Infection Exemplars: MRSA, VRE, Cellulitis

1
Infection Exemplars MRSA, VRE, Cellulitis

• Taylor, ch 27, 37

2
Exemplars

• MRSA, VRE, Cellulitis, UTI, C-diff, and Herpes
  zoster (shingles) are representative of the
  infection concept for this semester.

3
MRSAMethicillin-resistant Staphylococcus aureus

• One of the most troublesome resistant bacteria in
  the country.
• MRSA is resistant to all medicines in the
  beta-lactamase family that include all
  penicillins, cephalosporins (Ancef, Keflex), and
  carbapenems (Doribax, Invanz), as well as other
  antibiotics such as erythromicin.
• Hospital-associated MRSA is more resistant than
  community-associated.

4
Pathology of Resistance

• Resistance occurs when pathogens change in ways
  that decrease the ability of a drug or family of
  drugs to treat disease.
• Bacteria are highly adaptable and have evolved to
  the point that their genetic and chemical makeup
  has changed.

5
Pathology of Resistance

• The antibiotics have lost their effectiveness
  because the DNA and cell walls of the bacteria
  have changed and the antibiotic can no longer
  penetrate the cell wall.
• Also, some bacteria now produce enzymes that
  destroy or inactivate antibiotics.

6
Contributory Practices to Resistance

• Giving antibiotics for viral infections
• Prescribing unnecessary antibiotics
• Inadequate drug regimens to tx cases
• Using broad-spectrum antibiotics when specificity
  would be better
• Pts who dont finish their course of tx
• Pt lack of or other psychosocial issues

7
MRSAs Importance

• Pathogenicityvery virulent frequently cause
  bloodstream, wound, ventilator, and catheter
  infections in hospitalized pts and skin and
  respiratory infections in community
• Limited treatment options
• Transmissiblecolonized health care workers
  close contact in community

8
Risk Factors

• Repeated contact with health care system
• Severity of illness
• Previous exposure to antimicrobials
• Underlying conditions
• Invasive procedures
• Previous colonization
• Advanced age

9
Modes of Transmission

• Main mode is via contaminated hands from
• colonized or infected patients
• colonized or infected staff
• contaminated articles or surfaces

10
Clinical ManifestationsHA-MRSA

• Colonized patients and workers have no symptoms.
• Colonies usually located in nose, respiratory or
  GI tract, or skin
• SS from persons infected with MRSA are no
  different from SS from other infections.
• Definitive dx is from a culture.

11
Clinical ManifestationsCA MRSA

• Purulent lesion with a central head that has a
  yellow or white center and may be draining.
• Pts sometimes complain about a spider bite.
• May have a fever

12
Microscopic MRSA
13
MRSA Abscess
14
(No Transcript)
15
Comparison
16
Recommendations

• Standard Precautions, specifically handwashing
  guidelines
• Transmission Based Precautions, specifically
  Contact Precautions
• Donning gown and gloves upon entry to the room
  for all interactions involving contact with
  patient or areas in the patients environment.
  Gown and gloves should be discarded before
  exiting.

17
Additional Precautions

• Private room is preferred.
• Semi-private with another similar patient who
  does not have another infection or with patient
  who has no risk factors.
• Allow socialization as long as wounds are
  covered, body fluids are contained, and
  handwashing is observed.

18
Prevention and the Nurse

• Wash hands before and after patient contact.
• Wear PPE as directed by the infection control
  team and dispose of contaminated articles in a
  manner that prevents spread.
• Make sure visitors are protected.
• Be aware of own health.

19
Treatment

• Vancomycin and two newer agents, linezolid and
  daptomycin, are usually used to treat HA-MRSA.
  Isolation precautions are implemented.
• CA-MRSA is usually treated by draining and
  culturing the skin lesion and giving clindamycin
  or doxycycline.

20
Nursing Care and Education

• Administer antibiotic tx.
• Follow infection control guidelines and teach
  visitors the guidelines.
• Teach those in the community
• Wash or use hand sanitizer
• Keep cuts and lesions covered
• Dont touch other peoples cuts or lesions
• Do not share personal items like towels or razors

21
Vancomycin-Resistant Enterococcus (VRE)

• Enterococcus is normally found in the GI and
  genital tracts
• If it gets outside of those areas, it can cause
  an infection
• If Enterococcus is resistant to vancomycin, it
  has a high morbidity and mortality rate.

22
Transmission

• Feces
• Urine
• Blood
• Can be from infected or colonized person

23
Risk Factors

• Immunocompromise
• Catheters
• Abdominal or chest surgery
• Prolonged hospitalization or antibiotics

24
Treatment

• Handwashing
• Contact precautions
• Linzeloid or quinupristin-dalfopristin

25
Cellulitis

• Inflammation and infection of subcutaneous
  tissuesbacterial gain access thru a break in
  skin
• Staphylococcus aureus and streptococci are usual
  causative agents
• Most commonly found in feet or legs
• Complicated by poor perfusion

26
Etiology (Cause)

• Primary infection from trauma (sharp objects,
  burns)
• Secondary infection from scratching
• Insect bites
• Impetigo
• Complication of leg ulcers in people with
  diabetes or peripheral vascular disease

27
Risk Factors

• Diabetes
• Immunosuppression
• Peripheral Vascular Disease (PVD)
• Lymphedema
• Malnutrition

28
Clinical Manifestations

• Localized
• Hot, tender, erythematous, and edematous area
  with diffuse borders
• Deep tissue inflammation caused by enzymes
  produced by bacteria and inflammatory response
• Edema sometimes severe and can cause skin to
  crack and weep.
• Systemic
• Chills, malaise, fever, elevated WBC

29
Cellulitis
30
Cellulitis
31
Cellulitis
32
Periorbital Cellulitis
33
Treatment

• Moist heat
• Immobilization
• Elevation
• Systemic antibiotic therapyusually with a
  penicillin derivative or cousin
• Hospitalization may be necessary
• Surgery may be necessary for debridement and to
  R/O fasciitis

34
Complications

• Progression of inflammation and infection can
  lead to
• Necrotizing fasciitis (flesh-eating)
• Gangrene (death of tissue)skin turns black
  purulent drainage present foul odor
• Amputation
• Sepsis (blood infection)

35
Nursing Care

• Assess area and recordoutline area
• Check for blood culture order
• Administer meds for infection and pain
• Wound care as ordered
• Consider effects of immobility and practice
  prevention techniques
• Assist with mobility when pt can be OOB
• Address fears and concerns
• Evaluate effectiveness of care

36
Infection Exemplars UTI, C-diff, Shingles

• Taylor, ch 27, 37

37
UTI

• A.K.A. urinary tract infection
• Inflammation occurs concurrently with infection
  altho can occur without infection
• Women are at greatest risk
• 80 caused by Escherichia coli from
  cross-contamination from the rectum.

38
Classifications

• Upperkidney (pyelonephritis)
• Lowerbladder (cystitis) and urethra (urethritis)
• Initialfirst or isolated
• Recurrentafter first was resolved, new one
  occurs
• Unresolved and persistentcontinue even after
  antibiotic tx
• Sepsis d/t UTI (previously called urosepsis)

39
Risk Factors

• Female
• Pregnancy
• Structural abnormalities
• Foreign bodies (stones, catheters, dx
  instruments)
• Obstruction (tumors, strictures)causes urinary
  stasis
• Impaired immunity (age, disease)
• Multiple sex partners
• Poor personal hygiene

40
Contributory Medical Practices

• Poor handwashing practices
• Use of urinary catheters
• Poor technique in inserting catheters
• Poor catheter care
• Poor perineal care
• Use of diagnostic instruments

41
Clinical Manifestations

• Dysuria (difficulty voiding)
• Frequency (more than every 2 hours)
• Urgency
• Retention
• Suprapubic pain, pressure, burning with
  urination, flank pain, CVA tenderness, abdominal
  discomfort (all from inflammation)
• Cloudy urine frank hematuria

42
Clinical Manifestations contd

• Dribbling
• Hesitancy
• Incontinence
• Nocturia nocturnal enuresis
• Weak stream
• Confusion in elderly
• Fever, chills, N/V, malaise if pyelonephritis or
  urosepsis

43
Clinical ManifestationsDx Tests

• Microscopic urinalysis reveals pyuria, numerous
  WBCs, bacteria, nitrites, blood
• Urine culture obtained by clean catch midstream
  or cath specimen shows greater than 10,000 colony
  growth
• Blood cultures (urosepsis)
• Imaging studies prn (IVP, CT, MRI)

44
Treatment

• Antibioticsoral, IM, or IV. Type empirically
  selected or by C S testing. Usually need to
  start ASAP, but may need to change based on labs.
• Urinary analgesic
• Prophylactic antibiotic tx

45
Nursing Assessment

• Hx of UTIs, stones, dx procedures or surgery, BPH
• Hygiene practices, SS, sexual practices
• Urine appearance
• Labs or other dx tests

46
Goals/Evals

• Pt will have relief from sx
• Pt will have no complications or spread of UTI
• Pt will have no recurrence

47
Interventions

• Teach health promotion practices to prevent UTIs
• Empty bladder regularly and before and after
  intercourse
• Good hygiene practices
• Fluid intake 15 mL/lb/day--20 from food
• Daily cranberry juice
• No douches, harsh soap, Bbaths, sprays
• Teach S/S UTI

48
Interventions contd

• Prevent hospital-aquired infections (HAIs) by
• Handwashing
• Avoid catheterization if possible
• Practice aseptic technique with procedures
• Good cath care and perineal hygiene

49
Interventions

• For acute care
• Encourage fluids
• Avoid caffeine, ETOH, citrus, chocolate,
  spicycause bladder irritation
• Heat application
• Administer antibiotics (will need 14-21 days) and
  analgesics
• Teach pt about meds and to continue meds at home
  until all gone

50
Clostridium difficile (C-diff)

• Normally found in the intestines
• Accounts for 75 of all HA diarrhea
• Overgrowth causes inflammation and damage to
  intestinal walls (colitis)
• Abdominal cramping, watery stools (up to 15x/d),
  blood or pus in stool

51
Transmission/Risk factors

• Via healthcare workers hands
• Contamination via fecal-oral route
• Risk factors
• Antibiotic therapy
• Elderly
• Long term care residents

52
Other Risk Factors

• Surgery of the GI tract
• Diseases of the colon such as IBD or cancer
• Immunocompromise
• Chemo drugs
• Previous C. diff infection
• Kidney disease
• Use of drugs called proton-pump inhibitors, which
  lessen stomach acid

53
Treatment

• Handwashingsoap and water preferred to
  alcohol-based cleansers
• Contact precautions
• Metronidazole (Flagyl) is preferred
• Probiotics
• Fluids

54
Herpes Zoster (shingles)

• a.k.a. Varicella zoster, chicken pox virus
• Re-emergence of the virus from a previous
  outbreak
• After initial outbreak, virus goes dormant and
  comes back during times of physical or emotional
  stress

55
Transmission/Risk

• Via contact with fluid from lesions. After
  lesions dry, no longer contagious
• Only contagious if the person has not had c-pox.
• Can give someone c-pox who has not had it, but
  cant give someone shingles.
• Risk factors are hx of c-pox, gt50 yo,
  immunocompromised, pregnancy

56
Manifestations

• Headache
• Flu-like symptoms
• Pain under the skin
• Paresthesia
• Eruption of a vesicular, band-like rash which is
  very painful
• Postherpetic neuralgia

57
Microscopic view (WebMD)
58
Eruption on Torso
59
Close-up on Torso
60
Dried lesions
61
Shingles in Eye
62
Treatment

• Antivirals (-virs)
• Pain meds
• Steroids
• Cool compresses