Objetivos: 1) estudio descriptivo de los episodios de infección nosocomial (IN) en el hospital Sant Jaume de Calella durante 2 años; 2) estudio de los factores de riesgo (FR) de las tres IN más frecuentes, la infección de la herida quirúrgica (IHQ), la infección del tracto urinario (ITU) y la neumonía nosocomial (NN) en un hospital de menos de 200 camas y 3) estudio del impacto económico atribuible a la IN, mediante dos perspectivas distintas: a) cálculo del coste de la prolongación de la estancia hospitalaria y b) cálculo del coste variable. Pacientes y Método: Estudio prospectivo caso-control anidado en una cohorte. El apareamiento fue 1:1 para la IHQ y para la ITU y de 1:4 para la NN. Para el estudio de los FR los controles se aparearon por sexo, edad y fecha de ingreso. Para el estudio del coste económico el apareamiento fue por sexo, diagnóstico principal, procedimiento quirúrgico principal, edad y fecha de ingreso. Para el estudio de los FR se efectuó un análisis univariado y multivariado, utilizando la regresión logística. Para el estudio del coste económico se utilizó el test de Wilcoxon.Resultados: Hubo 408 episodios de IN, con una incidencia del 3.06%. Los FR asociados fueron: a) en la IHQ: cirugía urgente, cirugía abdominal, aplicación incorrecta de la profilaxis quirúrgica, ingreso hospitalario previo y días de estancia hospitalaria; b) en la ITU: sonda vesical y c) en la NN: sonda nasogástrica, inmunosupresión, accidente vascular cerebral actual y días de estancia hospitalaria. La IN supuso un prolongación de la estancia hospitalaria de 8 días de mediana; 13 días para la IHQ, 6 días para la ITU y 9 días para la NN. Ello condicionó una ocupación permanente de 5 camas durante un periodo de 2 años. El coste económico global de la IN fue de casi 100 millones de Ptas., cuando el cálculo se efectuó en base a la prolongación de la estancia y de casi 24 millones de Ptas., cuando el cálculo se realizó en base a los costes variables o por procedimientos.Conclusiones: Unas medidas de prevención adecuadas, sobre todo en aquellos factores modificables, sin duda reducirán la incidencia de IN y, con ello, no solo la morbilidad y mortalidad, sino los costes que se generen, tanto si éstos se calculan mediante la prolongación de la estancia o mediante los costes variables. / Study Objective: 1) descriptive study of the nosocomial infection (NI) episodes in the Sant Jaume of Calella hospital during 2 years; 2) study of the risk factors (RF) of the thre NI more frequents, the site surgical infection (SSI), the urinary tract infection (UTI) and the nosocomial pneumonia (NP) in a hospital of less than 200 beds and 3) To evaluate the economic cost of NI by two methods, by calculation of cost resulting from increase of hospital stay attributable to NI and by calculation of cost attributed to services and procedures.Patients and method: A matched case-control prospective study with a cohort population. The matched was 1:1 for the SSI and the UTI and was 1:4 for the NP. To evaluate the RF the control were matched for sex, age and date of admission in the hospital. Both univariate and multivariate analysis were performed using the logistic regresion method.To evaluate the economic cost, the controls were matched for sex, principal diagnosis, surgical procedure, age and date of admission. A test of Wilcoxon was practiced.Results: There were 408 episodes of NI, with an incidence of the 3.06%. The RF associated were: a) for de SSI: emergency surgical, abdominal surgery, inadecuate surgical prophylaxis, previous admission and days of stay in the hospital; b) for the UTI: urinary catheter and c) for the NP: nasogastric tube, immunosupression, stroke and days of admission in the hospital. We compared of costs between cases and controls by two methods: 1) calculation of cost resulting from an increase of hospital stay attributable to NI and 2) calculation of costs attributed to services or procedures.Conclusions: Accurated prophylactic methods, specially in modificable factors, would ameliorate the incidence of NI and then improve the morbility and mortality results, but also would disminish the cost generated, calculated both by the increase of hospital stay or by the costs attributed to services.

AntecedentesLas Infecciones Nosocomiales (IN) son un importante problema de Salud Pública, asociadas a una elevada morbilidad y mortalidad en unidades de alto riesgo, así como a una prolongada estancia y elevada carga económica para el sistema sanitario.ObjetivoDescribir el perfil epidemiológico de las IN en las Unidades de Cuidados Intensivos Pediátricos (UCIP) y Neonatal (UCIN), y estudiar los factores de riesgo asociados a su desarrollo.MétodosEstudio prospectivo de vigilancia de 6 meses de duración, mayo a octubre del 2000, en un Hospital Universitario de nivel III. El seguimiento fue activo, utilizando como definición estándar de IN los criterios del CDC. La asociación entre los factores de riesgo y la presencia de IN se ha estimado mediante el cálculo del RR ajustado, por el análisis de Prentice-Williams-Peterson-Counting-Process.ResultadosEl total de pacientes incluidos en la UCIP fue de 257 y en la UCIN de 121. El 56% y 61% eran niños, con una media de edad de 7,5±6,1 años y de 3±2,5 días, respectivamente en cada unidad. En la UCIP, el 15,2% (39 pacientes) presentaron al menos un episodio de IN, con una tasa de incidencia de 26,5 infecciones por cada 100 ingresos y una densidad de incidencia de 1,7 infecciones por cada 100 pacientes-día. En la UCIN, el 46,3% (56 neonatos) adquirieron al menos una IN, con una tasa de incidencia de 74,3 infecciones por cada 100 ingresos y una densidad de incidencia de 2,7 infecciones por 100 pacientes-día. La bacteriemia fue el episodio de IN más frecuente, en más del 50% de los casos en las dos unidades, seguido de la infección respiratoria en la UCIP (20,6%) y conjuntivitis (20%) en la UCIN. Los microorganismos gram positivos fueron los más frecuentes, 47,2% y 72,7% en la UCIP y UCIN, respectivamente, siendo el Staphylococcus coagulasa negativo el más aislado. Las tasas más altas de incidencia de IN por 100 pacientes-día se presentan en niños con cirugía cardiaca (2,55 infecciones) y politraumatizados (2,46 infecciones) en la UCIP, en la UCIN, la aspiración de meconio (6,8 infecciones) y la enfermedad de membrana hialina (3,11 infecciones). La estancia media en pacientes infectados fue de 35±32,3 y en no infectados de la UCIP de 11,5±9,3 (p<0.0001). La estancia media en neonatos infectados fue de 43,4 ± 34,2 y no infectados de 13,1 ± 12,1 (p<0.0001). Los factores más asociados al desarrollo de IN en la UCIP han sido: edad inferior a 1 año (RR 5,05; IC 95% 1,66-15,4) o superior a 15 años (RR 3,87; IC 95% 1,28-11,7), categorías III y IV del índice de gravedad (RR 2,54; IC 95% 1,17-5,55 y RR 3,70; IC 95% 1,24-11,1 respectivamente), presencia de coma (RR 2,94; IC 95% 1,44-6,01), insuficiencia renal (RR 16,0; IC 95% 5,62-45,6), exposición a ventilación mecánica (RR 2,55; IC 95% 1,08-6,04), cateterización venosa central (RR 2,21; IC 95% 1,07-4,6) y nutrición parenteral (RR 2,0; IC 95% 1,09-3,68), y en la UCIN, neonatos con peso inferior a 1000 g (RR 2,85; IC 95% 1,02-8,0), la exposición a catéter umbilical arterial (RR 5,76; IC 95% 1,16-28,5), nutrición parenteral (RR 2,42; IC 95% 1,28-4,60) y exposición a catéter venoso central de inserción periférica (RR 1,63; IC 95% 1,00-2,68).ConclusionesEl presente estudio permite conocer a fondo el perfil epidemiológico de las IN en dos unidades pediátricas de alto riesgo, la importancia que representan las IN en el medio hospitalario y su asociación a factores de riesgo susceptibles de control. Estos hallazgos sugieren la necesidad de evaluar las medidas de control de infección, para reducir las complicaciones de morbilidad y mortalidad asociadas, y mejorar la calidad asistencial. / BACKGROUNDNosocomial infections (NI) are an important problem of public health and are associated with substantial morbidity, mortality in the high-risk units, prolonged hospital stay, and increased health care costs.OBJECTIVETo describe the epidemiological profile of NI in the Pediatrics Intensive Care Unit (PICU) and Neonatal Intensive Care Unit (NICU), and its related risk factors.METHODSA prospective surveillance study from may through October 2000 at a University Hospital level III in Barcelona. The surveillance was active and Centers for Disease Control and Prevention (CDC) criteria were used as standard definitions of NI. The association between risk factors and the development of NI was calculated by the Prentice Williams Peterson-Counting Process (PWP-CP) analysis, and expressed as adjusted relative risk (RR).RESULTSDuring the study period 257 patients were admitted in the PICU and 121 neonates in the NICU. 56% and 61% were boys, the mean age was 7,5±6,1 years and 3±2,5 days, respectively in each unit. In the PICU, 15,2% (39 patients) had at least one episode of NI, with an incidence rate of 26,5 NI per 100 admissions and 1,7 NI per 100 patient-days. In the NICU, 46,3% (56 neonates) had at least one episode of NI, with an incidence rate of 74,3 IN per 100 admissions and 2,7 NI per 100 patient-days. The most frequent episode of NI was bacteremia, which represented more than 50% of the total infections in both units, followed by respiratory infection (20,6%) in the PICU, and conjunctivitis (20%) in the NICU. The most common microorganisms isolated were Gram-positive bacteria (47,2% and 72,7%) in each unit, being Coagulase-negative Staphylococci the main pathogen. The highest incidence rates of NI per 100 patient-days were in patients with cardiac surgery (2,55 NI) and trauma (2,46 NI) in the PICU, in the NICU, meconium aspiration (6,8 NI) and hyaline membrane disease (3,11 NI). The mean hospital stay in the PICU was higher in infected patients (35±32,3) than in non-infected patients (11,5±9,3), (p<0.0001). In the NICU the medium hospital stay was higher in infected patients (43,4 ± 34,2) than in non-infected patients (13,1 ± 12,1), (p<0.0001).The factors more frequently associated with the development of NI in the PICU were: patients under 1 years old (RR 5,05; IC 95% 1,66-15,4) or more than 15 years old (RR 3,87; IC 95% 1,28-11,7), grades III and IV of Clinical Classification System (RR 2,54; IC 95% 1,17-5,55 and RR 3,70; IC 95% 1,24-11,1), respectively, coma (RR 2,94; IC 95% 1,44-6,01), renal failure (RR 16,0; IC 95% 5,62-45,6), exposition to ventilator (RR 2,55; IC 95% 1,08-6,04), central venous catheter (RR 2,21; IC 95% 1,07-4,6) and parenteral nutrition (RR 2,0; IC 95% 1,09-3,68). In the NICU, neonates with birth weight less than 1000 g (RR 2,85; IC 95% 1,02-8,0), exposition to umbilical arterial catheter (RR 5,76; IC 95% 1,16-28,5), parenteral nutrition (RR 2,42; IC 95% 1,28-4,60) and central venous catheter of peripheral insertion (RR 1,63; IC 95% 1,00-2,68).CONCLUSIONSThis study allows to know the epidemiological profile of NI in two high-risk pediatrics units, the impact of the infections in the hospital environment and the risk factors associated to NI. These findings suggest the need to evaluate the infection control measures aimed to reduce the morbidity and mortality associated to NI, and improve the quality assistance.

published_or_final_version / Nursing Studies / Master / Master of Nursing

published_or_final_version / Public Health / Master / Master of Public Health

Enteral feeding is commonly used in paedaitric patients. It helps to improve the digestive, absorptive, immunologic and nutrition status. However, poor handling in enteral feeding can lead to bacterial contaminations and severe consequences resulting in significant morbidity and mortality. At present, there are no definite guidelines on the handling of enteral feeding in local setting, therefore developing evidence based guideline on enteral feeding is critically important to eliminate inconsistent practices and prevent nosocomial infections related to enteral feeding. This dissertation is a translational nursing research that aims at developing evidence based guideline on enteral feeding in infants. The objectives of this thesis are to search for existing literatures on enteral feeding; perform a critical appraisal on the literatures; develop guideline on enteral feeding in infants; assess the implementation potential of the proposed guidelines, and develop the implementation and evaluation plans. The ultimate goal is to reduce the nosocomial infections in infants with enteral feeding in an acute hospital. A systemic search for relevant and valid evidence was performed using three electronic databases and nine relevant studies were retrieved. Critical appraisals on the nine studies were performed and the level of evidence for each study was graded according to the Scottish Intercollegiate Guidelines Network (SIGN). By synthesizing the data from nine studies, it is concluded that optimal hang time and proper hand hygiene appeared to have significant effect in reducing nosocomial infections related to enteral feeding. The implementation potential of the innovation was assessed in terms of the transferability, feasibility and cost benefit ratio. After assessing the implementation potential, it is found that the evidence is transferable and feasible to implement the proposed guideline in the target paeditaric setting. An evidence based guideline on enteral feeding in infants was developed. An implementation plan of the new guideline included a comprehensive communication plan with both administration and nurses and a pilot test were developed to ensure a smooth implementation and optimize the transferability and effectiveness of the evidence based guideline in the target population. A systematic evaluation plan on patient outcomes, health care provider outcomes and systemic outcomes was developed. The evidence based guideline on enteral feeding was expected to be implemented in the long run to reduce the risk of nosocomial infections in infants with enteral feeding. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Understanding the extent of infection control measures to be taken to protect immunosuppressed and other types of patients from airborne infection agents during construction is crucial knowledge for both healthcare and construction professionals. The number of aspergillosis-related fatalities due to dust transmission during construction activity has decreased with the improvement of antifungal therapy, however the illness is particularly debilitating and the treatment is not always successful. This experimental work is the first stage in a research program to develop better dust controls for construction at existing medical facilities to reduce the incidence of dust borne fungi, such as Aspergillus spp. To better protect at-risk patients from exposure to Aspergillus spp. and other airborne fungal infections, an experiment was conducted to determine what materials can be used to create a barrier for infection control to moderate particle transmission from the construction area to the treatment area. This study investigated the relationship between construction barriers and particle transmission. A new experimental procedure and equipment simulates the transmission of disturbed dust from construction activity across a barrier. The effective of the barrier is determined from measured particle count on filter. The results show that an effective barrier manufactured from simple and readily available building supplies stops the transmission of 12-micron dust particles under a standard set of conditions. The test provides a simple and cost effective method to compare transmission rates for dust.

This research project investigated the impact of an action research intervention implemented to reducing surgical wound infection in one of the acute care hospitals in India. The study aimed to develop and implement a clinical practice improvement program in reducing surgical wound infection by improving the hand washing and wound dressing practices of nurses. The study also aimed to identify the important contributing factors to a model that predicts surgical wound infection. Pre-post evaluation measures were taken to compare the results of surgical wound infection rate before and after the implementation of the intervention. Surgical wounds of two thousand patients (one thousand before the intervention and another one thousand after) were assessed to determine the wound infection rate and severity of wound infection. The hand washing and wound dressing practices of forty nurses were observed. These same nurses were involved in the intervention using a participatory action research process. The results of the study suggest that there was a marked, significant reduction in the rate and severity of wound infection following the implementation of the intervention. By increasing the hand washing facilities in the ward, educating nurses on the importance of better hygiene, pre-operative shaving and post-operative wound care, the hand washing and wound dressing practices of nurses improved considerably. These improvements resulted in a reduction in the number and severity of patients' surgical wound infections. The study also examined the contribution of different factors to surgical wound infection in a Indian hospital. Significant predictive factors were the patients' age, longer pre-operative hospital stay, extended pre-operative shaving time before surgery, wound class, and co-morbidity of the patient. The identification of risk factors that contributed to increased surgical wound infection for example pre-operative skin preparation, pre-operative hospital stay of the patient would help in taking appropriate measures at the ward level and organisation as a whole. Nosocomial infections extends to an unnecessary lengthy hospital stay, additional treatment increased mortality and morbidity, and increased cost to the patients and the nation as a whole. This project proved that educational mentoring, data surveillance processes and involving the nurses in an action research process were effective in enabling participants to improve their clinical practice and thereby reduce the incidence of patients' surgical wound infections. Establishing infection control teams, ongoing surveillance and feedback to staff of nosocomial infection rates is an urgent need in all Indian hospitals. Organisational management, as a priority, need to provide funding and staff dedicated to undertaking this essential work. Health care professionals can no longer plead ignorance of a situation for which all have a moral and professional responsibility.

Master of Science / The role of the microbiology laboratory is (1) to provide infection control information, so that highly transmissible isolates may be identified and appropriate control measures instigated as rapidly as possible and (2) to provide adequate information to the clinician enabling correct antibiotic choices to be made, particularly in the critically ill. Microbiological data is by definition slow as it is culture dependent: this study focused on the development of genetic, culture-independent methods for detection of resistance in nosocomial pathogens that could be introduced into the routine microbiology department and would fit into the routine workflow with a consequent reduction in time to result. Initially a duplex real-time polymerase chain reaction was developed for the rapid identification and detection of S. aureus and methicillin-resistance. This was optimised for immediate as-needs testing of positive blood cultures signalling with “Gram positive cocci, possibly staphylococcus” evident on Gram stain, on a random access real-time PCR platform. This technology, allowing early identification of S. aureus and its susceptibility to methicillin, by simple automated methodology, may soon become the standard for all microbiology laboratories servicing the critically ill. The second part of the study involved the development of a selective broth and multiplex PCR for detection of three important nosocomial isolates at this institution, methicillin-resistant S. aureus (MRSA), carbapenem-resistant Enterobacteriaceae, and multi-resistant Acinetobacter baumannii (MRAB). A multiplex PCR using four primer sets was designed to detect low colonisation levels of these isolates after overnight incubation in selective broth, significantly reducing the time to result and associated costs. This potentially useful epidemiological screening tool is practical, reproducible and sensitive with the potential of moving to an automated test (using real-time PCR, for example) in the future. The availability of early negative results judged by simple visual scanning (or by densitometry), means that the result is less operator-dependent, potentially reducing error rate. The last part of the study dealt with an important resistance phenotype, aminoglycoside resistance. There had been no recent comprehensive local surveys performed to determine the frequency of aminoglycoside resistance amongst the Enterobacteriaceae, or to identify the genetic determinants and their transmissibility. The isolates collected for the study were all resistant to at least one of gentamicin, tobramycin or amikacin. Identification of integron cassette arrays and use of specific internal primers identified at least one genetic determinant for gentamicin and tobramycin resistance in 22 of 23 isolates. Three isolates had two aminoglycoside resistance genes, and three isolates had three aminoglycoside resistance genes identified (Table 6.1). Transferable gentamicin-resistant plasmids were predominant amongst Klebsiella spp., but less so amongst Enterobacter spp. and E. coli. Gentamicin-resistant Klebsiella spp. were often ESBL positive, the genetic determinants of which were typically co-transferred on a conjugative plasmid. The importance of screening at a local level was demonstrated by the unexpected predominance of aac(6')-IIc amongst Enterobacter spp. and the detection of a new gene (aac(6')-LT). This part of the study has provided an understanding of the primary aminoglycoside resistance genes present in the local setting and their association with other resistances. This knowledge will allow development of assays for patient screening (clinical isolates and colonising flora), to better understand the epidemiology of aminoglycoside resistance and to allow better choice of antibiotic therapy related to presence or absence of these genes.

Thesis (M.A.)--Northern Kentucky University, 2007. / Made available through ProQuest. Publication number: AAT 1445115. ProQuest document ID: 1342744201. Includes bibliographical references (p. 35-36)

Thesis (M.S.)--University of Michigan, 1981. / eContent provider-neutral record in process. Description based on print version record.