The Science of Nosocomial Infections
Introduction
Dear readers,
Let me welcome you to the November edition of Science! Monthly. In November, our main concern in EPSA is raising awareness about antimicrobial resistance (AMR) and its disastrous consequences on public health. For that, we celebrate the AMR week from the 18th to the 24th of this month.
In this issue, we will tackle the topic of nosocomial infections, infections that appear in clinical settings, such as hospitals, and sometimes can be fatal.
First, we will count the history of those infections. Have you ever thought of medical care in the Mediaeval Times? When did the first nosocomial infection appear? If you are excited to know the answer, you will find it in the first article.
Countless microorganisms circulate in hospitals’ environments and can lead to lifethreatening infections, such as blood and respiratory ones. The most alarming ones are addressed and discussed in the second article.
In the third part of this edition, we will touch upon the infections associated with the use of ventilators; this is a crucial topic, mainly because of the excessive use of ventilators we witnessed during the COVID 19 pandemic.
In the last article, you will learn about one of the most endangered groups to catch a hospital infection. Do not miss this article if you are excited to discover this group of patients and the science behind their weak immunity.
Lastly, more editions of S!M are on the way carrying fascinating topics from highly motivated European students. You can be one of those students and share your interest in being an author of S!M over this email address science@epsa online.org
Enjoy reading,
Science Coordinator 2022-2023
Blast from the past – historical nosocomial infections
Nosocomial infections are a huge problem in modern hospitals. However, how common were they in the past? Every visit to a hospital meant a risk of getting an infection, both for young and elderly patients. Now, we are lucky that medical staff do their best to avoid the spread of contagious diseases, and without a doubt, every medical student learns about asepsis, disinfection, and sterilisation. For the common good of patients, medical workers must be familiar with these procedures. However, could medical staff from the past be aware of them too? For example, do mediaeval doctors work on sterilising their instruments as it is in these days?
Nosocomial patient zero
Nosocomial infections are infections that develop during or after a patient’s stay in the hospital. However, when was the first nosocomial infection? Probably when the first hospital appeared! When was it? It is hard to affirm, but the first surgical procedures we have evidence of took place in the Neolithic period in France, 6500 BCE. Forty trephined skulls were found together in one archaeological site. Some of them showed signs of healing. That begs the question: were there a place assigned for patients to spend their post operative time? Trephination, an old surgical procedure that implies removing a circular piece of the bone, commonly the skull, was also performed in the Cusco region. In that region, archaeologists discovered caves suspected to be hospitals due to their flat surface and shape close to hospital rooms nowadays. That gave evidence of surgeries performed there.
Nonetheless, researchers disagree about where the first "real" hospital was built, a place dedicated to treating patients as in modern hospitals. Some believe that Mesopotamia was the first place, while others opt for Buddhist monasteries in India and present-day Sri Lanka. Ancient writings indicate that hospitals were built in present day Sri Lanka in the 4th century BCE; however, the oldest architectural evidence of a hospital appears to be dated to the 9th century AD1 .
Mediaeval hospitals the deadliest place for patients
Mediaeval hospitals were religious institutions. That explains why the spread of Christianity implied the dissemination of public healthcare1,2. Another cause of the increased number of hospitals was the need to isolate people suffering from leprosy. During the Middle Ages, hospitals were hazardous as the number of hospital infections and associated death rates were high. Diseases such as smallpox, one of the most common mediaeval nosocomial infections, hospital fever (louse-borne typhus), typhoid, and dysentery were spreading quickly, infecting and killing patients.
Touching upon the question from the introduction: did mediaeval physicians sterilise their medical tools? The answer is no, as primitive surgical instruments with no asepsis were used. Surprisingly, not only surgeons used to operate during the mediaeval era, but barbers also used to do it. The absence of basic hygiene and unsanitary conditions caused appallingly high mortality rates, as 60% 80% of patients were dying of postoperative hospital gangrene. Mediaeval wards were overcrowded, with the medical staff decimated by the plague.
Moreover, unsanitary conditions resulted from the lack of clean sheets and mattresses cleaned annually at best. It was common for dead patients to be left in beds for 24
hours or longer with alive people next to them3. Therefore, no wonder why nosocomial infections were so ordinary.
Modern and progressive Era
In the modern era, healthcare was still insufficient; however, the mortality rate became 25% lower than in the Middle Ages. Smallpox remained one of the most lethal nosocomial diseases, as did yellow fever, cholera, dysentery, and typhoid fever. Hospitals were religious institutions; however, some became under the government's responsibility. Even so, wards were still overcrowded and unsanitary. Also, one bed was occupied by a few patients.
Contagious diseases were dangerous, especially for soldiers, because they caused more deaths than in any battle. Soldiers weakened by wounds got infected instantly. One of the groups with the highest mortality rates was women who underwent caesarean sections, as death from sepsis was very common among them.
In the 19th and 20th centuries, things started to go in the right direction as mortality rates dropped in many hospitals3. The decline resulted from increased awareness. One of the persons worth mentioning here is the Hungarian doctor Ignaz Semmelweis (figure 1.1). He is considered the father of asepsis and the first person to consider hand washing for medical staff. He based his idea on a comparison between maternity wards where doctors rarely washed their hands or instruments between operations and ones where midwives delivered the babies. He found that mortality rates were higher in the first case among previously healthy women4
The fundamental understanding of hospital infections is owed to Louis Pasteur, Robert Koch, and Joseph Lister. Pasteur came up with the idea that microorganisms spread through the body and cause infections. Inspired by this theory, Lister proposed performing operations in aseptic conditions by washing hands, disinfecting, and cleaning surgical instruments. Koch proved conclusively that germs are the cause of infectious diseases. He also showed that dry heat and steam sterilisation are effective in preventing the growth of bacteria.
However, Florence Nightingale (Figure 1.2) was the one who managed to persuade the government to reform health. In her book Notes on Hospitals (1859), she used statistical evidence to demonstrate that most of the soldiers during the Crimean War died from infection, not wounds themselves. Her actions improved hygiene standards in hospitals 2,3,5
Another significant development in avoiding hospital infections took place after World War II. Surgical techniques and equipment were getting more and more advanced. Also, new infection control programs focused on environmental cleanliness were established. Malaria was a common infection found in hospital wards, and pacific veterans were usually infected during World War II. Other diseases were, for example, smallpox, pneumonia, sepsis, influenza, scarlet fever, and dysentery3 .
In conclusion, patients have been suffering from contagious hospital diseases since the first hospital was established; however, the risk of getting infected with nosocomial infection has progressively declined throughout the ages. Current effective methods of preventing such diseases result from observations and research made only in the 19th and 20th centuries. The death rate from nosocomial infections in the past was dreadful. Nowadays, hygiene and asepsis in hospitals are apparent, and shockingly, there was not the slightest knowledge of them in the past. We should better appreciate that we live in a time when the hospital is a chance of cure, not a death sentence!
The most dangerous nosocomial infections
Failure to maintain proper hygiene and cleanliness in medical facilities poses a threat to patients. People under medical care are all exposed to nosocomial infections (hospital acquired infections HAI). Still, the higher risk group includes young children, immunocompromised people, the elderly, and people undergoing more extended hospitalisation. For the above groups of patients, the appearance of infection can lead to severe complications and even death1,2. The Center for Disease Control and Prevention (CDC) reports that only in the USA hospitals, 1.7 million infections occur yearly, and about 99.000 are associated with patient death2
HAIs and the corresponding infectious agents are categorised as follows:
1- Central line-associated bloodstream infection (CLABSI): CLABSIs are linked to using central vein catheters, for example, to carry out total parenteral nutrition (TPN) or to administer high doses of drugs directly into the blood1,3 Failure to comply with the rules of sterility causes microbes to enter the bloodstream through the catheter, quickly proliferating and moving throughout the body in large quantities. Bloodstream infections have the highest mortality rate among hospitalised patients1,4,5 .
The microorganisms that most commonly cause CLABSI are:
Escherichia coli
Enterococcus faecium
Staphylococcus aureus Coagulase negative Staphylococci Candida spp. Streptococcus spp 5,6,7
2- Ventilator-associated Pneumonia (VAP) VAP occurs in patients intubated endotracheally for more than 48 hours. An increased rate of death from bacterial pneumonia was observed. A mechanical respirator that forces air into the patient's lungs can cause pathogens from the mouth and throat flora to flow into the lower respiratory tract. Ventilator-associated Pneumonia is the deadliest nosocomial infection after blood infections. It is caused by the increasing number of bacteria resistant to the antibiotics used for VAP treatment, such as cephalosporins, vancomycin, and linezolid. In general, microorganisms responsible for VAP are:
Pseudomonas aeruginosa
Acinetobacter baumannii
Enterobacteriaceae, such as Klebsiella pneumonia
Staphylococcus aureus - Candida spp.
Streptococcus pneumoniae1,4, 5,8,9
3- Surgical site infections: Infections at the operation site are associated with the lack of sterility and asepsis during surgery. These infections most often come from a patient's endogenous flora or the operating room (infected surgical instruments, hands of surgeons, airborne
particles) 10,11,12,13. Unfortunately, among these microorganisms, increased resistance to commonly used antibiotics has been observed1. In the USA, 39% to 51% of the bacteria responsible for infections in wounds and operated areas are resistant to commonly used antibiotics14. The occurrence of post operative infections may be caused by the following:
Pseudomonas aeruginosa
Staphylococcus aureus - Enterococcus spp. Streptococcus pyogenes11,15
4- Catheter-associated urinary tract infections (CAUTI) They are the most common group of nosocomial infections, associated mainly with too long use of urinary catheters. Bacteria, usually opportunistic, with the help of biofilm (multicellular aggregates of bacteria immersed in an extracellular matrix with strong adhesive properties), move from the body's surface into the depth of the catheter, causing urinary tract infections. Although the percentage of mortality from urinary tract infections is lower than that of other nosocomial infections, the appearance of multidrug resistant bacteria (MDRs) can lead to bacteraemia and death1,4,16. The most commonly diagnosed bacteria in CAUTI infections are:
Escherichia coli
Pseudomonas aeruginosa
Klebsiella pneumoniae and Klebsiella oxytoca
Proteus mirabilis
Staphylococcus aureus Enterococcus spp.5,16,17 .
5- Infections caused by Clostridium difficile Clostridium difficile is an anaerobic Gram positive bacillus and the leading cause of hospital gastroenteritis in adults18,19. Infection occurs due to prolonged antibiotic therapy, as the patient's natural gut bacteria are destroyed, giving space for the development of C. difficile, which, by producing toxins, damages colon tissues and can cause deadly diarrhoea. Additionally, spores can stay on objects, surfaces, and other materials in the medical centre even for years, making bacteria resistant to disinfection4,19
Multi-drug resistant bacteria and severe hospital infections As aforementioned, bacteria are the most common pathogens responsible for nosocomial infections. They can come from the natural microbial flora or be pathogenic microorganisms. However, the greatest threat to the health and life of patients is nosocomial infections caused by multidrug-resistant bacteria (MDR)1. MDR can develop in the hospital environment due to non compliance with sanitary rules and excessive or improper use of broad spectrum antibiotics. This is undoubtedly a serious threat to public health, especially in high risk patients. MDR bacteria are very difficult to treat, and the lack of new antibiotics facilitates the transmission of pathogens to other patients within a hospital ward or an entire medical facility20 .
In 2017, the World Health Organization (WHO) published the first catalogue of antibiotic resistant bacteria that proclaimed the greatest threat to human health and
life. They were divided into three groups according to the demand for new antibiotics for given bacteria (from priority 1: critical to priority 3: the medium need for new antibiotics). Among them, there are bacteria responsible for the most dangerous nosocomial infections (coloured)21 .
a. Priority 1 bacteria: CRITICAL
o Acinetobacter baumannii, carbapenem resistant
o Pseudomonas aeruginosa, carbapenem resistant
o Enterobacteriaceae, carbapenem-resistant, extended-spectrum β-lactamase ESβL producing
b. Priority 2 bacteria: HIGH
o Enterococcus faecium, vancomycin-resistant
o Staphylococcus aureus, methicillin resistant, vancomycin intermediate, vancomycin resistant
o Helicobacter pylori, clarithromycin resistant
o Campylobacter spp., fluoroquinolone resistant
o Salmonellae, fluoroquinolone-resistant
o Neisseria gonorrhoeae, cephalosporin resistant, fluoroquinolone resistant
c. Priority 3 bacteria: MEDIUM
o Streptococcus pneumoniae, penicillin-non-susceptible (resistant or not completely susceptible)
o Haemophilus influenzae, ampicillin-resistant
o Shigella spp., fluoroquinolone resistant21
Conclusion
The most dangerous nosocomial infections are those caused by multidrug resistant bacteria, especially from the “critical priority group”, associated with the excessive use of antibiotic therapy such as C. difficile. Mortality is also influenced by the risk group to which the patient belongs, such as elderly or long term hospitalised patients1,21 . To reduce the number of deaths in medical facilities caused by nosocomial infections, hygiene and sterility guidelines should be followed without a doubt. In addition, appropriate use of antibiotics should be ensured (selecting the correct antibiotics and the appropriate doses) to minimise the risk of resistance20
Ventilator-associated pneumonia
Resistance to antibiotics is an ongoing health problem and a challenge in healthcare settings. Infections caused by resistant bacteria can be devastating, especially in weak patients whose treatment in intensive care units is a long term process and often requires antibiotics intake. However, the use of antibiotics should always be justified and fitted to the specific case. Unfortunately, this is not the case nowadays as, according to the World Health Organisation (WHO), we are endangered by increased healthcare costs and death rates due to ineffective antimicrobial therapy1. Ventilator associated pneumonia (VAP) is one of the main concerns of many health experts. VAP is defined as a pulmonary infection in patients exposed to invasive mechanical ventilation for at least 48 hours2. It results from the invasion of the lower respiratory tract by microbes that may be resistant to many antimicrobials. This growing problem requires modern solutions as healthcare experts consider that one single measure is not enough and believe that a successful prevention program should use a combination of multiple interventions. In this article, we will take a closer look at them.
The hidden threat No wonder patients need additional protection in hospitals despite the comprehensive care provided by the medical staff. Many invasive procedures performed during a patient's hospitalisation pose additional risks to patients’ immune systems. Mechanical ventilation with endotracheal intubation (figure 3.1) is introducing a tube in the trachea through the mouse or nose to allow airflow to the lungs; this tube is typically associated with a ventilator, a machine used to deliver air to the lungs3
Figure 3.1 Mechanical ventilation with endotracheal intubation
The endotracheal tube binds the ventilator to the airways. This tube can be a source of dangerous bacteria because4,5
1. It allows air aspiration from the mouse, oropharynx, nose, sinuses, and pharynx to the lungs. Those cavities are considered reservoirs of infective microorganisms that can move and colonise the lung.
2. The tube’s surface is considered a suitable environment for the growth of bacterial biofilms. Air flowing from the ventilator helps in moving biofilm parts to the lungs.
3. This process also leads to the violation of natural defence mechanisms such as intact cough reflex and mucociliary clearance6. That, in turn, implies more predisposition to infections7 .
The most common pathogens that lead to VAP are Pseudomonas aeruginosa, methicillin-sensitive Staphylococcus aureus (S.aureus), and methicillin-resistant S. aureus. Other microbes include enteric gram negative bacteria, such as Enterobacter species. Klebsiella pneumoniae and Escherichia coli are also mentioned as potential infectious agents8
The unequal battle Intensive care units are more frequently associated with geriatric patients with organ failure, not young ones. It is noteworthy that paediatric patients have underdeveloped immune systems that cannot protect children from hospital infections while the whole organism tries to regain functionality. In addition, it is essential to consider and be aware of groups’ diversity. There are fundamental differences between the organism of a newborn and a 12 year old, so when it comes to preparing guidelines in medicine, using a universal treatment regimen is not recommended at all.
Risk factors of VAP in children do not differ significantly from those in adults. Prolonged exposure to inappropriate antibiotic therapy, often used prophylactically, increases the risk of antibiotic resistance 9 That, in turn, increases morbidity and mortality among patients. The problem of antibiotic resistance seems crucial, as the absence of an effective antibiotic worsens patients’ prognosis. However, some factors are not so obvious and can still be very important. For example, the low availability of ventilator beds in paediatric care units often leads to increased transport, manual ventilation, or transfer to the general ward. Furthermore, unplanned intubation often poses a risk of infection2
Better protect than cure Any intubated patient is at risk of developing VAP. Some factors decrease the risk of those infections, such as4,5
1. Shortening the ventilation periods, as shortening the mechanical ventilation time would help in reducing the chances of infections. Waning trials can help and imply interrupting the ventilator’s support and allowing the patient to breathe in a more significant proportion.
2. Performing early tracheostomy (figure 3.2). Tracheostomy is a medical procedure involving placing a tube in a hole created from the front neck to the trachea to help patients breathe. Tracheostomy leads to less need for mechanical ventilation. In addition, it helps in cleaning the air path from secretions that can carry different infectious agents.
Figure 3.2 Tracheostomy tube placed in the tracheostomy hole
3. Reducing the spread of bacteria in hospital wards. Education is critical, and all healthcare professionals should actively participate in VAP prevention. Experts emphasise the impact of reducing person to person transmission of bacteria, which simple actions like appropriate hand washing can improve. Oral care and removal of subglottic secretions are also mentioned as preventive measures10
Conclusion
VAP is the second most common nosocomial infections among intensive care unit patients11. Nevertheless, the issue may seem to be removed from our daily lives or interests. Unfortunately, antibiotic resistance has a direct impact on the described risks. Therefore, more specialised drugs, targeted therapies and more consistent and precise approaches to diagnosing VAP are needed. Every mentioned intervention is more likely to be successful when it results from a multimodal strategy. The influence of a multidisciplinary team is invaluable. For instance, researchers often emphasise the role of nurses12, who have the most frequent contact with patients. Still pharmacists can also have an essential role in developing new strategies to fight against antibiotic resistance. It is worthwhile to share our knowledge and educate others for common safety.
Author: Zuzanna Wójcik Nicolaus Copernicus University in Torun, Poland; 4th year pharmacy student, PPSA Poland
Post-transplant Nosocomial Infections
Infectious pathogens have always afflicted humans. As science progressed through the years, more attention was drawn to the study of infectious diseases. There are now continuous efforts to minimise them through practices such as sterilisation and rules to ensure proper hygiene. Nevertheless, total elimination is unfeasible, especially in hospitals and clinics where regardless of the regular cleaning, the number of daily patients and visitors makes the goal of zero contamination unattainable. Infections acquired in a healthcare environment, such as a hospital or a clinic, fall under the term nosocomial infections1 .
Infections and organ transplantations
Infections are caused by microorganisms such as viruses, fungi, and bacteria. Some typical hospital acquired infections are catheter associated bloodstream or urinary tract infections (CRBSI, CRUTI, respectively), ventilator associated pneumonia, and surgery associated infections often seen in organ transplantation cases2,3 Transplantation is a therapeutic practice in which organs are surgically transferred from a living or dead donor to a chronically ill patient to restore the function of an organ in a state of insufficiency. In the modern era, techniques are constantly improving Therefore more organs, tissues, and cell transplants are possible, given that the most frequent ones are heart, kidney, liver, and lung transplants4 .
What causes nosocomial infections?
Immunosuppressants prescribed after organ transplantations weaken the immune system’s fight against the new organ to prevent possible rejection. Because of immunosuppressants, the body becomes prone to pathogenic infections, making it easy for harmful microorganisms to threaten its well being5. After an organ transplant, it takes around 3 to 12 months for the immune system to recover6 . Besides the effects of immunosuppressants on the patient’s immune system, the repeated use of surgical items, which can be contaminated easily, and the post operation environment, often consisting of catheter use and ventilators, raise the possibility of infections. In these cases, the infection can lead to a more extended stay in the hospital, rejection of the graft and, in extreme cases, even death.
Prevention of nosocomial infections
Prevention of nosocomial infections in general, and post transplantation ones in particular, can be achieved by implementing certain practices.
First, proper disinfection of the skin and the equipment used during medical procedures should always be mandatory, as well as the use of protective masks and gloves. Additionally, a significant factor is the controlled use of pharmaceuticals pre- and postoperation7. For example, antibiotics are often prescribed in erroneous doses due to their developed bacterial resistance and subsequently limited effectiveness in fighting the microorganisms8. Another example of poor use of medicines can be found in immunosuppressants and corticosteroids that weaken the immune system and subsequently expose the body to infectious factors. The use of these substances ought to be limited to the minimum amount to ensure both their function and the lowest possible impact on the person’s immune system9. Finally, proper post-operative care is of great significance since regular catheter change, disinfection, and in general, the
maintenance of a clean environment for the patient can be crucial to the outcome of the treatment10 .
Nosocomial infections in lung transplantation
Lung transplantations refer to replacing a failing lung with a functioning healthy one. Lung transplant procedures can be categorised into single lung, double lung, bilateral, and heart lung. After such a procedure, the vulnerability of the respiratory system increases, and infections caused by respiratory viruses, as well as infections attacking the oral area, such as herpes and oral yeast infection (thrush), become frequent. Despite being harmless, thrush can cause much discomfort to patients and can be challenging to control, especially in patients with a weakened immune system11. After lung transplantation, according to a study conducted from 2016 to 2020, including 107 recipients, around 75% of the patients acquired an infection. The most common bacteria amongst the microorganisms responsible for the infections were Gram negative bacteria (highly resistant to antibiotics), including Acinetobacter baumannii, which poses a threat to the respiratory system, urinary tract, blood, and wounds and Klebsiella pneumoniae12.In general, even though bacterial infections are the most common after lung transplantation, fungal ones are more feared since they are highly associated with bronchial problems. The bronchi are part of the foundation of lung functionality, and their damage in some cases can lead to fatality13 . Some common fungal infections in organ transplant patients are invasive candidiasis, aspergillosis and cryptococcosis. In lung transplantation patients, the most common one is aspergillosis14
Nosocomial infections in heart transplantations
As for heart transplants, they are becoming more and more widespread, with 50,000 patients worldwide on the waiting list and approximately 5,500 transplants per year15 . Most of the post operative infections are caused by bacteria and are related to catheter use and open wounds. Some nosocomial bacteria responsible for the infections are Legionella pneumophila, Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae, and Escherichia coli16,17. In some cases, simultaneous heart lung transplantations are performed. The possibility of hospital acquired infection for these patients is increased, with the fungus Pneumocystis carinii and Pseudomonas aeruginosa being amongst the most common pathogenic microorganisms affecting patients. They mainly cause problems in the respiratory system, such as chronic sputum production and bronchial colonisation, which require Intravenous antibiotics18 .
Nosocomial infections in kidney transplantation
The most common type of transplant is that of the kidneys as end-stage chronic kidney disease patients undergo transplantation to survive and improve life quality19 Transplanted individuals suffer mainly from bacterial infections. Bacteria like Staphylococcus aureus, Streptococcus pneumonia, Haemophilus influenzae and Mycoplasma hominis take advantage of the weakened immune system to target the host causing pneumonia. Prompt diagnosis becomes imperative because delay in administering appropriate medication and medical care leads to morbidity and even mortality20 .
Conclusion
Concluding, the field of organ transplantation has progressed a lot since the first successful transplantation in 1954. However, infections continue to pose a threat to patients to this day. While many transplantations are performed successfully without the rejection of the transplant, failure comes after the acquisition of infections with dreadful consequences.
References:
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Infographic 3:
[1] Foglia, E., Meier, M. D., & Elward, A. (2007). Ventilator-Associated Pneumonia in Neonatal and Pediatric Intensive Care Unit Patients. Clinical Microbiology Reviews, 20(3), 409 425. https://doi.org/10.1128/CMR.00041 06
[2] Amanati, A., Karimi, A., Fahimzad, A., Shamshiri, A. R., Fallah, F., Mahdavi, A., & Talebian, M. (2017). Incidence of Ventilator Associated Pneumonia in Critically Ill Children Undergoing Mechanical Ventilation in Pediatric Intensive Care Unit. Children, 4(7), 56. https://doi.org/10.3390/children4070056
Article 3:
[1] Papazian, L., Klompas, M., & Luyt, C.-E. (2020). Ventilator-associated pneumonia in adults: A narrative review. Intensive Care Medicine, 46(5), 888 906. https://doi.org/10.1007/s00134 020 05980 0
[2] Kumar, V. (2018). Ventilator Associated Pneumonia in Children: Current Status and Future Prospects. The Indian Journal of Pediatrics, 85(10), 830 831. https://doi.org/10.1007/s12098-018-2783-0
[3] Hunter, J. D. (2006). Ventilator associated pneumonia. Postgraduate Medical Journal, 82(965), 172 178. https://doi.org/10.1136/pgmj.2005.036905
[4] Kalanuria, A. A., Zai, W., & Mirski, M. (2014). Ventilator associated pneumonia in the ICU. Critical Care, 18(2), 208. https://doi.org/10.1186/cc13775
[5] Ventilator-Associated Pneumonia Pulmonary Disorders. (n.d.). MSD Manual Professional Edition. Retrieved 6 November 2022, from https://www.msdmanuals.com/professional/pulmonary disorders/pneumonia/ventilator associated pneumonia
[6] Wu, D., Wu, C., Zhang, S., & Zhong, Y. (2019). Risk Factors of Ventilator Associated Pneumonia in Critically III Patients. Frontiers in Pharmacology, 10, 482. https://doi.org/10.3389/fphar.2019.00482
[7] Keyt, H., Faverio, P., & Restrepo, M. I. (2014). Prevention of ventilator associated pneumonia in the intensive care unit: A review of the clinically relevant recent advancements. The Indian Journal of Medical Research, 139(6), 814 821.
[8] Shan, L., Hao, P., Xu, F., & Chen, Y. G. (2013). Benefits of Early Tracheotomy: A Meta-analysis Based on 6 Observational Studies. Respiratory Care, 58(11), 1856 1862. https://doi.org/10.4187/respcare.02413
[9] Foglia, E., Meier, M. D., & Elward, A. (2007). Ventilator Associated Pneumonia in Neonatal and Pediatric Intensive Care Unit Patients. Clinical Microbiology Reviews, 20(3), 409 425. https://doi.org/10.1128/CMR.00041 06
[10] Ventilator Associated Pneumonia and Role of Nurses in Its Prevention PubMed. (n.d.). Retrieved 15 November 2022, from https://pubmed.ncbi.nlm.nih.gov/29453481/
Infographic and article 4:
[1] Sikora, A. & Zahra, F. (2022, Sept. 23). Nosocomial Infections. StatPearls Publishing, Treasure Island (FL) https://www.ncbi.nlm.nih.gov/books/NBK559312/ [2] Liu, Jia Yia., & Dickter, Jana K. (2020). Nosocomial Infections: A History of Hospital Acquired Infections. Gastrointestinal Endoscopy Clinics of North America, 30(4), 637 652. https://doi.org/10.1016/j.giec.2020.06.001
[3] Dorschner, P., McElroy, L. M., Ison, M. G. (2014). Nosocomial infections within the first month of solid organ transplantation. Transplant Infectious Disease, 16(2), 171 187. https://doi.org/10.1111/tid.12203
[4] Antonakopoulos, N., Transplantation, Novartis https://www.novartis.gr/ourwork/therapeutic areas/transplant
[5] Infection After Transplant, (2019), Cleveland Clinic https://my.clevelandclinic.org/health/articles/21123 infection after transplant
[6] Returning Home After Your Autologeous Stem Cell Transplant, (2022), Memorial Sloan Kettering Cancer Centre https://www.mskcc.org/cancer care/patient education/returning home after your autologous-stem-cell-transplant
[7] Haque, Mainul., McKimm, Judy., Sartelli, Massimo., Dhingra, Sameer., Labricciosa, Francesco M., Islam, Salequl., Jahan, Dilshad., Nusrat, Tanzina., Chowdhury, Tajkera Sultana., Coccolini, Federico., Iskandar, Katia., Catena, Fausto., Charan, Jaykaran. (2020). Strategies to Prevent Healthcare Associated Infections: A Narrative Overview. Risk Management and Healthcare Policy, 2020(13), 1765 1780 https://doi.org/10.2147/RMHP.S269315
[8] Barshes, Neal R., Goodpastor, Sarah E., Goss, John A. (2004). Pharmacologic Immunosuppression. Frontiers in Bioscience 9, 411-420 https://article.imrpress.com/bri/Landmark/articles/pdf/Landmark1249.pdf
[9] What is a Nosocomial Infection?, (2021). Web MD https://www.webmd.com/a-to-zguides/what is a nosocomial infection
[10] Lung transplant, John Hopkins Medicine https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/lungtransplant
[11] Oral thrush, Mayo Clinic https://www.mayoclinic.org/diseases conditions/oral thrush/symptoms causes/syc 20353533
[12] Meng, Die., Chang, Rui., Zhu, Ren., (2022). Analysis of nosocomial infection and risk factors in lung transplant patients: a case-control study. Annals Of Translational Medicine, 14(10), 804 https://doi.org/10.21037%2Fatm 22 3023
[13] Nosotti, Mario., Tarsia, Paolo., Morlacchi, Letizia Corinna. (2018). Infections after lung transplantation. Journal Of Thoracic Disease, 10(6), 3849 3868 https://doi.org/10.21037%2Fjtd.2018.05.204
[14] Organ Transplant Patients and Fungal Infections, (2020), Centers For Disease Control and Prevention https://www.cdc.gov/fungal/infections/organ-transplant.html
[15] Kim, In Cheol., Youn, Jong Chan., Kobashigawa, Jon A. The Past, Present and Future of Heart Transplantation, Korean Circulation Journal 2018, 48(7) 565 590 https://doi.org/10.4070/kcj.2018.0189
[16] M.Jordan, Andrew., Tatum, Robert., Ahmad, Danial., Patel, Sonali V., Maynes, Elizabeth J., Weber, Matthew P., Moss, Sean., Royer,Tricia L., Tchantchaleishvilia, Vakhtang., Massey, H. Todd., Rame, J. Eduardo., Zurlo, John J., Aburjania, Nana. (2022). Infective endocarditis following heart transplantation: A systematic review. Transplantation Reviews, 36(1) https://doi.org/10.1016/j.trre.2021.100672
[17] Eisen, Howard J. Patient education: Heart transplantation (Beyond the Basics), (2021) Up To Date https://www.uptodate.com/contents/heart-transplantation-beyondthe basics
[18] Dummer JS, Montero CG, Griffith BP, Hardesty RL, Paradis IL, Ho M, (1986), Infections in heart lung transplant recipients., Transplantation Journal, 41(6), 725 729 https://doi.org/10.1097/00007890 198606000 00012
[19] Saleh, Naveed. Top 6 Single-Organ Transplants, (2021) Very Well Health https://www.verywellhealth.com/common single organ transplants 4082949
[20] Wilmes, D., Coche, E., Rodriguez Villalobos, H., Kanaan, N. Bacterial pneumonia in kidney transplant recipients (2018). Respiratory Medicine Journal, 137(2018), 89-94 https://doi.org/10.1016/j.rmed.2018.02.022
Multiple-choice questions
1. Which fungal infection is the most common in lung transplant patients?
a) Aspergillosis
b) Candidiasis c) Cryptococcosis d) Pneumocystis pneumonia
2. Which of the following is the most common organ transplant?
a) Heart Transplantation b) Kidney Transplantation c) Lung Transplantation d) Heart Lung Transplantation
3. Immunosuppressants:
a) Weaken the immune system and raise the possibility of transplant rejection b) Strengthen the immune system and increase the possibility of transplant acceptance
c) Weaken the immune system and raise the possibility of transplant rejection d) None of the above
4. Ignaz Semmelweis:
a) Came with the idea that microorganisms spread through the body and cause infections.
b) Persuaded the government to reform health by using statistical evidence in which he demonstrated that most of the soldiers during the war died from infection, not wounds.
c) Was the first person to consider hand-washing for medical staff.
d) Compared maternity wards where doctors delivered babies to those where midwives were responsible for parturition. e) c and d
5. During World War II, common nosocomial infection(s) were: a) Malaria b) Smallpox c) Pneumonia d) Scarlet fever e) All of the above
6. The nosocomial infections with the highest mortality rate among hospitalised patients are: a) CAUTI b) Surgical site infections c) VAP d) CLABSI
7. Bacteria usually responsible for surgical site infections are: a) Pseudomonas aeruginosa b) Acinetobacter baumanii c) Escherichia coli d) Staphylococcus aureus e) a and d
8. Which of the following sentences is correct about tracheostomy: a) Tracheostomy implies inserting a tube into the trachea through the neck b) Tracheostomy implies inserting a tube into the trachea through the nose c) Tracheostomy implies inserting a tube into the trachea through the mouse d) Tracheostomy increases the risk of VAP e) All of the above
Answers: A, B, D, E, E, D, E, A
Images: Figure 1.1 Retrieved from the Encyclopedia Britannica https://www.britannica.com/science/puerperal fever
Figure 1.2 Retrieved from the Encyclopedia Britannica https://www.britannica.com/biography/Florence Nightingale
Figure 3.1 Retrieved from the National Heart, Lung, and Blood Institute https://www.nhlbi.nih.gov/health/ventilator
Figure 3.2 Retrieved from the National Heart, Lung, and Blood Institute https://www.nhlbi.nih.gov/health/respiratory failure/treatment
Front page image: Retrieved from Canva