Chapter 25 Care of Patients with Infection

Overview of the infectious process

▪ Pathogen is any microorganism (MO) (agent) capable of producing
disease.
▪ An infection can be communicable (the flu) or non-communicable
(peritonitis)
▪ Virulence is the degree of communicability and ability to invade
and damage a host
▪ Some microbes are beneficial and a body harbors its own
characteristic bacteria called normal flora
▪ Normal flora compete with and prevent infection from unfamiliar
agents attempting to invade a body site
▪ Colonization is the process in which MO that are often pathogenic
may be present in the tissues of the host and yet not cause
symptomatic disease because of normal flora.

Transmission of infectious agents

▪ Transmission requires 3 factors:
o Reservoir or source of infectious agents
o Susceptible host with a portal of entry
o Mode of transmission
▪ Reservoirs: people, animals, insects, soil, water, other
environmental sources, medical equipments (IV solutions,
urine collections devices), feces, sputum, saliva, wound
drainage, sewage, stagnant or contaminated water,
improperly handled foods.
▪ Asymptomatic carrier is one who harbors an infectious agent
without active disease
▪ Bacteria can exist in resp tract causing no illness
▪ If bacteria invade the bloodstream or cerebrospinal fluid they
become extremely pathogenic
▪ Bacteria that is part of the normal body flora, if it gets to the
bloodstream it can also be pathogenic
▪ Toxins are protein molecules release by bacteria to affect host
cells at a distant site. They are brought about by continued
multiplication of a pathogen.
▪ Exotoxins are produced and released by certain bacteria into the
surrounding environment
▪ Endotoxins are produced in the cell walls of certain bacteria and
released only with cell lysis.
▪ Host defenses provide the body with an efficient system for
protection against pathogens
▪ Breakdown of the body’s defense mechanisms may increase the
susceptibility (risk) of the host to infection.
▪ The patient’s immune status plays a large role in determining risk
for infection.
▪ Congenital abnormalities as well as acquired health problems (eg
renal failure, steroid dependence, cancer, AIDS) can result in
numerous immunologic deficiencies.
▪ Immunity is resistance to infection- presence of antibodies or
cells that act on specific MO.
▪ Passive immunity is of short duration- eg transplacental
▪ Active immunity lasts for years- natural by infection or artificial by
stimulation
▪ Environmental factors also influence immune status – alcohol
consumption, nicotine use, inhalation of bone marrow-
suppressing toxic chemicals, and certain vitamin deficiencies,
malnutrition, Diabetes mellitus.
▪ Older adults have decreased immune systems, as well as other
physiologic changes that make them very susceptible to
infection
▪ Medical and surgical interventions may impair immune response –
steroid therapy, chemotherapy, and anti-rejection drugs
increase the risk of infection.
▪ Medical devices may interfere with normal host defense
mechanisms
▪ The body is one of the best barriers or defenses against infection
▪ MO may enter the body through- respiratory tract, GI tract, GU
tract, skin and mucous membranes, and bloodstream
▪ Pathogens may enter through the resp tract
▪ Microbes in droplets are sprayed into the air when people with
infected oral or nasal tissues talk, cough, or sneeze
▪ Other pathogens enter the body through the GI tract. Some stay
and produce disease, others produce local and distant
infection, leading to GI symptoms, causing systemic infection,
and may involve other organs
▪ MO also enter through the GU tract in the form of UTIs- the most
common health care associated infection. Indwelling urinary
caths are the primary cause of UTIs
▪ Intact skin is the best barrier however some pathogens can eneter
through intact skin (Treponema pallidum)
▪ Medical procedures can create a break in the barrier and cause
bacteremia (bacteria in the bloodstream) and surgical site
infections.
▪ Fragile skin of older patients and those receiving prolonged
steroid therapy increases infection risk.
▪ MO gain access to the bloodstream when invasive devices and
tubes are used - Central venous cath are the primary cause of
these infections
▪ Insects can inject organisms into the bloodstream, causing
infection
▪ Several routes of transmission:
o Contact transmission (direct or indirect)- the usual mode of
transmission of most infections. Direct contact is the source and
host have physical contact- person to person. Indirect involes the
transfer of MO from a source to a host by passive transfer from a
contaminated object.
o Droplet transmission- stay at least 3 feet away
o Airborne transmission- small airborne particles containing
patogens leave the infected source and enter the susceptible host.
The pathogens are suspended in the hair for a prolonged time and
the host inhales the particles directly into the resp tract.
▪ Infectious agents include the environment – contaminated food,
water, or vectors.
▪ Vectors are insects that carry the pathogen between 2 or more
hosts
▪ The portal of exit completes the chain of infection – some
organisms can exit from the infected host by several routes

Physiologic Defenses for infection

▪ Strong and intact host defenses can prevent microbes from
entering the body or can destroy a pathogen that has entered.
Impaired host defenses- allow entry of organisms that can
destroy cells and cause infection.
▪ Common defense mechanisms:
o Body tissues
o Phagocytosis
o Inflammation
o Immune systems
▪ Intact skin forms the first and most important physical barrier to
the entry of MO.
▪ The skin is slightly acidic pH and normal skin flora creates an
unfriendly environment for many bacteria
▪ Lysozymes dissolve the cell walls of some bacteria and are
present in large quantities in many body secretions,
particularly in tears and nasal mucus.
▪ Other body systems provide natural barriers to infection:
o Healthy resp tract- clears about 90% of all inhaled material
o Peristaltic action- mechanically empties the GI tract of
pathogens
o Stomach acid, intestinal secretions, pancreatic enzymes, and bile
together with the competition from normal flora provide an
environment that protects the GI tract
o GU tract- flushing action of urine eliminates pathogens
o pH of urine- maintains sterile environment
▪ Phagocytosis- occurs when a foreign substance evades the firs
line mechanical barriers and enters the body
o Neutrophils bear the primary responsibility for phagocytosis
o Process: engulphing, ingesting, killing, and disposing of an
invading organism.
o If this goes wrong- increased risk for infection
o Inflammation- nonspecific defense mechanism for preventing
the spread of infection- occurs when the tissue becomes damaged.
o Damaged cells release enzymes and PMN leukocytes
(neutrophils) are attacked to the infected site
o Histamine increases the permeability of the capillaries in the
inflamed tissues, allowing fluid proteins, and WBCs to enter an
inflamed area.
o Fibrogen causes leaked fluid to clot and prevents its flow away
from the damaged site into unaffected tissue
o Phagocytosis disposes of the invading MO and often dead tissue.
o If inflammation is caused bu the infection, the end products of
inflammation form pus, which is then absorbed or exits the body
through the break in skin.
▪ Specific defenses:
o Antibody-mediated immune system- produces antibodies
directed against certain pathogens. Inactivate and destroy invading
MO and protect against future infection from that MO
o Cell-mediated immunity- resistance to other MO is mediated by
the action of specifically sensitized T-lymphocytes

Health promotion and maintenance

▪ Infections occur most often in high risk patients – older adults
and those with inadequate immune systems
▪ Implement interventions to prevent infection and detect S&S as
early as possible
▪ Chart 25-2 The patient at risk for infection
▪ Infection acquired from a health care setting- HAI
▪ HAI can be endogenous (from a patient’s flora) or exogenous
 (from outside the patient, often from the hands of health care
workers)
▪ HAI occurs in 2 million patients a year and can cause death
▪ Infection control in hospitals
▪ CIC- certified in infection control
▪ Every facility must designate someone to have the responsibility
for coordinating and implementing an infection control
program

Infection control in community-based setting

▪ Health care workers in these settings have not followed basic
infection control principles, especially aseptic technique and
injection practices

Methods of infection control

▪ All health care workers who come in contact with patients or care
areas are involved in some aspect of the infection control
program of the agency
▪ 5 major ways infections can be controlled or prevented:
o Hand hygiene
o Personal protective equipment (PPE)
o Adequate staffing
o Disinfection/sterilization
o Patient placement and transport
▪ Health care workers’ hands are the primary way in which infection
is transmitted from patient or staff to patient
▪ Hand hygiene refers to both handwashing and alcohol-based
hand rubs
▪ Effective handwashing includes wetting, soaping, lathering,
applying friction under running water for at least 15 seconds,
rinsing, and adequate drying.
▪ Friction is essential to remove skin oils and to disperse transient
bacteria and soil from hand surfaces.
▪ If your hands are visibly soiled or feel sticky or you just toileted
 WASH your hands instead of alcohol based rub
▪ ABHRs are ineffective against spore-forming organisms such as
Clostridium difficile.
▪ PPE refers to the use of gloves, isolation gowns, face protection
(masks, goggles, face shields). Gloves are an essential part of
infection control and should always be worn as part of
standard precautions.
▪ Latex allergy- usually have allergy to foods such as bananas,
kiwis, and avocados.
▪ Adequate staffing- studies have found that infection rates
increase when float, pool, pr agency nurses are substituted for
full time regular staff.
▪ Sterilization means destroying all living organisms and bacterial
spores
▪ Disinfection does not kill spores and only ensures a reduction in
the level of disease-causing organisms.
▪ Patient placement has been used as a way to reduce the spread of
infection. EG private rooms.
▪ CDC DOES recommend that private rooms always be used for
patients on Airborne preclusions and those in protective
environment.
▪ Cohorting is the practice of grouping patients who are colonized
or infected with the same pathogen.

Centers for disease control and prevention transmission-based

guidelines
▪ Standard Precautions- reflect that all body excretions, secretions,
and moist membranes and tissues, excluding perspiration, are
potentially infectious.
▪ RH/CE respiratory hygiene/cough etiquette is now required
o Patient, staff, and visitor education
o Posted signs
o Hand hygiene
o Covering the nose and mouth with a tissue and prompt tissue
disposal or using surgical masks
o Separation from the person with resp infection by more than 3
feet

Transmission-based precautions
▪ Airborne precautions- used for patients known or suspected to
have infections transmitted but he airborne transmission
route. Negative air flow room, enclosed booths with high-
efficiency particulate air filtration, ultraviolet light.
▪ Droplet precautions- used for patients known or suspected to
have infections transmitted by the droplet transmission route.
Droplets may travel 3 feet but are not suspended for ling
periods.
▪ Contact precautions- used for patients known or suspected to
have infections transmitted by direct contact or contact with
items in the environment.

Multidrug-resistant organism infections and colonizations MDROs

▪ Antibiotics used
▪ MOs have become resistant to certain antibiotics

Methicillin-resistant Staphylococcus aureus (MRSA)

▪ S. aureus is common bacterium found on the skin and perineum
and in the nose of many people
▪ Within the past 40 years more and more S. aureus infections are
not responding to methicillin or other penicillin based drugs.
▪ MRSA infections are one of the fasted growing in health care
today.
▪ MRSA is spread by direct contact and invades hospitalized
patients through indwelling urinary caths, vascular access
devices, and endotracheal tubes.
▪ Patients most at risk are older adults and those whoa re
immunosupporesssed, have a long hx of antibiotic therapy, or
have invasive tubes or lines.
Vancomycin-resistant enterococcus (VRE)
▪ Enerococci are bacteria that live in the intestinal tract and are
important for digestion.
▪ The can move to another part of the body for example during
surgery and can cause an infection
▪ In recent years, ober a fourth of these infections have been
resistant to the drug and VRE results.
▪ Risk factors include: prolonged hospital stays, severe illness,
abdominal surgery, enteral nutrition, and
immunosuppression.
▪ These patients with VRE are on contact precautions.
▪ VRE can live on almost any surface for days or weeks and still be
able to cause an infection – contaminated toilet seats, door
handles, and other objects.

Other Multidrug-resistant organisms

▪ Gonorrhea
▪ VISA vancomycin-intermediate S. aureus
▪ VRSA cancomycin-resistant S. aureus
▪ Two drugs have been effective so far against these 2 infections-
linesolid (Zyvox) and quinupristin-dalfopristin (Synercid)

Occupational exposure to sources of infection

▪ OSHA (occupational safety and health admin)- federal agency that
protects workers form injury or illness at their place of
employment
▪ Reduction of skin and soft tissue injuries (eg needle sticks) is
essential to reduce bloodborne pathogen transmission to
health care personnel
▪ OSHA mandates that sharp objects and needles be handled with
care
▪ To prevent transmission from work to home, wear scrubs and
change clothes before leaving work. Keep work and personal
 clothes separate.

Problems from inadequate antimicrobial therapy

▪ Range from incorrect choice of drug to poor patient adherance
▪ Drug regiment non-compliance (on purpose) or nonadherance
(accidental) prevents contact of harmful MO with sufficient
concentrations of the drug to resistant-organism
development
▪ TB has legal sanctions that patient must complete treatment
▪ DOT directly observed therapy- the health care worker must
observe and validate patient compliance
▪ Septic shock- sepsis-induced distributive shock- insufficient
cardiac output is compounded by hypovolemia. Inadequate
blood supply to vital organs leads to hypoxia and organ
failure

Patient-centered collaborative care

▪ History
o Age, hx of tobacco or alcohol, current illness, past and current
drug use
o Previous vaccinations or immunizations and dates of admin
o Determine whether pt has been exposed to infectious agents
o Contact with animals, including pets, may increase exposure to
infection.
o Leisure activities eg hiking
o Travel hx
o Sexual hx
o Type and location of symptoms
▪ Physical assessment/clinical manifestations
o Common clinical manifestations are associated with specific
sites of infection
o Inspect skin for pain swelling heat redness and pus
o Fever (above 101), chills, malaise are primary indicators of a
systemic infection
o Fever may accompany other noninfectious disorders, and
infection can be present without fever
o Hyperthermia (fever) is a normal immune response that can help
destroy the pathogen
o Lymphadenopathy (enlarged lymph nodes), pharyngitis, and GI
disturbance (usually diarrhea and vomiting) are often associated
with infection.

Psychosocial assessment
▪ Feelings of malaise and fatigue often accompany infection
▪ Potential spread of infection and diagnosis causes stress

Laboratory assessment
▪ The definite diagnosis of infectious disease requires ID of a MO in
the tissues of an infected patient
▪ Direct exam of the blood, body fluids and tissues under a
microscope may not yield a definite ID.
▪ Lab assessment usually provides helpful info about organisms,
such as shape, motility and reaction to staining agents.
▪ The best procedure for ID an MO is culture. Culture- or isolation
of the pathogen by cultivation in tissue cultures or artificial
media
▪ Proper collection and handling of specimens for culture, using
Standard Precautions, are essential for obtaining accurate
results
▪ After isolation of a MO in culture, antibiotic sensitivity testing is
performed to determine the effects of various drugs on that
particular MO
▪ A CBC with differential is often done for the patient with a
suspected infection. Five types of leukocytes (WBC) are
measured as part of the results
o Neutrophils
o Lymphocyt
o Monocytes
o Eosinophils
o Basophils
▪ Inmost active infections –esp ones caused by bacteria- the total
leukocyte count is elevated.
▪ The differential count usually shows an increased number of
immature neutrophils, or a shift to the left (“left shift”).
▪ Malaria and infectious mononucleosis are associated with
neutropenia (decreased neutrophils)
▪ ESR erythrocyte sedimentation rate measures the rate at which
RBCs fall through plasma. An elevated ESR indicates
inflammation or infection somewhere in the body (>20mm/hr)
▪ Serologic testing- ID pathogens by detecting antibodies to the
organism.
o The antibody titer tends to increase during the acute phase of
infectious diseases such as hep B.
o The titer tends to decrease as the patient improves

Imaging assessment
▪ X-ray- determine activity or destruction by an infectious MO
▪ Radiologic studies (chest films, sinus films, joint films, GI studies)
are available for diagnosis of infection in a specific body site
▪ CT scans and MRIs for assessing abscesses
▪ Ultrasonography- noninvasive- detecting infection involvement in
heart valves
▪ Scanning techniques- gallium- determine the presence of
inflammation

Analysis
▪ Nursing diagnosis
o Hyperthermia
o Risk for social isolation
o Acute pain
o Fatigue
o Risk for deficient fluid volume
Planning and implementation
▪ Hyperthermia
▪ Risk for social isolation

Community-based care
▪ Infections among older adults in nursing homes.
▪ Care for the confused patients

Home care management

▪ Superinfetion- reinfection or a second infection of the same kind

Health teaching
▪ Explain the disease
▪ Teach family if the disease is transmissible
▪ Ensure patient understands antimicrobial therapy
▪ Encourage discussion of feelings r/t the disease

Home care resources

▪ Used to teach appropriate admin of drug therapy in the patients
home.

Evaluation: Outcomes
▪ Eval the care of the patient
▪ Patient will be expected to
o Have body temp and other vitals within baseline
o Adhere to drug therapy
o Copes with feelings of social isolation
o Interacts with others as appropriate

Critical issues for the next decade

▪ Bioterrorism and emerging infections
Table 25-6 emerging infectious diseases in the US