MRSA active surveillance testing should be implemented as part of a comprehensive strategy to control and prevent hospital-acquired MRSA infections. This strategy continues to be a consistent, evidence-based practice to reduce MRSA infections (Jones et al., 2019; Siddiqui & Koirala, 2018).

Nursing Care and Nursing Implications

Nursing care for patients with hospital-acquired MRSA infections includes hand hygiene, maintaining contact precautions, and administering antibiotics as prescribed. The administration of antibiotics on time is vital to attaining adequate serum levels of the medication to resolve the infection. It is also important to monitor the lab work, including the antibiotic peak and trough levels, and the white blood cell count to ensure it returns to normal as the infection resolves.  Many states require mandatory reporting of all new MRSA infections, so the nurse should determine if MRSA infections are reportable to the health department in the state where they practice nursing (Siddiqui & Koirala, 2018).

Future Research and Trends

The Department of Veterans Affairs Medical Centers (VAMC) examined clinical data for any veteran admitted to all of the 153 VAMC’s from January 1, 2005, to December 31, 2017, to determine the effectiveness of their multifaceted MRSA prevention program. The results of this study indicate a 55% decrease in MRSA infections during the study period (p< 0.001). The study findings support the VAMC system-wide multifaceted infection control interventions, which include admission screening for nasal MRSA carriage and maintaining contact precautions for veterans colonized and actively infected with MRSA (Jones et al., 2019).

Vancomycin-Resistant Enterococci Infection

Epidemiology and Pathophysiology

Enterococci are Gram-positive, non-spore forming cocci that colonize the human gastrointestinal and biliary tracts and cause hospital-acquired infections. Vancomycin (Vancocin) is a glycopeptide that works by inhibiting cell wall synthesis in Gram-positive bacteria.  In the 1990s, VRE became prevalent in hospitals in the United States due to the increasing use of vancomycin (Vancocin) to treat hospital-acquired infections. The incidence and prevalence of vancomycin-resistant Enterococci (VRE) have increased significantly in the past two decades, particularly in intensive care units (ICUs). Colonization with VRE precedes VRE infection. However, not all patients who are colonized with VRE will become infected (Archibald, 2014; O’Driscoll & Crank, 2015). 

Risk factors and Protective factors

Risk factors for VRE colonization or VRE infection include prolonged hospital or ICU stay, invasive procedures, immunocompromise, prior exposure to vancomycin (Vancocin) or third-generation cephalosporins, and proximity to individuals with VRE colonization or infection. Exposure to healthcare personnel assigned to care for another patient with VRE colonization or infection also increases risk. Prior exposure to antimicrobials is the most significant predictor of VRE colonization (O’Driscoll & Crank, 2015). 

Protective factors include prompt initiation of infection control and prevention strategies: active surveillance, meticulous hand hygiene, contact precautions (a private room is preferable for all VRE-colonized or actively infected patients) and environmental disinfection (Cheng et al., 2016).

Signs and Symptoms

Enterococci are more likely to infect debilitated, immunocompromised, or ICU patients. Some common sites for VRE infections include the urinary tract, the bloodstream, wounds associated with catheters or surgical procedures, or other body sites. VRE bloodstream infections (bacteremia) are associated with increased mortality when compared with vancomycin-sensitive Enterococcus bacteremia. VRE can cause infective endocarditis or meningitis. Symptoms of VRE will depend on the site of infection but include fever and pain at the site. Symptoms of a wound infection caused by VRE can also include swelling, redness, and purulent drainage (O’Driscoll & Crank, 2015; Virginia Department of Health, 2018).

Diagnosis and Treatment

The determination of an infection caused by VRE is made based on the patient’s clinical presentation and diagnostic tests. Culture results will guide the provider in selecting and prescribing the most appropriate antibiotic therapy. The provider may elect to consult with a provider who specializes in infectious diseases (Archibald, 2014).

VRE bacteremia, infective endocarditis, central nervous system infections, intra-abdominal infections, or wound infections may be treated with linezolid (Zyvox) or daptomycin (Cubicin). The preferred drugs for VRE urinary tract infections are nitrofurantoin (Macrobid) or Fosfomycin (Monurol), although linezolid (Zyvox) or daptomycin (Cubicin) may be prescribed as alternative medications (Archibald, 2014; O’Driscoll & Crank, 2015).

Prevention

Use of good infection prevention practices, such as contact precautions (wearing a gown and gloves when caring for patients with VRE), and frequent hand hygiene by healthcare workers, patients, and visitors can limit the spread of VRE in healthcare settings. Patients with VRE should follow all instructions given by their care providers and keep their hands clean, especially after touching the infected area or using the bathroom. Friends or family members visiting a hospitalized patient with VRE should follow the hospital’s recommended precautions (Virginia Department of Health, 2018).

Nursing Care and Nursing Implications

Nursing care for patients with hospital-acquired VRE infections includes hand hygiene, maintaining contact precautions, and administering antibiotics as prescribed. Nurses need to administer antibiotics on time as this is critical to attaining adequate blood levels of the antibiotic and to resolving the infection. It is also important to monitor the patient’s lab work for signs that the infection is resolving, such as the white blood cell count returning to normal (Archibald, 2014; Virginia Department of Health, 2018).

Future Research and Trends

Cheng et al. (2016) conducted a prospective observational study to assess VRE infection control interventions that are standardized throughout public tertiary care hospitals in Hong Kong. In addition to healthcare worker hand hygiene, active surveillance, contact precautions, and environmental cleaning and decontamination, they implemented a directly observed patient hand hygiene program which resulted in a significant decrease in the incidence of hospital-acquired VRE between January 2011 and October 2015. Based on the results of this research, adding patient hand hygiene to existing hospital protocols for the care and treatment of patients with VRE is an effective strategy to decrease hospital-acquired VRE infections (Cheng et al., 2016).

SHEA convened a group of infection prevention and control subject matter experts who serve voluntarily on the SHEA Guidelines Committee. This group developed evidence-based guidelines in 2018 for the duration of contact precautions in acute care hospitals for drug-resistant organisms, including VRE. The primary purpose of these guidelines is to provide evidence-based information regarding when contact isolation precautions can be safely discontinued. Contact precautions for patients with VRE colonization or infection can be discontinued after the patient has had one to three negative stool cultures. Contact precautions should be extended for patients with VRE who are immunosuppressed, are in burn units, or hospitals with high VRE rates (Banach et al., 2018).

Central Line-Associated Bloodstream Infection

Epidemiology and Pathophysiology

Central line-associated bloodstream infections (CLABSI) are among the most prevalent HAIs and are associated with increased morbidity, mortality, and longer hospital stays. (Azar et al., 2019).  According to Haddidin and Regunath (2019), a CLABSI is defined as a “laboratory-confirmed bloodstream infection, not related to an infection at another site that develops within 48 hours of central line placement.”   The risk of CLABSI infections in ICU patients is high, but the majority of CLABSIs occur in hospital units outside of the ICU (SHEA, 2014).

Risk factors and Protective factors

Risk factors for CLABSI include prolonged hospitalization, duration of the central line, heavy microbial colonization at the insertion site or catheter hub, femoral catheter placement in adults, premature infants, excessive catheter manipulation, reduced nurse to patient ratio in the ICU, and patients receiving total parenteral nutrition. Protective factors for CLABSI include female sex and antibiotic administration (Crnich & Maki, 2014; SHEA, 2014).

Signs and Symptoms

Signs and symptoms of CLABSI include fever, chills, elevated WBC, redness or inflammation at the insertion site, and positive blood culture results (Crnich & Maki, 2014; Haddidin & Regunath (2019).

Diagnosis and Treatment

To successfully identify the causative organism and treat the CLABSI, careful technique needs to be used to obtain the blood cultures. When obtaining blood cultures, the patient’s skin needs to be thoroughly disinfected, and an adequate amount of blood (at least 20 to 30 ml of blood per patient or 10 to 15 ml per site) must be obtained. Blood cultures are obtained from two different sites when a CLABSI is suspected (Crnich & Maki, 2014). Treatment of a CLABSI is directed at the causative organism based upon these cultures as well as antimicrobial susceptibility results (Haddidin & Regunath, 2019).

Prevention

According to SHEA (2014), best practices for preventing CLABSIs in acute care hospitals include: 

Before insertion

  • Provide access to current evidence-based indications for central line placement.
  • Require education on CLABSI prevention for healthcare providers responsible for insertion, care, and maintenance of central lines.
  • Daily chlorhexidine baths for ICU patients over two months of age.

At insertion

  • Maximum sterile barrier precautions during central line insertion.
  • Mandatory use of central line catheter insertion kits.
  • Perform hand hygiene before catheter insertion or manipulation.

After insertion

  • Assure appropriate nurse-patient ratios in the ICU and minimize the use of float nurses.
  • Disinfect ports, hubs, and needleless connectors before accessing the central line.
  • Remove nonessential catheters.
  • Use current evidence-based guidelines for central line dressing changes.
  • Perform ongoing surveillance for CLABSI.

Nursing Care and Nursing Implications

APIC partnered with the CDC in 2016 to develop evidence-based infection prevention observation tools. There are four observation tools: urinary catheters, ventilators, central venous catheters, and neonatal central catheters. Nurse Managers and staff nurses can use the central venous catheter observation tool as a quality improvement strategy to detect issues or discrepancies and correct these before an HAI occurs. Infection prevention and control experts, including APIC and SHEA, advocate for the use of evidence-based tools and checklists in the prevention of HAI’s. The 2016 observation tools can be accessed on APIC’s website. 

Nursing care for patients at risk for CLABSIs includes hand hygiene, appropriate infection control precautions, and administering antibiotics as prescribed. Nurses also need to continue to assess their patients to monitor if their CLABSI is resolving (Haddidin & Regunath, 2019).

Future Research and Trends

Curlej and Katrancha (2016) conducted a quantitative, descriptive, retrospective study that evaluated one rural hospital’s efforts to implement the 2014 SHEA evidence-based recommendations for decreasing CLABSI rates. Implementation of the SHEA guidelines resulted in a decrease in CLABSI rates. This study had a small sample size of 76. CBLASI rates during the study period decreased from 1.9 to 1,3 CBLASI per 1000 central line days. (Curlej & Katrancha, 2016).

Azar et al. (2019) completed an observational study of adult patients with central lines in two adult tertiary care hospitals in Indianapolis, Indiana, from January 2015 to June 2017. By adopting current evidence-based practices along with interdisciplinary communication and collaboration, they significantly reduced the CLABSI infection rates (p = .011). Their research emphasizes the importance of using evidence-based guidelines, along with multidisciplinary approaches to decrease CLABSIs (Azar et al., 2019).

Catheter-Associated Urinary Tract Infection

Epidemiology and Pathophysiology

A urinary tract infection (UTI) is defined as an infection involving any part of the urinary system, including the urethra, bladder, ureters, and kidney. UTIs are the most common type of HAI. 75% of hospital-acquired UTIs are associated with a urinary catheter (CDC, 2015a). According to Imam (2018), a catheter-associated urinary tract (CAUTI) is defined as a UTI with a positive urine culture when an indwelling urinary catheter has been in place for greater than 48 hours. Gram-negative bacilli are the primary bacteria that cause UTIs (Carr, 2014).

Risk factors and Protective factors

Those at increased risk for CAUTI include patients that are female, sexually active, very young males, older adults, diabetic, immunosuppressed, debilitated, or those managing a spinal cord injury with an indwelling bladder catheter. Protective factors center on using a sterile technique for inserting and managing indwelling bladder catheters (Carr, 2014).

Signs and symptoms

Symptoms of CAUTI include fever, malaise, loss of appetite, feeling that they need to urinate, or suprapubic discomfort. Feeling the urge to urinate and/or suprapubic discomfort could also indicate an obstruction in the urinary catheter (Carr, 2014; Imam, 2018)

Diagnosis and Treatment

The initial diagnostic test used for CAUTI is a urinalysis, followed by urine culture and sensitivity. Urine culture should be done after replacing the indwelling bladder catheter to avoid culture results that contain colonized bacteria.  The nurse should always use an aseptic technique and sterile supplies to obtain a urine specimen for culture and sensitivity. Antibiotic treatment is based upon the urine culture and sensitivity results (CDC, 2015a; Imam, 2018).

Prevention

    The most effective strategy for the prevention of CAUTI is to avoid the use of indwelling bladder catheters and remove existing catheters as soon as possible. For patients who have an indwelling catheter inserted before surgery, it is critical to remove the catheter within 24 hours postoperatively. Intermittent catheterization is preferable to an indwelling catheter whenever possible. It is also crucial that nurses utilize appropriate aseptic technique and sterile equipment for catheter insertion in the hospital environment. If breaks in aseptic technique, disconnections, or leaks occur, the catheter and drainage bag should be replaced using aseptic technique and sterile supplies (American Association of Critical Care Nurses [AACN], 2016; CDC, 2015a; Imam, 2018). 

Prevention of hospital-acquired CAUTI requires a facility-wide comprehensive approach. Hospital leadership needs to provide sufficient resources such as written evidence-based guidelines for insertion, use, and maintenance of indwelling bladder catheters; adequate supplies that are readily available; and education for healthcare personnel regarding CAUTI prevention and catheter insertion (CDC 2015a; SHEA, 2014). 

    CAUTI surveillance should use a targeted approach that identifies patient units in need based on the frequency of catheter use and the potential risk of CAUTI. Consider providing quarterly feedback on unit-specific CAUTI rates to nursing staff (CDC, 2015a). 

    An evidence-based infection prevention tool that can be completed by staff nurses on the unit is the APIC (2016) Urinary Catheters Quick Observation Tool. The use of this tool by frontline staff enables nurses to identify infection prevention deficiencies and take prompt corrective action at the patient’s bedside to prevent CAUTIs. The 2016 observation tools can be accessed on APIC’s website.    

Nursing Care and Nursing Implications

    Nursing responsibilities include the administration of prescribed antibiotics and monitoring the patient’s response to treatment. As previously mentioned, urinary catheters should be used only when necessary, and strict aseptic technique is essential. According to evidence-based guidelines, the vital elements of nursing care center on the appropriate management of urinary catheters to prevent infection:

  • Properly secure indwelling catheters after insertion.
  • Maintain a sterile closed drainage system.
  • Replace the catheter and drainage bag using an aseptic technique.
  • Obtain urine samples by aspirating urine from the sampling port using a sterile syringe.
  • Maintain unobstructed urine flow.
  • Keep the urinary drainage bag below the level of the bladder at all times, but do not place the bag on the floor.
  • Perform routine hygiene, do not use antiseptics to clean the periurethral area (SHEA, 2014; CDC, 2015a; AACN, 2016).

Future Research and Trends

Rahimi, Farhadi, Babaei, & Soleymani (2019) completed a narrative review of the prevention and management of CAUTIs in the ICU. Their study determined that prevalence is directly related to the widespread use of urethral catheters in the ICU and the use of current evidence-based guidelines can be an effective strategy to reduce CAUTI’s (Rahimi et al., 2019).

Ventilator-Associated Pneumonia 

 Epidemiology and Pathophysiology

Ventilator-associated pneumonia (VAP) is defined as healthcare-associated pneumonia that develops in patients who have been intubated and who have received mechanical ventilation for at least 48 hours. 3 to 15% of ventilated patients will develop VAP.  A variety of pathogens in the healthcare environment can cause VAP, with multidrug-resistant organisms, such as MRSA, becoming more common etiologic agents (Peyrani, 2014; SHEA, 2014).  

Risk factors and Protective factors

Endotracheal intubation is the major risk factor for VAP. Additional risk factors for VAP include emergent intubation, nasotracheal intubation, etomidate (Amidate, which has an immunosuppressive action) use during intubation, head of bed not elevated, and suboptimal oral care. Protective factors center on the strategies to prevent VAP (CDC, 2019c; Peyrani, 2014; Sethi, 2019).

Signs and Symptoms

Symptoms of VAP include fever, increased respiratory rate, increased heart rate, and increased respiratory secretions. The patient may also have leukocytosis, purulent secretions, or worsening hypoxemia (Sethi, 2019).

Diagnosis and Treatment

VAP is diagnosed based upon the patient’s symptoms, a chest x-ray with evidence of a new infiltrate, leukocytosis, and sputum cultures. The 2016 IDSA Guidelines for Management of Adults with Hospital-acquired and VAP recommend that sputum specimens be obtained using noninvasive sampling such as endotracheal aspiration. The IDSA guidelines endorse the use of an antibiogram, which specifies local antibiotic resistance data, to guide initial provider empiric treatment decisions. Empiric antibiotic therapy is started as the initial treatment for VAP because these patients are critically ill. According to Sethi (2019), “the mortality associated with hospital-acquired VAP is high, despite the availability of effective antibiotics”. Once sputum culture results become available, they should guide the provider in prescribing the most effective pathogen-specific therapy. A seven-day course of antimicrobial therapy is recommended (Kalil et al., 2016; Sethi, 2019).  

Prevention

The SHEA (2014) guidelines focus on strategies to prevent VAP in adult patients including the use of noninvasive positive pressure ventilation, interrupting sedation daily, assessing readiness to extubate daily, performing spontaneous breathing trials with sedatives turned off, changing ventilator circuits only if visibly soiled or malfunctioning, and elevating the head of the bed 30 to 45 degrees. 

Parisi et al. (2016) studied the use of a VAP prevention bundle and staff education to decrease VAP in intensive care patients using a prospective intervention study over two years in a 30 bed ICU. Their ICU used a standard VAP bundle consisting of oral care, elevating the head of the bed, daily sedation interruption, daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep vein thrombosis prophylaxis. Educational interventions included a combination of an educational pamphlet distributed to staff and face to face instruction on VAP risk factors and incidence in the ICU. The study results found a significant decrease in ICU length of stay and duration of mechanical ventilation. As a result of these findings, the hospital continues to use the VAP bundle in the ICU (Parisi et al., 2016).

Additional evidence-based prevention strategies include hand hygiene and implementing appropriate isolation precautions (CDC, 2019d). Patients diagnosed with VAP require standard precautions. Contact precautions are required for patients with MRSA. For patients with respiratory MRSA, healthcare providers should wear gloves, gowns, and surgical masks if contact with respiratory secretions is anticipated (Peyrani, 2014; CDC, 2019e). 

An evidence-based infection prevention tool that can be completed by staff nurses is the APIC (2016) Ventilator Quick Observation Tool. The use of this tool by frontline staff enables nurses to identify infection prevention deficiencies and take prompt corrective action at the patient’s bedside to prevent VAP. The APIC (2016) tool can be accessed on their website. 


Nursing Care and Nursing Implications

Nursing care for patients with VAP includes administration of antibiotics as prescribed, monitoring lab work and assessing the patient’s response to treatment as well as the consistent implementation of infection prevention and control strategies. Patient diagnosed with VAP would require consistent hand hygiene and standard precautions. For patients diagnosed with MRSA or multidrug resistant VAP contact precautions are required (CDC, 2019d; Peyrani, 2014; Siegel et al. 2019). 

Future Research and Trends

Wang, Pan, and Hu (2019) completed a systematic review and meta-analysis of chest physiotherapy for the prevention of VAP.  A total of 6 randomized controlled trials were identified. These researchers concluded that chest physiotherapy might not significantly reduce the incidence of VAP. Due to the small number of studies that met the inclusion criteria, these researchers recommended interpreting their findings cautiously and suggested additional large-scale, well-designed studies on this topic in the future (Wang et al., 2019).

Conclusion

The prevention and control of HAIs require buy-in and active participation by all members of the healthcare team. Knobloch, Thomas, Musuuza, and Safdar (2019) examined the role of leadership within a work-systems approach to reduce HAIs. Prevention of HAIs requires teamwork and collaboration. Knobloch et al. (2019) assert that strong healthcare leadership and clear communication can positively impact the prevalence of HAIs. Infection control is everyone’s responsibility.

References

American Association of Critical Care Nurses. (2016). AACN practice alert: Prevention of catheter-associated urinary tract infections in adults. Critical Care Nurse, 36(4), e9-e11. doi:10.4037/ccn2016208

Archibald, L. K. (2014). Enterococci. Grota P. (Ed.).  In APIC text online: Association for Practitioners in Infection Control and Epidemiology. Retrieved from http://text.apic.org/toc/healthcare-assoicated-pathogens-and-diseases/enterococci

Association for Practitioners in Infection Control and Epidemiology. (2016). Infection prevention observation tools. Retrieved from http://ipcobservationtools.site.apic.org/about/

Azar, J., Kelley, K., Dunscomb, J., Perkins, A., Wang, Y., Beeler, C., … Boustani, M. (2019). Using the agile implementation model to reduce central line–associated bloodstream infections. American Journal of Infection Control, 47(1), 33–37. doi:10.1016/j.ajic.2018.07.008

Banach, D. B., Bearman, G., Barnden, M., Hanrahan, J. A., Leekha, S., Morgan, D. J., … Wiemken, T. L. (2018). Duration of contact precautions for acute-care settings. Infection Control & Hospital Epidemiology, 39(2), 127–144. doi:10.1017/ice.2017.245

Becker, K. & Kock, R. (2014). Staphylococci. Grota P. (Ed.). In APIC text online: Association for Practitioners in Infection Control and Epidemiology. Retrieved from http://text.apic.org/toc/healthcare-associated-pathogens-and-diseases/staphylococci

Bowling, J. E. (2018). Clostridium difficile infection and pseudomembranous colitis. Grota P. (Ed.). In APIC text online: Association for Practitioners in Infection Control and Epidemiology. Retrieved from http://text.apic.org/toc/healthcare-associated-pathogens-and-diseases/clostridium-difficile-infection-and-pseudomembranous-colitis

Carr, H. (2014). Urinary tract infection. Grota P. (Ed.). In APIC text online: Association for Practitioners in Infection Control and Epidemiology. Retrieved from http://text.apic.org/toc/prevention-measures-for-healthcare-associated-infections/urinary-tract-infection

Centers for Disease Control and Prevention. (2015a). Catheter-associated Urinary Tract Infections. Retrieved from https://www.cdc.gov/hai/ca_uti/uti.html

Centers for Disease Control and Prevention. (2015b). Healthcare-associated Infections. Retrieved from https://www.cdc.gov/hai/prevent/prevention.html 

Centers for Disease Control and Prevention. (2017). Appropriate Antibiotic use in Hospitals and Long-term Care. Retrieved from https://www.cdc.gov/antibiotic-use/healthcare/index.html

Centers for Disease Control and Prevention (2019a).  Core Elements of Hospital Antibiotic Stewardship Programs. Retrieved from https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html

Centers for Disease Control and Prevention. (2019b). FAQ’s for Clinicians about C. diff. Retrieved from https://www.cdc.gov/cdiff/clinicians/faq.html

Centers for Disease Control and Prevention. (2019c). FAQ’s about VAP. Retrieved from https://www.cdc.gov/hai/vap/vap_faqs.html

Centers for Disease Control and Prevention. (2019d). Hand Hygiene in Healthcare Settings. Retrieved from https://www.cdc.gov/handhygiene/

Centers for Disease Control and Prevention. (2019e). Methicillin-resistant Staphylococcus aureus. Retrieved from https://www.cdc.gov/mrsa/healthcare/inpatient.html

Cheng, V. C. C., Tai, J. W. M., Chau, P. H., Lai, C. K. C., Chuang, V. W. M., So, S. Y. C., … Yuen, K. Y. (2016). Successful control of emerging vancomycin-resistant Enterococci by territory-wide implementation of directly observed hand hygiene in patients in Hong Kong. American Journal of Infection Control, 44(10), 1168–1171. doi:10.1016/j.ajic.2016.03.050

Crnich, C. J. & Maki, D. C. (2014). Intravascular device infection. Grota P. (Ed.). In APIC text online: Association for Practitioners in Infection Control and Epidemiology. Retrieved from http://text.apic.org/toc/prevention-measures-for-healthcare-associated-infections/intravascular-device-infection

Curlej, M. H. & Katrancha, E. (2016). One rural hospital’s experience implementing the Society for Healthcare Epidemiology of America guidelines to decrease central line infections. Journal of Trauma Nursing, 23(5), 290–297.

Haddidin, Y. & Regunath, H. (2019). Central line-associated bloodstream infections (CLABSI). Stat Pearls. Retrieved from https://www,ncbi.nlm.nih.gov/books/NBK430891/

Harris, A. (2019). Methicillin-resistant Staphylococcus aureus: Beyond the basics. Retrieved from https://www.uptodate.com/contents/methicillin-resistant-staphylococcus-aureus-mrsa-beyond-the-basics 

Imam, T. H. (2018). Catheter-associated urinary tract infections (CAUTI). In Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/genitourinary-disorders/urinary-tract-infections-utis/catheter%E2%80%93associated-urinary-tract-infections-cautis

Jones, M., Jernigan, J. A., Evans, M. E., Roselle, G. A., Hatfield, K. M., & Samore, M. H. (2019). Vital Signs: Trends in Staphylococcus aureus infections in Veterans Affairs Medical Centers - United States, 2005-2017. MMWR: Morbidity & Mortality Weekly Report, 68(9), 220–224. doi:10.15585/mmwr.mm6809e2

Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., …Brozek, J. L. (2016). Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society, Clinical Infectious Diseases, 63 (5), e61–e111. doi:10.1093/cid/ciw353

Knobloch, M. J., Thomas, K. V., Musuuza, J., & Safdar, N. (2019). Exploring leadership within a systems approach to reduce healthcare–associated infections: A scoping review of one work system model. American Journal of Infection Control, 47(6), 633–637. doi:10.1016/j.ajic.2018.12.017

McDonald, L. C., Gerding, D. N., Johnson, S., Bakken, J. S., Carroll, K. C., Coffin, S. E., …Wilcox, M. H. (2018). Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases, 66(7), e1-e48. doi:10.1093/cid/cix1085

O’Driscoll, T. & Crank, C. W, (2015). Vancomycin-resistant Enterococcal infections: Epidemiology clinical manifestations and optimal management. Infection and Drug Resistance, (8), 217-230. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521680/pdf/idr-8-217.pdf

Parisi, M., Gerovasili, V., Dimopoulis, S., Kampisiouli, E., Goga, C., Perivolioti, E., …Nanas, S. (2016). Use of ventilator bundle and staff education to decrease ventilator-associated pneumonia in intensive care patients. Critical Care Nurse, 36(5), e1–e7. doi:10.4037/ccn2016520

Peyrani, P. (2014). Pneumonia. Grota P. (Ed.). In APIC text online: Association for Practitioners in Infection Control and Epidemiology. Retrieved from http://text.apic.org/toc/prevention-measures-for-healthcare-associated-infections/pneumonia

Rahimi, M., Farhadi, K., Babaei, H., & Soleymani, F. (2019). Prevention and management catheter-associated urinary tract infection in intensive care unit. Journal of Nursing & Midwifery Sciences, 6(2), 98–103. doi:10.4103/JNMS.JNMS_47_18

Siegel, J. D., Rhinehart E., Jackson M., Chiarello, L. & the Healthcare Infection Control Practices Advisory Committee. (updated July 2019). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

Sethi, S. (2019). Ventilator-associated pneumonia. In Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/pulmonary-disorders/pneumonia/ventilator-associated-pneumonia

Shabot, M. M., Chassin, M. R., France, A-C, Inurria, J., Kendrick, J., & Schmaltz, S. P. (2016). Using the Targeted Solutions Tool® to improve hand hygiene compliance is associated with decreased health care-associated infections. The Joint Commission Journal on Quality and Safety, 42(1), 6-17. Retrieved from https://www.centerfortransforminghealthcare.org/improvement-topics/hand-hygiene

Siddiqui, A. H. & Koirala, J. (2018). Methicillin-resistant Staphylococcus aureus (MRSA). Stat Pearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482221/

Society for Healthcare Epidemiology of America. (2014). Healthcare-associated infections pocket guideline. Retrieved from https://www.shea-online.org/index.php/practice-resources/shea-pocket-guidelines

Srinivasa, V. R., Hariri, R., Frank, L. R., Kingsley, L., Magee, E., Pokrywka, M., & Yassin, M. H. (2019). Hospital-associated Clostridium difficile infection and reservoirs within the hospital environment. American Journal of Infection Control, 47(7), 780–785. doi:10.1016/j.ajic.2018.12.013

Virginia Department of Health. (2018). Vancomycin-resistant Enterococci infection. Retrieved from http://www.vdh.virginia.gov/epidemiology/epidemiology-fact-sheets/vancomycin-resistant-enterococci-vre-infection/

Wang, M.-Y., Pan, L., & Hu, X.-J. (2019). Chest physiotherapy for the prevention of ventilator-associated pneumonia: A meta-analysis. American Journal of Infection Control, 47(7), 755–760. doi:10.1016/j.ajic.2018.12.015