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o understand how infections can be transmitted by medical equipment, it is important to understand how infections are transmitted and by which routes. For an infection to occur, microorganisms must be transmitted from a reservoir (ie, the place where the microorganisms live and multiply). From the reservoir, there must be an acceptable entry site on a susceptible host, such as an open cut on an immunocompromised individual, and there must be a sufficient number of microorganisms that can cause an infection. In a healthcare setting, the reservoir of the microorganism may include patients, healthcare workers, soap dispensers, mechanical ventilators, tap water, multidose vials, intravenous (IV) devices, IV fluids, and other factors in the environment. The 5 mechanisms of transmission follow.
       Direct transmission. This is the transfer of an infection from another person or the environment. Examples of direct transmission routes include shaking hands, which can transmit the rhinovirus better known as the common cold; kissing, which can transmit mononucleosis; and droplet transmission (from coughing, sneezing), such as whooping cough or the flu.
       Vertical transmission. An example of this is the transfer of human immunodeficiency virus (HIV) or hepatitis B from a mother to the fetus. Infections can be transmitted through the birth canal or by breast milk.
       Indirect transmission. This is the most common mechanism of transferring infections. Hands of healthcare workers, toys, contaminated food or water, air, work surfaces, and medical devices have all been found to indirectly transfer infections. Water can act as a breeding ground for Pseudomonas. Toys shared in pediatric units can spread respiratory viruses, such as respiratory syncytial virus (RSV) or influenza. The Norwalk virus, which causes diarrhea, can survive in the environment and can easily transfer to susceptible individuals. Medical devices that have become contaminated with hepatitis B and C or HIV may become the source of infection for both the patient and the healthcare worker.
       Airborne transmission. This is another form of indirect transfer for infections. Droplet nuclei of the infected agent can stay suspended in the air for long periods of time. This is the main route of transmission for Mycobacterium tuberculosis, chicken pox and the measles. Aspergillus spp. and/or Legionella spp. can be transmitted through air-conditioning systems or respiratory humidification devices.
       Vector-borne transmission. Some examples of these include dengue fever, malaria, and West Nile virus. Vector-borne transmissions are infections transmitted to humans by insects like the mosquito.
       Infections caused by the use of medical devices have occurred in the healthcare setting across the continuum of care. Medical devices used in long-term care and home health that have been sources of infection include:
1. Contaminated solutions, including IV solutions
2. Enteral therapy
3. Indwelling catheters
4. Respiratory therapy
5. Pharmaceuticals, including multidose vials and parenteral medication.
       Any procedure done for diagnostic or treatment purposes that requires a break in skin integrity can cause an infection if proper aseptic technique is not adhered to. Let us look at medical devices used in long-term care and home care that can lead to infections.

The Effect of Indwelling Catheter Use

       The most common nosocomial infection in the long-term care arena is the urinary tract infection (UTI). This relates to the use of urinary catheters (urethral, suprapubic, or nephrostomy). It is estimated that 5–10% of residents in long-term care facilities have chronic indwelling catheters.^1,2 The daily incidence of new infections for residents is similar to that of residents with short-term catheters, about 3–7% per day.³ This means that anyone with an indwelling catheter in place for more than 30 days will be bacteriuric; the prevalence of bacteriuria in residents with chronic catheters is almost 100%.⁴ Residents with chronic indwelling catheters may experience:
1. Increased morbidity
2. Febrile infections 10 times more frequently
3. Bacteremia from a urine source 40 times more frequently
4. Episodes of gross hematuria from catheter trauma
5. Complications, including paraurethral abscesses, urethritis, epididymo-orchitis, or prostatic abscesses.^5–8
       Methods that have been studied to decrease infections in the catheterized residents include:
1. Aseptic insertion
2. Closed drainage systems
3. Individual drainage equipment
4. Unobstructed drainage
5. Antimicrobials for the first 4 days only.^9,10
       Methods that have not been proven efficacious are:
1. Routine perineal care with soap or disinfectant
2. Antibiotic irrigation
3. Disinfectants in the drainage tube or bag.
       The best way to prevent a catheter-related infection is to avoid the use of indwelling catheters. Catheters and tubing changes are only necessary if there is an obstruction in the flow of urine or leaking; routine replacement is not recommended.

Infections Related to Respiratory Therapy

       Pneumonia is the second most common nosocomial infection in the elderly. Patients on ventilators do not represent a major proportion of home care patients; there are a number of ventilated patients in long-term care facilities. Patients who require ventilators are between 6 and 21 times more at risk for acquiring pneumonia compared to nonventilated patients.¹¹
       A breach of a breathing circuit occurs each time the ventilator is disconnected from the patient’s tracheostomy tube for suctioning, to change circuits, or to empty condensate from ventilator circuits. Each time the circuit is breached, there is an increased risk for infection. The Centers for Disease Control and Prevention (CDC) recommends for the breathing circuit with a humidifier to not be changed routinely. The agency recommends the breathing circuit to be changed only when it is visibly soiled or mechanically malfunctioning.¹² The American Association of Respiratory Care (AARC)’s clinical practice guideline on long-term mechanical ventilation in the home recommends for ventilator circuits to not be changed more often than once each week.¹³ Home care staff should periodically drain and discard condensate that collects in the tubing of the ventilator. It is important to prevent backup of the condensate, which, if not handled properly, can cause patient aspiration.
       Suctioning of patients on mechanical ventilators can introduce microorganisms into the patients’ lower respiratory tract, causing pneumonia. There are currently 2 types of suction catheter systems on the market. The first one is the open, single-use catheter system, the second the closed, multiuse catheter system. There are no recommendations from CDC for the use of one system over the other. Many long-term care facilities have changed to the closed, multiuse catheter system to decrease the chances of introducing bacteria while suctioning. Home care organizations use different techniques. Some rinse the suction catheter after suctioning, store it to keep it dry, and replace it with a new sterile catheter every 8–24 hours; other agencies choose to soak, disinfect, and rinse catheters and reuse at the end of the day.
       Cleaning and disinfecting the inner tracheal cannula as well as respiratory equipment and supplies (eg, nebulizers) are also important factors in preventing lower respiratory tract infections and pneumonia in both long-term care and the home care patients. Nebulizers should be cleaned and disinfected between each use. Whenever possible, aerosolized medications should be used in single-dose vials. If multidose vials are used, the manufacturer’s recommendations should be followed for handling, storing, and dispensing the medications.
       Direct instillation of aerosolized-contaminated medications can cause lower respiratory tract infections. Both colonization and pneumonia caused by Klebsiella pneumoniae have resulted from the use of contaminated bottles of bronchodilator.¹⁴ The use of contaminated saline vials has been known to cause multiple outbreaks when used for intermittent positive pressure breathing (IPPB) treatments. Pneumonia and sepsis resulted from Serratia marcescens.¹⁵ Disposable saline squeeze vials used during suctioning are often found to be contaminated with coagulase-negative staphylococci, Staphylococcus aureus, streptococci, and enterococci.¹⁶ In some cases, the hands of nursing staff were found to be contaminated with the same microorganisms, leading to the conclusion that the contamination occurred during opening of the vials.

Infusion Therapy

       Another medical procedure that can cause infections in the long-term care and the home health setting is infusion therapy. Infusion therapy includes the peripheral venous catheter, midline catheter, and central venous catheter. Specific examples of a venous catheter include the nontunneled catheter, the peripherally inserted central catheter (PICC), tunneled central venous catheters, and implanted ports.
       To prevent central line-associated infections, strict adherence to hand hygiene and aseptic technique is a must. Other measures to reduce the risk of central line infections follow.
       Selecting an appropriate catheter-insertion site. This includes an assessment of the patient’s age, condition, and diagnosis; vein size and location; and the type and duration of infusion therapy.¹⁷
       Selecting the appropriate type of catheter. Catheter selection should be made on an individual basis with consideration of the insertion site with the lowest risk of complications (both infectious and noninfectious), the insertion technique, and the anticipated type and duration of infusion therapy.¹⁷
       Using barrier precautions during catheter insertion. Good handwashing and aseptic technique during the insertion of any intravenous catheter is necessary to protect against infections. According to the CDC, when inserting a PICC, maximal sterile-barrier precautions including a cap, mask, sterile gown, and sterile gloves, and a large sterile sheet is necessary.¹⁸
       Replacing peripheral IV access devices appropriately. The CDC recommends for peripheral catheters to be changed every 72–96 hours, while the Infusion Nurses Society recommends for peripheral catheters to be removed every 72 hours for adults to decrease the risk for phlebitis.^18,19
       Replacing administration sets. The CDC recommends for administration sets to be replaced at intervals of no more than 72 hours unless an infection is suspected.18 The Infusion Nurses Society recommends changing administration sets every 24 hours.¹⁹
       Replacing IV fluids. The CDC does not have a recommended frequency for IV fluid replacement. Infusions containing lipids must be completed within 24 hours of hang time. When lipid emulsions are given alone, the lipid infusion must be completed within 12 hours of hang time. Infusion of blood or blood products must be completed within 4 hours of hang time.¹⁸
       Maintain catheter site care. Skin cleaning and antisepsis of the insertion site are the most import measures in preventing central line-associated infections. Skin preparation can be done using 2% chlorhexidine (which is preferred), tincture of iodine, an iodophor, or 70% alcohol.¹⁹
       In-line filters. There are no data to suggest that in-line filters prevent infections associated with IV access devices.
       Insertion by experienced staff. Only qualified and highly trained staff should be inserting IV access devices.
       Flushing the IV catheter. Whether to flush lines with anticoagulants and/or normal saline depends on the type of line placed.

Infections and Multidose Vials

       Numerous studies have been done related to bacterial contamination of multidose vials. Information obtained from these studies has shown bacterial contamination rates to be between 0% and 27%.²⁰ For this reason, single-dose vials should be used for parenteral additives or medications whenever possible.¹⁸ If multidose vials are used, they should be refrigerated after opening. Most facilities require for multidose vials to be dated and discarded 30 days after opening. The manufacturer’s recommendations for both storage and expiration dating should be followed. These recommendations apply only to properly stored, unopened, or unentered containers.²¹

Nosocomial Infections Associated With Hydrotherapy

       Various outbreaks have been reported in the use of hydrotherapy. Its tanks may be contaminated with bacteria from patients being treated and serve as a reservoir for colonization of other patients. Outbreaks have been attributed to Pseudomonas, Staphylococcus aureus, and Enterobacter. Following manufacturer’s recommendations for cleaning and disinfecting hydrotherapy equipment before each patient is important.

Conclusion

       It is essential to understand that any medical device used in long-term care facilities and/or home care has the potential to cause infections if not used, stored, cleaned, and disinfected properly. Strict aseptic techniques must be adhered to in these settings. Manufacturer’s recommendations for the use, cleaning, and disinfecting of equipment are very important to assure the integrity of the device as well as decrease the risk of infection to patients. A well-run infection control program and proper staff training will keep everyone safe and infection-free.