The Scenario

1
The Scenario

• 72 year old lady, NOF
• Redness, swelling, discharge of wound
• wound swab
• Catheter in place
• catheter stream urine

2
Wound Infection

• Most likely causative organism?
• Staphylococcus aureus
• Why do we say this?
• Most common pathogen of clean wounds.
• Reservoirs of infection?

3
Antibiotic Therapy

• Why not wait for wound swab report?
• At least 24 - 48 hrs!!
• Empiric therapy - factors.
• Most probable organism/sensitivity
• Any other information?

4
An Urgent Gram stain
5
Good news or bad news
6
Pathology Report

• Patient name Dot Evans
• Specimen Wound swab - post op, hip
• Culture Staphylococcus aureus
• Penicillin R Tetracycline R
• Erythromycin R Ciprofloxacin R

• Vancomycin SENSITIVE
• MRSA

7
Impact of the Ron the patient?

• Delay appropriate therapy
• Second choice drug
• IV, broad spectrum
• toxicity
• Isolation
• Length of stay

• Clinical course

8
MRSAReservoirs/transmission

• Must be exogenous - WHY?
• Sources of MRSA
• Hospital environment, patients
• Hospital staff ???
• Staff as mechanical vectors
• Handwashing
• Gloves

9
MRSA Institutional Issues

• Isolate positive patients
• Why? It isnt airborne
• Screen incoming patients
• Which patients?
• How do you screen, how long does it take?
• What do you do with the patients while you wait?

10
Meanwhile back at the bladder

• Patient also has a UTI.
• General risk factors - nosocomial UTI
• Posture, hydration, urinary stasis
• Increased colonisation
• Catheterisation - MAJOR factor

11
UTI Reservoir of Infection

• Endogenous bowel flora.
• But the organism was a hospital bug
• Bowel flora is a dynamic entity
• reflects the microbial environment

12
Pathology Report

• Patient Dot Evans
• Specimen Catheter stream urine
• Culture Pseudomonas aeruginosa
• Ampicillin R Augmentin R
• Gentamicin S Cefotaxime S
• Pseudo is normal bowel flora but uncommon in
  UTIs in non hospital pts

13
Not a happy camper

• Empiric - flucloxacillin, ampicillin
• Spectacularly unsuccessful.
• Now on - vancomycin, cefotaxime.
• Showing renewed signs of sepsis
• ? ? pneumonia !! - ? ?septicaemia
• But we have fixed the broken hip !

14
Nosocomial pneumonia

• Types of organisms ?

15
Klebsiella pneumoniae
16
Extended spectrum B-lactamase
17
Noso pneumoniarisk factors

• Essential pre-requisite
• Nasopharyngeal colonisation
• Antibiotic therapy promotes this.
• Progression to infection
• Posture, aspiration
• Cough reflex
• Gastric bacterial overgrowth

18
The Demtel syndrome

• Broken hip
• Post op wound infection and UTI
• Flucloxacillin and ampicillin
• Vancomycin and cefotaxime
• Pneumonia - added imipenem

BUT WAIT, theres more!!
19
Blood cultures

• Collection issues
• Asepsis
• Timing
• volume

20
Positive blood culture

• Which organism and portal of entry?
• Klebsiella / pneumonia
• S.aureus / wound infection
• Pseudomonas / urinary tract infection
• Anything else?

• What about the venous catheter?

21
Central venous catheter
22
Central venous catheter
23
Colonised CVC
24
All part of the service

• Post op wound infection, UTI , pneumonia and
  septicaemia
• MRSA Pseudomonas Klebsiella
• Flucloxacillin, ampicillin, vancomycin and
  imipenem

INCREASED LENGTH OF STAY
25
Not surprisingly...

• . All this is giving Dot, the shits

• Nosocomial diarrhoea
• Most likely causative organism?
• Clostridium difficile
• Predisposing factors
• Most likely reservoir (problems)

26
Has anybody seen my bowel flora ?
27
Forget my bowel flora- check out my bowel?
28
Clostridium difficile treatment

• More antibiotics ?
• Vancomycin or metronidazole
• Re-populate the bowel
• Oral or enema with lactobacillus capsules
• ? Faecal enema

29
Hello,there Mrs Evans,now what have we been
doing to you then?

• Wound infection - cured that.
• Urinary tract infection - cured that.
• Pneumonia - cured that.
• Septicaemia - cured that.
• Diarrhoea - cured that.
• and what have you been doing?
• ooooh, just lying here Doctor

30
Lying there and pressure sores
31
Moral of the story..Pt 1

• One thing stood between Mrs Evans and a speedy
  uneventful recovery..
• Nosocomial infection (MRSA)
• and what got Mrs Evans and those nasty little
  bugs together?
• Grubby little hands

32
Moral of the story..Pt 2

• Flucloxacillin, ampicillin, vancomycin,
  cefotaxime, imipenem and an extra 6 weeks
  hospitalisation at 500 per day..
• or a 2 minute, 50 cent handwash.
• ITS YOUR CHOICE !