Chiaramente, ogni formato ha i propri vantaggi e svantaggi
comprare ampicillina online in italia per effettuare un acquisto, non è necessario fornire la prescrizione medica.
Guideline for the management of nosocomial infections
The Southern African Journal of Epidemiology and Infection 2006; 21 (4):152-160
Guideline for the management of nosocomial
infections in South Africa*
A Brink, C Feldman, A Duse, D Gopalan, D Grolman, M Mer, S Naicker, G Paget,
O Perovic, G Richards
Objective: To write a guideline for the management and prevention of nosocomial infections
in South Africa in view of the following: i) nosocomial infections are a common and
increasing problem globally, including South Africa; ii) widely varying standards of
prevention and management of these important infections; iii) increasing and emerging
antimicrobial resistance among commonly isolated pathogens, and iv) the significant
economic burden of these infections on the healthcare system as well as their impact on
patient morbidity and mortality. The main aims of the guideline are to provide
recommendations for the initial choice of antimicrobial agents and the appropriate
management of these infections encompassing the following conditions: i) nosocomial
pneumonia, healthcare-associated pneumonia and ventilator-associated pneumonia; (ii)
nosocomial bloodstream infections; (iii) nosocomial intravascular infections; (iv)
nosocomial urinary tract infections; (v) nosocomial intra-abdominal infections; and (vi)
nosocomial surgical skin and soft-tissue infections. Evidence: Working group of clinicians
from relevant disciplines, following detailed literature review. Recommendations: These
include details of the likely pathogens, an appropriate diagnostic approach, antibiotic
treatment options and appropriate preventive strategies. Endorsement: The guideline
document was endorsed by the South African Thoracic Society, the Critical Care Society of
Southern Africa and the Federation of Infectious Diseases Societies of Southern Africa.
Guideline sponsor: The meeting of the Working Group and the guideline publication were
sponsored by an unrestricted educational grant from Sanofi Aventis South Africa.
Process of guideline development
The complete and detailed background guideline was published in the June 2005 issue of the
Southern African
The South African Thoracic Society (SATS) was offered an
Journal of Epidemiology and Infection (
SAJEI 2005;
20: 37-
unconditional educational grant from Sanofi-Aventis to
76 (www.fidssa. co.za), link to guidelines). The guideline
develop a guideline for the management of nosocomial
presented here is a summarised version, and includes
infections in South Africa. Prof Charles Feldman, as Council
antibiotic dosages.
Member of SATS, offered to organise the development of such a guideline. On invitation, Prof Guy Richards (Critical
Care Society of Southern Africa) and Dr Adrian Brink (Infectious Diseases Society of South Africa) agreed to co-
This statement is published for educational purposes only.
organise the guideline development.
The recommendations are based on currently available scientific evidence together with the consensus opinion of the
Members of the editorial board prepared draft documents on
authors and the working group. The guideline is not meant to
the various topics. These were circulated initially to the
replace clinical judgement, but rather to give logical
editorial board for comment and then to a working group
framework to the evaluation of patient management.
drawn from professionals around the country, representing the private and public sector and including individuals from
Authors of the guideline
various disciplines, viz. physicians, infectious disease specialists, pulmonologists, intensivists, trauma surgeons,
Adrian Brink, Charles Feldman, Adriano Duse, Dean
cardiothoracic surgeons, clinical microbiologists, and
Gopalan, David Grolman, Mervyn Mer, Sarala Naicker,
Graham Paget, Olga Perovic, Guy Richards.
A workshop meeting was held at Caesar's Palace,
Working group members
Johannesburg, in February 2005 at which the papers were presented to the group, critiqued, and specific final decisions
The authors above plus: V Ballhausen, AL Biebuyck, DJ du
were taken on the various recommendations. Changes were
Toit, PJ du Toit, L Fingelson, P Grolman, G Hammond, E
made to the original draft documents by the editorial team,
Hodgson, I Hunt, J Kilian, G Kretsmer, L Krige, G Lups, G
and the documents were then re-circulated to the workshop
Maartens, A Mackinlay, D Muckart, H Pahad, A Pieterse, A
group for comment.
Roodt, G Schleicher, MA Seedat, M Senekal, W Sieling, M Sussman, M van der Heiden, H van Straaten, JA Venter, LA Venter, P Williams.
Correspondence to: Dr Adrian J Brink, PO Box 1873, Houghton, 2041Johannesburg. Tel. 011-726-6260, e-mail:
[email protected]
* Reprinted with the kind permission of the
South African Medical Journal.
South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections
Infection control in developing countries, with particular
time and fairly close contact with patients (within 1 - 2 m) is
emphasis on South Africa
required for transmission to occur. Organisms such as
Neisseria meningitidis,
Streptococcus pneumoniae and
Healthcare-associated infections (HAIs) are a cause of
Mycoplasma pneumoniae, infections such as pneumonic
significant morbidity and mortality in patients receiving
plague and streptococcal pharyngitis and viral infections
healthcare, and the costs (direct and indirect) of these
such as influenza virus infections are spread via this route.
infections deplete the already limited financial resources
!
Airborne spread occurs when droplets less than 5
allocated to healthcare delivery.
microns in size are produced by coughing, sneezing, or consequent to procedures such as bronchoscopy and
! Approximately one in seven patients entering South
suctioning. These small droplets desiccate to form droplet
African hospitals are at high risk of acquiring an HAI.
nuclei that remain suspended in the air for long periods and
! Lower respiratory tract infections, urinary tract infections,
travel long distances. The airborne nature of these
bloodstream infections and post-surgical infections account
contaminated droplet nuclei enables them to infect
for the majority (about 80%) of HAIs.
susceptible hosts several metres away from where they are
! Indiscriminate and inappropriate use of antibiotics leads
produced. Organisms typically spread by this route include
to the selection of antimicrobial-resistant organisms.
Mycobacterium tuberculosis, measles virus and varicella-
! Bi-directional flow of resistance from hospitals into
zoster virus.
communities and vice versa makes it difficult to distinguish community-acquired multidrug-resistant pathogens from
Prevention and control of HAIs
those that are nosocomial.
! To counter the emergence and spread of multidrug-
! All patients presenting to healthcare facilities, irrespective
resistant pathogens the only feasible strategy is the
of their diagnoses, must be treated using standard
implementation of an effective and integrated programme
precautions. These include hand washing (using either
that involves antimicrobial resistance surveillance, a rational
aqueous or non-aqueous hand decontamination agents),
antimicrobial-use programme, and infection control.
wearing of personal protective equipment as necessary
! Infection control activities on their own are primarily
(gloves, masks, gowns, and eye protection), safe disposal of
centred around the goal of decreasing or preventing the
waste, appropriate cleaning, disinfection or sterilisation of
transmission of nosocomial (healthcare-associated)
equipment and patient-care items as well as appropriate
pathogens to patients and staff, irrespective of whether these
decontamination of linen and the environment. Stringent
organisms are multidrug-resistant or not.
attention to aseptic technique is crucial.
! To further reduce and control the emergence of
! In addition to standard precautions, additional patient
antimicrobial resistance it is therefore essential that infection
isolation procedures (contact isolation, droplet isolation and
control activities be coupled with an optimised, effective and
airborne isolation) are required, depending on the mode of
highly restrictive antimicrobial-use programme.
transmission of the suspected micro-organism.
! Most importantly, such a programme must be realistic,
! The judicious use of preoperative prophylaxis to prevent
adaptable, and take cognisance of the severe limitation of
post-surgical infections cannot be overemphasised.
resources characteristic of many developing countries.
Infection control and prevention programmes
In order to develop simple, effective and sensible infection control interventions it is necessary to understand the sources
! The efficacy of infection control and prevention
of HAIs and their modes of transmission.
programmes in decreasing HAIs (especially in outbreak situations), patient morbidity and mortality, and cost to
Transmission of HAIs
healthcare institutions is well established.
! Regrettably the implementation and/or quality of such
HAIs are transmitted in three ways.
programmes is variable across South African healthcare
!
Contact spread involves skin-to-skin contact and the
direct physical transfer of micro-organisms from one patient
! Good and standardised surveillance systems for HAIs are
to another or by a healthcare worker (HCW). Examples of
not currently in place in most South African healthcare
direct contact include patient examination, with cross-
infection occurring from contaminated hands of the HCW.
! HAIs are under-reported and data on antimicrobial
Although hand washing is singly the most important,
resistance trends are only available for academic hospitals
evidence-supported intervention for the prevention of
and from private-sector microbiology laboratories.
transmission of organisms as a consequence of direct contact,
! It is crucial that the true impact of HAIs and of
compliance is only 40% in intensive care units (ICUs).
antimicrobial resistance on healthcare delivery be
Indirect contact refers to contact with inanimate objects or
documented accurately and that strategies be formulated to
surfaces such as bedpans, thermometers, etc that are
minimise these problems.
contaminated with microbes. Organisms such as methicillin-
! Education on infection control and correct antimicrobial
resistant
Staphylococcus aureus, vancomycin-resistant
prescribing is often neglected in undergraduate curricula of
enterococci, extended-spectrum beta-lactamase (ESBL)-
the health sciences.
producing Gram-negatives, and
Clostridium difficile are typically spread by direct and/or indirect contact routes.
Multiple interventions are available that may help to
!
Droplet spread involves spread of pathogens by
minimise or control nosocomial infections and the
respiratory droplets produced during coughing, sneezing,
development and spread of microbial resistance to
talking, respiratory therapy and procedures such as
antimicrobial agents. Strategies to prevent and control the
bronchoscopy. Respiratory droplets larger than 5 microns do
emergence and spread of antimicrobial-resistant micro-
not remain suspended (airborne) in the air for long periods of
organisms may be grouped into those aimed at optimising
South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse,
et al
antimicrobial use and those preventing the transmission of
! An increase in multidrug-resistant
Escherichia coli.
! Emerging resistance among Gram-positive isolates including an increased prevalence of methicillin-resistant
S.
Interventions aimed at optimising antimicrobial use
aureus (MRSA) and emergence of glycopeptide-resistant enterococci (GRE).
! Optimising antimicrobial prophylaxis for operative procedures.
Antibiotic resistance is an inevitable consequence of the
! Optimising the choice and duration of empirical
inappropriate use of antibiotics, and impacts on every
hospital to varying degrees.
! Improving antimicrobial prescribing by educational and administrative means.
Risk factors for inappropriate antibiotic use
! Monitoring and providing feedback on antibiotic resistance.
! Not using local epidemiological and antibiotic
! Defining and implementing healthcare delivery system
guidelines for important types of antimicrobial use.
! Use of broad-spectrum antibiotics when not absolutely necessary.
Interventions aimed at preventing nosocomial transmission
! Treatment of contamination or colonisation rather than
of resistant organisms
invasive infection.
! Inappropriate surgical prophylaxis.
! Developing systems to recognise and report trends in
! Excessive antimicrobial treatment (i.e. continuing
antimicrobial resistance within institutions.
antibiotics when infection is cured).
! Developing systems to rapidly detect and report resistant micro-organisms in individual patients and ensuring rapid
Recommendations for the antimicrobial management of
response by caregivers.
! Increasing adherence to basic infection control policies and procedures.
! Early appropriate empirical antibiotic therapy for severe
! Incorporating detection, prevention, and control of
nosocomial infections reduces mortality.
antimicrobial resistance into institutional strategic goals and
! Timeous broad-spectrum empirical therapy must be
providing the required resources.
utilised for nosocomial infections until the pathogen is
! Developing a plan for identifying, transferring,
discharging, and readmitting patients colonised with specific
! Prescribe an initial antibacterial regimen that will cover
the most likely pathogens associated with infection, based on local surveillance (‘ know your bugs').
As we are seeing increasing numbers of vulnerable
! However, increased use of antimicrobial therapy with this
individuals at our healthcare facilities we should be
practice (‘getting it right the first time') may inevitably lead
continuously aware of the consequences of poor infection
to increase in resistance.
control practices and the misuse and abuse of the
! Therefore antibiotic therapy is subsequently scaled down,
antimicrobial armamentarium. Good infection control
de-escalated or tailored to a narrow spectrum once identity
practices can usually contain the majority of infections,
and susceptibility patterns of the infecting pathogen(s) are
including those caused by multidrug-resistant organisms,
using simple measures. An infection control programme is as
! Shorter duration of therapy is currently recommended
effective as the personnel responsible for its implementation:
because antibiotics that are continued after an infection has
dedication, knowledge, education, constructive feedback and
resolved are harmful in that they predispose to superinfection
sensitivity to the needs of both patients and healthcare
with more resistant bacteria.
workers are essential. Furthermore, rational and restrictive antibiotic prescribing strategies together with continuing
General principles for the duration of antibiotic treatment
developments in the search for new antimicrobials must ensure that these so-called miracle drugs will retain their
! If a response to a particular antibiotic is seen within 48
value in the treatment of infections in years to come.
hours, treatment should be continued for another 5 - 7 days
Education in infection control practices, nosocomial
after which it should be discontinued.
infection epidemiology, and antimicrobial resistance is
! Prolonged use beyond a week is therefore strongly
critically important. The development of these guidelines is a
discouraged for most nosocomial infections.
step in the right direction.
! If no response is seen in 48 hours:
! Discontinue the antibiotic
Antimicrobial resistance in nosocomial infections in
! Re-culture the patient
South Africa
! Review source control! Switch to another class of antibiotic.
In South Africa the following patterns of antimicrobial
! If septic markers worsen on an antibiotic, resistance
resistance have recently been noted:
should be considered and a change to another class also
! A dramatic increase in ESBL production, particularly in
Klebsiella and
Enterobacter spp.
! An increase in carbapenem resistance, including
Measures to reduce nosocomial infections
multidrug resistance in
Pseudomonas aeruginosa and
Acinetobacter baumanii.
In the past not enough attention was given to prevention of
! Emergence of carbapenem resistance in strains of
infection. Accepted practices include:
Enterobacter spp and
Klebsiella pneumoniae.
! Elevation of the head of the bed in ventilated patients
South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections
! Perioperative normothermia
hospital admission that was neither present nor incubating at
! Restriction of blood transfusions
the time of admission to hospital.
! Early enteral nutrition
! VAP is a pneumonia occurring in a patient undergoing
! Avoidance of urinary catheters wherever possible
mechanical ventilation that was neither present nor
! Recently, intensive insulin therapy in critically ill patients
incubating at the time of intubation (occurring > 48 hours
has been shown to reduce mortality
after intubation).
! Implementation of special ‘programmes' such as for the
! Healthcare-associated pneumonia (HCAP) is a
prevention of ventilator-associated pneumonia (VAP) or
pneumonia occurring in a patient who has: (i) been
central venous catheter infections.
hospitalised in an acute care hospital for 2 or more days within 90 days of the infection; (ii) resided in a nursing home
Dilemmas in the antimicrobial management of nosocomial
or long-term care facility (LTCF); or (iii) received
intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection, or attended a
! Combination versus monotherapy - ‘should antibiotics be
hospital or haemodialysis clinic.
! There is no evidence that a combination of antibiotics
Microbiology of nosocomial pneumonia
increases efficacy or decreases resistance, particularly when using the newer antimicrobial agents such as the
! Early-onset bacterial NP occurring within the first 4 days
4th generation cephalosporins (i.e. cefepime),
in patients with no risk factors for multidrug-resistant
betalactam/betalactamase inhibitor combination agents
bacteria is more frequently due to
S. pneumoniae,
(i.e. piperacillin/tazobactam), fluoroquinolones (i.e.
Haemophilus influenzae, methicillin-sensitive
S. aureus and
ciprofloxacin, levofloxacin) and the carbapenems (i.e.
Moraxella catarrhalis and antibiotic-sensitive aerobic,
enteric Gram-negative bacilli. The latter include
! Controversy still currently exists with regard to
Enterobacter spp,
E. coli,
Klebsiella spp,
Proteus spp, and
whether mono- or combination therapy is optimal for
Serratia marcescens (‘core pathogens').
pseudomonal infections, particularly in the critically ill
! Late-onset bacterial NP can occur with the same
pathogens but is more commonly due to MRSA and
! Antibiotic cycling ‘should antibiotics be rotated?'
multidrug-resistant pathogens including
Pseudomonas spp,
! Antibiotic cycling has been suggested as a means of
Acinetobacter spp and
Klebsiella spp (including isolates
reducing antibiotic pressure and selection of resistant
producing ESBLs).
mutants. A recent review of antibiotic cycling or
! The elderly residents of LTCFs have a spectrum of
rotation concluded that studies do not permit reliable
pathogens that more closely resemble that of late-onset HAP
conclusions regarding efficacy of cycling. Therefore
or VAP than early-onset HAP.
routine implementation of cycling as a means of reducing antibiotic resistance rates is currently not
! The most commonly used clinical definition of NP
A systematic approach in selecting an antibiotic for
includes the following:
! New or progressive radiographical shadowing plus at
least two of the following:
A systematic approach in selecting an antibiotic promotes
! Fever > 38.3ºC or hypothermia < 35ºC
appropriate antimicrobial use. The following should be
! Leukocytosis > 12 x 109/l or leukopenia < 4 x 109/l
! Purulent respiratory secretions.
! Which pathogens are likely to be encountered?
! Although a controversial area, more recent studies and
! What are the likely susceptibility patterns of these
guidelines suggest that invasive diagnostic techniques are
not essential or routinely recommended for diagnosis of VAP.
! What is the antimicrobial spectrum of the chosen
! A fresh specimen of lower respiratory secretions should be
submitted at the time of clinical diagnosis of possible NP (eg.
! Use appropriate dosing schedules based on the
through a sterile suction catheter in patients who are
pharmacokinetic and pharmacodynamic properties of the
intubated), before initiating antibiotic treatment.
chosen agent.
! A chest radiograph, blood cultures and evaluation of
! What are the pharmacological considerations in the
oxygenation should also be undertaken and may be helpful in
management of these cases.
! Direct therapy to a narrow spectrum once microbiology results are available.
! But foremost, always consider whether an antibiotic is really necessary.
! Initiate antibiotics as soon as possible once the presence of an active infection is suspected as the early initiation of
Management of nosocomial pneumonia, healthcare-
antibiotics (within 24 hours and preferably 12 hours) to
associated pneumonia, and ventilator-associated
which the causative organisms are sensitive is associated
with the best outcome.
! In the choice of empirical antibiotic therapy, consideration
should be given to which antibiotics the patient has had in the recent past; it is preferable that an agent from a different class
! Nosocomial pneumonia (NP) or hospital-acquired
pneumonia (HAP) is a pneumonia occurring > 48 hours after
! Factors to consider in empirical therapy include:
South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse,
et al
! Whether the pneumonia is of ‘early' or ‘late' onset
! The severity of illness of the individual patient,
including a consideration of whether the patient is in or
! The most important currently recommended preventive
out of the ICU, and
measures for VAP are:
! Whether there are any specific risks factors for
infection with severe Gram-negative pathogens such as
! Application of general infection control measures
Acinetobacter and
Pseudomonas spp.
! General aseptic techniques
! In patients not in an ICU, with an early and/or mild to
! Judicious antibiotic use
moderately severe NP, and without specific risk factors for
! Semi-recumbent patient positioning
resistant pathogens such as
Pseudomonas and
Acinetobacter
! Oral endotracheal tube
spp, initial antibiotic treatment should target the so-called
! Oral gastric tube
‘core pathogens', which may be accomplished with the
! Aseptic tracheal suctioning
following various agents:
! Avoiding unplanned extubation
! 3rd generation cephalosporins, particularly in regional
! Less frequent ventilator tube changing
centres outside the central academic and private sectors
! Heat and moisture exchangers with bacteriological
(i.e. ceftazidime, ceftriaxone, or cefotaxime)
Management of nosocomial bloodstream infections
! Group 1 carbapenem (i.e. ertapenem)
! Fluoroquinolones (i.e. ciprofloxacin or levofloxacin),
particularly if there is severe allergy to beta-lactams.
! Bloodstream infection is referred to as being primary
! In patients with additional risk factors for specific
when there is no obvious source, or secondary when arising
pathogens, cover for the ‘core pathogens' and add specific
as a complication of infection elsewhere.
treatment indicated below, if also required:
! Anaerobes - piperacillin/tazobactam or ertapenem
Microbiology of nosocomial bloodstream infections
alone will be sufficient, or add metronidazole or clindamycin to cephalosporin- or fluoroquinolone-
! The micro-organisms responsible include Gram-positive
containing regimens
and Gram-negative bacteria and/or fungi.
!
S. aureus - for methicillin-sensitive isolates add
! The most common Gram-positive organisms include
S.
cloxacillin and for methicillin-resistant isolates add a
aureus, coagulase-negative staphylococci and enterococci
glycopeptide (teicoplanin or vancomycin) or linezolid
! The most common Gram-negative organisms include
! ESBL-producing isolates - ertapenem.
Enterobacter spp.,
P. aeruginosa, E. coli, Klebsiella spp, and
! In patients with severe HAP, particularly those treated in
the ICU, cases with VAP and cases with risk factors for infections with resistant Gram-negative pathogens, treatment
should be instituted using one of the following agents:
! 4th generation cephalosporin (i.e. cefepime)
! Seek a potential source of origin.
! Institute appropriate source control measures.
! The importance of source control cannot be
! Group 2 carbapenem (i.e. meropenem or
! Initiate appropriate antimicrobial therapy.
! Fluoroquinolone (ciprofloxacin or levofloxacin)
! Give suitable supportive interventions and care.
! ± combinations of the above, such as with the addition
! Factors involved in the initial antimicrobial choice should
of an aminoglycoside
! Add vancomycin only if MRSA is strongly suspected.
! Consideration of the site of infection
Alternatives include teicoplanin and linezolid. There is
! Knowledge of prevalent and likely pathogens and their
some emerging evidence of the possible advantage of
susceptibility patterns
linezolid over vancomycin for the treatment of proven
! Whether or not the patient is immunosuppressed.
HAP or VAP due to MRSA.
! Specific risk factors for resistant pathogens such as
Management of nosocomial intravascular infections
Pseudomonas and
Acinetobacter spp. include:
! Recent antibiotic treatment (preceding 90 days)
! Present hospitalisation for a period of > 5 days! Structural lung disease
! Catheter colonisation: growth of > 15 colony-forming
! High levels and frequency of antibiotic resistance in the
units (semi-quantitative culture) or > 10 colony-forming
community or the specific unit
units (quantitative culture) from a proximal or distal catheter
! Immunosuppression
segment in the absence of local or systemic infection.
! Local infection: erythema, tenderness, induration or purulence within 2 cm of the skin-insertion site of the
Duration of therapy
catheter.
! Catheter-related bloodstream infection (CRBSI):
! The general consensus is that treatment of NP, including
isolation of the same organism (i.e. the identical species as
VAP, has traditionally been longer than is required and the
per antibiogram) from culture (semi-quantitative or
currently recommended treatment duration is 5 - 7 days.
quantitative) of a catheter segment and from the blood of a patient with accompanying clinical symptoms and signs of
South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections
bloodstream infection and no other apparent source of
Duration of central venous catheter (CVC) use
! The duration of CVC use has remained controversial.
Microbiology of nosocomial intravascular infections
! Several studies have shown the duration of catheterisation to be a risk factor for infection.
! Coagulase-negative staphylococci
! Scheduled replacement remains widely practised.
! S. aureus
! No catheter should be left in place longer than absolutely
!
Candida spp
!
Acinetobacter spp
! Over the past few years, antimicrobial-impregnated
!
P. aeruginosa
catheters have been introduced in an attempt to limit catheter-
!
Stenotrophomonas maltophilia
related infections (CRIs) and increase the time that CVCs can
!
Klebsiella spp
safely be left in place.
!
Enterobacter spp!
S. marcescens
!
Citrobacter freundii!
Enterococcus spp
! The protocol for insertion and maintenance of CVCs and
!
Bacillus spp. (especially JK strains)
recommendations regarding insertion, maintenance and use of intravascular devices in general, may be found in the
original publication (www.fidssa.co.za).
! Strict adherence to hand washing and aseptic technique
! The clinical features are generally nonspecific and include
remains the cornerstone of prevention of CRI.
fever, rigors, hypotension and confusion.
! Infusion therapy teams.
! Fundoscopy should always form part of the clinical
! Maximum sterile barriers with use of gloves, gowns,
masks, cap and large drape for line insertion.
! Blood cultures are central to the diagnosis of CRBSI.
! Cutaneous antimicrobials and antiseptics for skin
! Paired quantitative cultures, which involve taking blood
decontamination before line insertion.
from both the catheter and a peripheral site, may be
! Dressing: there has been ongoing debate concerning the
particularly useful where luminal colonisation is
best method of catheter dressing.
predominant.
! The most widely used laboratory technique for culturing
Management of nosocomial urinary tract infections
the catheter is the semi-quantitative roll-plate method.
! Newer diagnostic culture techniques include the endoluminal brush and the Gram's stain and acridine-orange
leukocyte cytospin (AOLC) test.
The urinary tract is usually sterile except for the distal
urethra.
! Colonisation is defined as the presence of micro-
! Treatment depends on the stage of infection and the
organism/s in the urine without clinical manifestations.
! Urinary tract infection (UTI) is defined as invasive disease
! As a general rule, if CRBSI is suspected, the catheter must
by micro-organisms, inducing an inflammatory response and
be removed and replaced only if necessary.
symptoms and signs such as fever >38 C, urgency,
! Most of the infectious complications are self-limited and
frequency, and dysuria without any other cause.
resolve after removal of the catheter.
! Nosocomial urinary tract infection (NUTI) refers to a UTI
! Empirical antibiotic therapy is not recommended unless
acquired in a hospital setting.
there are specific indications. Indications for antibiotic therapy include:
Microbiology of NUTI
! Persistent sepsis despite catheter removal! Evidence of septic thrombosis of the great veins
! Gram-negative pathogens, especially
E. coli (50% of
! Clinical or echocardiographic evidence of endocarditis
infections), also
Klebsiella, Proteus, Enterobacter spp.
! Metastatic foci of infection
! Underlying valvular heart disease (especially
!
S. aureus (including MRSA)
prosthetic valves)
! Coagulase-negative staphylococci.
! Underlying immunosuppressed state.
! In the setting of uncomplicated
S. aureus CRBSI, the
!
Enterococcus faecalis.
catheter should be removed and at least 2 weeks (and
!
P. aeruginosa.
preferably 4 weeks) of parenteral antibiotics given because of
!
Candida spp.
a higher relapse rate with shorter courses.
! Urinary tract pathogens such as
S. marcescens and
! Systemic antifungal therapy (together with removal of the
Burkholderia cepacia have special epidemiological
catheter) should be given in all cases of catheter-related
significance; their isolation from catheterised patients
candidaemia in view of the potentially significant sequelae.
suggests acquisition from an exogenous source.
Amphotericin B and fluconazole (except for fluconazole-resistant organisms such as
Candida glabrata and
C. krusei)
for at least 14 days have been shown to be equally effective. Newer antifungal agents such as voriconazole may also be
! Non-catheterised patients
! In non-catheterised patients, significant bacteriuria
associated with signs and symptoms of infection.
South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse,
et al
! Catheterised patients
! The treatment should be shorter for UTIs without
! Diagnosis of UTI in catheterised patients is problematic
parenchymatous infection or in patients without a urinary
! Clinical symptoms are the key to diagnosis of infection
catheter, for a minimum of 7 days.
in catheterised patients.
! Pyelonephritis requires a 10 - 14-day treatment regimen.
! Symptoms indicative of infection in immunocompetent patients include fever and haematuria.
! There is no indication for systemic antifungal treatment in
Candida spp. colonisation. Removing or changing the
Urinary colonisation:
urinary catheter is mandatory in
Candida spp. colonisation.
! Candiduria may be a marker for disseminated candidiasis
! This is not an indication for systemic antibiotic treatment,
in ICU patients presenting with several colonised sites, in
whether the patient is catheterised or not, diabetic, elderly, or
which case patients should be treated with systemic
presenting with urinary bladder dysfunction due to
antifungals (amphotericin B as continuous infusion or
! Nevertheless treatment of urinary colonisation may be
! An amphotericin B bladder washout may be useful where
necessary in some specific cases:
continued catheterisation is required and there is no evidence
! When it poses a risk of morbidity and mortality in
of upper urinary tract infection.
neutropenic, immunosuppressed, and pregnant
! A positive blood culture warrants systemic therapy as
! In patients in a preoperative situation: surgery and
urological explorations, implanting prostheses.
! In patients with a joint, vascular, or cardiac prosthesis,
when undergoing invasive procedures.
! The urinary catheter should be removed as soon as it is no longer necessary, or changed when drainage is mandatory.
! The indications for an indwelling urinary catheter and its duration must be limited and reassessed every day.
All bacterial NUTIs should be treated, irrespective of
! The isolation of infected or colonised catheterised patients
whether the patient has a urinary catheter or not.
is recommended.
! It is strongly recommended that hands be disinfected with
Antibiotic therapy:
a hand sanitiser.
! For catheterised patients:
! In patients who are not severely ill:
! It is mandatory to use closed systems
! Insertion of a permanent catheter must be performed
! Fluoroquinolones (ciprofloxacin, levofloxacin)
under strict aseptic technique
! A 2nd (cefuroxime) or 3rd generation cephalosporin
! Urine bags must be kept below the patient for gravity
(cefotaxime, ceftriaxone, ceftazidime) which may be
preferable in pregnant women
Management of nosocomial intra-abdominal infections
! Patients can be switched to oral therapy with a
fluoroquinolone if culture results support the change of
! The switch to oral therapy can be made when the patient
Nosocomial intra-abdominal infection (IAI) is defined as an
has no nausea or vomiting, no fever and no evidence of
IAI occurring more than 48 hours after hospital admission
that was neither present nor incubating at the time of the
! Once culture results are known, antibiotic therapy can
patient's visit or admission to hospital. It may be
be adjusted if required.
postoperative or non-postoperative.
! In patients who are severely ill with urosepsis:
! 3rd generation cephalosporin (cefotaxime, ceftriaxone,
Microbiology of nosocomial intra-abdominal infections
! 4th generation cephalosporin (cefepime)
! The most common organisms encountered are Gram-
negative bacilli (
E. coli, P. aeruginosa, A. baumanii,
! Amikacin or another aminoglycoside (monitor levels)
Klebsiella spp.), Gram-positive cocci (enterococci,
S.
! Fluoroquinolone (ciprofloxacin, levofloxacin). Avoid
aureus), anaerobic bacteria (
Bacteroides spp.) and fungi
in pregnancy and children and rather consider a 3 or 4
(
Candida spp.)
generation cephalosporin
! Commonly encountered resistant organisms are:
! If infection with an ESBL-producing micro-organism
! ESBL-producing
Klebsiella and
Enterobacter spp.
is suspected, treatment with a carbapenem (e.g.
Including
E. coli
ertapenem) should be initiated. This is particularly
! Enterococci, including those that are glycopeptide-
likely to occur in elderly residents of long-term care
resistant although these are infrequent in South Africa
facilities. Carbapenems may also be used as part of
!
P. aeruginosa
directed therapy based on microbiological testing.
!
A. baumanii!
S. aureus, especially those resistant to cloxacillin
Duration of treatment
! Coagulase-negative staphylococci (CoNS)
! This depends on the site of infection.
!
Candida spp
South Afr J Epidemiol Infect 2006; Vol 21 (4)
Management of nosocomial infections
! Device-associated infections are frequently due to
SSIs involving fascia and muscle with or without superficial
resistant
S. aureus, CoNS,
E. faecalis and
E. faecium
(including glycopeptide-resistant species), ESBL
! Superficial SSIs occur within 30 days of a surgical
producers and fungi.
operative incision.
! Deep SSIs usually occur within one month of the
operation, but may present as much as one year later with implants or prostheses.
! Surgery remains the mainstay of treatment.
! Source control is the cornerstone in treating these
Microbiology of nosocomial surgical skin and soft-tissue
infections successfully and failure to achieve this is
associated with a very high mortality rate.
! Antibiotic therapy should be commenced empirically
! The vast majority of SSIs are caused by skin commensals,
based on knowledge of the common causative organisms,
usually
S. aureus and coagulase-negative staphylococci
surveillance data, and the prevalence and sensitivity of
organisms within each unit.
! Patients who have recently been hospitalised or on
! Where possible, therapy should be culture-driven.
antibiotics, those currently in hospital and those from LTCFs
! In this regard cultures should be performed initially and at
are at risk for infection with more resistant organisms such as
each re-look laparotomy.
methicillin-resistant
S. aureus (MRSA) or resistant Gram-
! There is also emerging evidence that antifungal preventive
negative organisms,
Klebsiella spp.,
Enterobacter spp,
therapy (amphotericin B or fluconazole) may be beneficial
Pseudomonas spp, etc.
especially in cases of necrotising pancreatitis and in patients
! In patients undergoing hollow visceral or mucous
with complicated IAIs, i.e. those with delayed initial surgery,
membrane surgery, the endogenous flora usually cause
those with anastomotic dehiscence, those requiring multiple
subsequent infections. Usual pathogens are Gram-negative
re-look procedures and those who have received multiple
aerobic bacilli, enterococci, and occasionally anaerobes.
courses of antibiotics.
Infections by staphylococci
, Pseudomonas, Proteus,
! The Gram-negative fluoroquinolones (ciprofloxacin,
Clostridia, streptococci and
Candida species are also not
levofloxacin) and cephalosporins have inadequate anaerobic
activity when used as monotherapy.
! In patients who have been in ICU additional pathogens to
! Additional anaerobic cover is unnecessary with the
consider besides MRSA and
Pseudomonas spp are
carbapenems or with piperacillin/tazobactam.
Enterobacter and
Acinetobacter spp.
! In cases of suspected or confirmed ESBL infections, the carbapenems, and in particular ertapenem, are the agents of
choice.
! Monotherapy is adequate for Gram-negative sepsis. Some
! Debridement and source control are essential.
practitioners may add an aminoglycoside or quinolone in the
! Culture is mandatory for all SSIs.
case of pseudomonal sepsis although the evidence for this
! If the SSI is superficial and there is no evidence of
practice is lacking.
systemic sepsis, an antibiotic is not necessary. Otherwise the
! A glycopeptide (teicoplanin or vancomycin) should be
antibiotic choice is determined by sensitivity or the potential
added empirically, should there be a significant chance of
for resistance and the site of surgery.
staphylococcal infection (MRSA or CoNS). De-escalation is
! Organisms cultured from patients who have been
essential if the organism is proved to be Gram-negative or if it
hospitalised or on antibiotics recently, those currently in
is sensitive to less broad-spectrum agents.
hospital and those from LTCFs are particularly likely to be
! In the scenario of nosocomial IAI, where cultures reveal
resistant. If Gram-positive organisms are isolated, a
an isolated enterococcal infection, this should be treated
glycopeptide (teicoplanin or vancomycin) or linezolid is
according to sensitivity.
reasonable until sensitivities are available. If Gram-negative,
! Linezolid should be reserved for VRE and VREF
a broad-spectrum agent such as a carbapenem,
infections, but may be used as second-line therapy for
piperacillin/tazobactam, fluoroquinolone (ciprofloxacin,
staphylococcal infection, which does not respond to
levofloxacin) or cefepime is indicated. De-escalate antibiotic
glycopeptide therapy (review source control).
therapy whenever possible.
! In patients who have had hollow visceral surgery or
Duration of therapy
mucous membrane surgery, amoxycillin/clavulanate or a 2 generation cephalosporin (cefuroxime) or a fluoroquinolone
Duration should be guided by clinical response and shorter
courses of antibiotics are now advocated, with no evidence
Metronidazole may be added as indicated. Alternatively
having shown that therapy beyond 5 - 7 days is beneficial.
ertapenem may be an option.
! If resistance is likely, broad-spectrum agents may be
Management of nosocomial surgical skin and soft-tissue
considered before availability of sensitivity.
! Preoperative antiseptic washing has been shown to
! Surgical site infections (SSIs) may be divided into organ
decrease the skin microbial count, but there is no definitive
or body cavity infections and skin/skin-related structures/soft
evidence that this decreases postoperative wound infection.
tissue infections.
! Preoperative hair removal should be performed as close to
! SSIs may be further divided into those that are superficial,
the operating time as possible. Clippers are preferable to
i.e. involving only skin and subcutaneous tissue, and deep
South Afr J Epidemiol Infect 2006; Vol 21 (4)
A Brink, C Feldman, A Duse,
et al
! Proper surgical site preparation with chlorhexidine-based,
Table 1: Currently recommended antibiotic dosing
alcohol-based or iodine-based antiseptic solutions is
essential.
! Apply guidelines for theatre and instrument preparation.
! Amikacin, 20 mg/kg daily
! The wearing of scrub suits, surgical caps, shoe covers,
! Amoxycillin/clavulanate, 1.2 g 8-hourly! Amphotericin B, 0.75 - 1 mg/kg daily
gowns, masks and gloves is standard worldwide.
! Ampicillin, 1 g 4 - 6-hourly‡
! Meticulous adherence to asepsis is essential.
! Caspofungin, 70 mg loading followed by 50 mg daily
! The exact choice of agent for preoperative hand
! Cefepime, 1 - 2 g 8- or 12-hourly
washing/scrubbing has not been shown to have a significant
! Cefotaxime, 1 - 2 g 8- or 12-hourly
impact on SSI; alcohol, iodine and chlorhexidine solutions
! Ceftazidime, 1 - 2 g 8- or 12-hourly
are all acceptable. Scrubbing itself is only of value under the
! Ceftriaxone, 1 - 4 g daily
nails and to remove macroscopic organic matter.
! Cefuroxime, 1.5 g 8-hourly
Preoperative MRSA screening for high-risk elective
! Ciprofloxacin, 400 mg 8-hourly
surgical cases may be necessary including patients
! Clindamycin, 600 mg 6-hourly! Cloxacillin, 1 g 4- or 6-hourly
transferred from other hospitals and institutions.
! Ertapenem, 1 g daily! Fluconazole, 800 mg 1st day followed by 400 - 800 mg daily
Prophylactic antibiotic usage
! Gentamicin, 5 - 7 mg/kg daily! Imipenem/cilastatin, 500 mg or 1 g 6-hourly
! The choice of antibiotic depends on the site of surgery and
! Levofloxacin, 750 mg daily or 500 mg 12-hourly
the pathogens likely to be encountered.
! Linezolid, 600 mg 12-hourly
! The best time to administer these antibiotics is within 30
! Liposomal amphotericin, up to 3 mg/kg daily
minutes of the commencement of the operation.
! Meropenem, 1 g 8-hourly
! A single dose has been shown to be adequate in most cases.
! Metronidazole, 500 mg 8-hourly IVI! Piperacillin/tazobactam, 4.5 g 6-hourly
This should only be repeated if the duration of the operation
! Teicoplanin, 400 mg 12-hourly loading dose (day 1) followed by
exceeds the half-life of the selected antibiotic. Benefit has not
400 mg 12 - 24-hourly thereafter
been seen in further antibiotic dosing.
! Tobramycin, 5 - 7 mg/kg/day
! Most clean surgical procedures do not require
! Vancomycin, 500 mg 6-hourly or 1 g 12-hourly (adjust dose to
maintain daily measured levels of 20 μg/ml)
! For elective surgery, cefazolin (2g) is usually
! Voriconazole, 6 mg/kg 12-hourly loading dose (day 1) followed
by 3 - 4 mg/kg 12-hourly
! Clindamycin is a reasonable alternative for penicillin allergy.
* The higher recommended doses of the various antimicrobial agents should be considered for use in seriously ill patients and/or more severe infections.
! For bone surgery, a 1st generation cephalosporin like
†Modifications may need to be made for alterations in renal and/or hepatic
cefazolin is sufficient.
! Glycopeptides are only rarely necessary and their use
‡Only as directed therapy in cases of enterococcal infections.
should be discouraged.
! For hollow visceral or mucous membrane surgery, amoxicillin/clavulanate or 2nd generation cephalosporin
Table 2: Alternative antibiotic options for multidrug- or
(cefuroxime) (1.5 g), with the addition of metronidazole or
pan-resistant bacteria
clindamycin to the latter, are the recommended agents.
! In patients who have been hospitalised for prolonged
! Aztreonam, 1 g 8-hourly
periods of time, piperacillin/tazobactam may be indicated
! Polymixin B*,†, ‡
! > 60 kg: 1 - 2 million units 8-hourly, maximum 6 million
although skin commensals are still the most likely organisms.
If a patient is known to be colonised with MRSA or has had
! < 60 kg: 50 000 units/kg/day divided in 3 doses, maximum
MRSA sepsis a glycopeptide (teicoplanin or vancomycin) or
75 000 units/kg/day
linezolid may be used.
! Tigecycline, 100 mg loading followed by 50 mg 12-hourly‡
! Most patients in ICU are already on antibiotics and do not need additional cover. If the unit has a high incidence of
* Nebulised polymixin B can also be in used in conjunction with the
MRSA sepsis a glycopeptide (teicoplanin or vancomycin) or
intravenous administration in cases of NP and VAP. Standard adult
linezolid may be indicated.
dose is 2 million units 12-hourly (dissolved in 2 - 4 ml 0.9% sodium chloride solution). (Doses up to 2 million units 8-hourly have been found to be safe and effective in patients with cystic fibrosis.)
†Dose adjustment in renal impairment:
Tables 1 and 2 have been added to the summarised guideline
Creatinine clearance (ml/min)
> 60 kg body weight
document and indicate the currently recommended standard
1 - 2 million units 8-hourly
antibiotic dosing regimens as well as alternative antibiotic
1 million units every 12 - 18 hours
options for the management of nosocomial infections.
1 million units every 18 - 24 hours
‡ As these antibiotics are not currently registered for routine use, requests need to be made to the Medicines Control Council (MCC) on the basis of compassionate grounds (www.mccza.com, tel. 012-312 0000). The following has to be faxed: (i) application form filled in by the attending doctor; (ii) consent form (patient or family, if not possible by the attending doctor); (iii) script; and (iv) a deposit of R200 in the MCC account.
South Afr J Epidemiol Infect 2006; Vol 21 (4)
Source: http://sajid.co.za/index.php/SAJEI/article/download/48/43
SATISFACCION Y PERDIDAS INTERMENSTRUALES CON EL USO CONSECUTIVO DE DISPOSITIVOS INTRAUTERINOS LIBERADORES DE LEVONORGESTREL Helsinki, Finlandia El uso consecutivo de dispositivos intrauterinos liberadores de levonorgestrel se asocia con una reducción de los días de sangrado y pérdidas intermenstruales, y con altos niveles de satisfacción respecto del tratamiento. Human Reproduction 25(6):1423-1427 Jun, 2010 Autores: Heikinheimo O, Inki P, Kunz M, Gemzell-Danielsson G Institución/es participante/s en la investigación: Helsinki University Central Hospital Título original: Predictors of Bleeding and User Satisfaction During Consecutive Use of the Levonorgestrel-Releasing Intrauterine System Título en castellano: Predictores de Hemorragia y Satisfacción de las Usuarias Durante el Uso Consecutivo de Dispositivos Intrauterinos Liberadores de Levonorgestrel Extensión del Resumen-SIIC en castellano: 2.64 páginas impresas en papel A4 Introducción El dispositivo intrauterino (DIU) liberador de levonorgestrel (LNG-DIU) se emplea en Finlandia desde 1990, actualmente se comercializa en más de 120 países y es uno de los dispositivos más usados, junto con el DIU con cobre, entre las mujeres europeas. La duración aprobada de uso es de 5 años. Entre aquellas mujeres que usan LNG-DIU, aproximadamente el 25% se encuentra utilizando su segundo dispositivo consecutivo. El uso del LNG-DIU se asocia con una alta tasa de amenorrea, que alcanza el 60%; en un ensayo clínico, este dispositivo mostró una alta tasa de continuidad, y reducción del sangrado o mantenimiento de la amenorrea durante el primer año de uso del dispositivo por segunda vez consecutiva. El uso de LNG-DIU se caracteriza por un patrón de sangrado irregular y pérdidas intermenstruales durante los primeros meses, que posteriormente disminuyen, a la vez que aumenta la tasa de amenorrea. Sin embargo, no se conocen con certeza los factores predictivos de este tipo de patrón de sangrado asociado al LNG-DIU; en un estudio, se determinó que existía una relación entre la presencia de oligomenorrea al cabo de un año de uso de LNG-DIU y factores tales como la duración basal de la menstruación inferior a los cinco días, el uso del dispositivo como método anticonceptivo y no como tratamiento de la menorragia, y la ausencia de menorragia previa. Sin embargo, no se han estudiado los factores que influyen en el patrón de sangrado durante el uso consecutivo de LNG-DIU. Este estudio tuvo por objetivo analizar los factores predictivos del patrón de sangrado durante el primer año de uso de un segundo LNG-DIU, en mujeres que habían empleado el primer LNG-DIU como anticonceptivo o como tratamiento de la menorragia.
UNIVERSITÉ PARIS DESCARTES FACULTÉ DE MÉDECINE Année 2014/2015 DIU REGULATION DES NAISSANCES : socio-épidémiologie, contraception, IVG, prévention des risques liés à la sexualité Lori SAVIGNAC-KRIKORIAN Docteur en médecine générale METHODE DE POSE DIRECTE DES