, Infection Control in ICU's

8/3/2019 , Infection Control in ICU's

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Dr.T.V.Rao MD

ICU INFECTIONSBASIS, DIAGNOSIS, AND PREVENTION

DR.T.V.RAO MD 1


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DEFINITIONS

NOSOCOMIAL INFECTION :

An infection acquired in a patient in a

hospital or other healthcare facility inwhom it was not present or incubatingat the time of admission or the residual

of an infection acquired during aprevious admission.

DR.T.V.RAO MD 2


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Nosocomial infectionshave been recognizedfor over a century as a

critical problemaffecting the quality ofhealth care and aprincipal source ofadverse healthcare

outcomes.

BACKGROUND OF

HOSPITAL INFECTIONS

DR.T.V.RAO MD 3


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RISK OF INFECTIONS IN ICU

Patients hospitalized in ICUsare 5 to 10 times

more likely to acquire nosocomial infections

than other hospital patients. The frequency ofinfections at different anatomic sites and the risk ofinfection vary by the type of ICU, and the frequency

of specific pathogens varies by infection site.

Contributing to the seriousness of nosocomial

infections, especially in ICUs, is the increasing

incidence of infections caused by antibiotic-

resistant pathogens

DR.T.V.RAO MD 4


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And why do they come to the ICU

Ventilator support respiratory failure pneumonia

Hemodynamic support shock

Renal replacement therapy renal failure, severe acidosis

Monitoring, Neurological dysfunction, Hematologic

WHY ONE MAY BE IN ICU

WITH

DR.T.V.RAO MD 5


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ICU : FACTORS THAT INCREASE CROSS-INFECTIONS

Lack of Hand washing facilities

Patient close together or sharing rooms

Understaffing

Preparation of IVs on the unit Lack of isolation facilities

No separation of clean and dirty AREAS

Excessive antibiotic use Inadequate decontamination of items & equipment's

Inadequate cleaning of environment

DR.T.V.RAO MD 6


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Hospital-acquired

fevers occur in

one-third of allmedical inpatients

Nosocomial fevers

even morecommon in the

ICU

NOSOCOMIAL FEVERS

7DR.T.V.RAO MD


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Ventilator associated

pneumonia

Catheter related blood

stream infections Urosepsis

Intra-abdominal infections

Sinus infections

Diarrhoea

INFECTIOUS CAUSES OFFEVER WHILST IN ICU

DR.T.V.RAO MD 8


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FEVER IN THE ICU

ICU patients have several underlying

medical/surgical conditions

ICU patients undergo many invasive diagnostic andtherapeutic procedures

Therefore, fever in ICU patients must be thoroughly

and promptly evaluated to discriminate infectiousfrom non-infectious etiologies

DR.T.V.RAO MD


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CAUSES OF FEVER IN THE ICU

Surgical site infections

Intravenous-line

infections

Nosocomial pneumonia

Nosocomial sinusitis

Intraabdominalinfections

Urinary catheter-

associated

bacteriuria Drug fever

Post-operative fever

Neurosurgical

causes

DR.T.V.RAO MD


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Community acquired pneumonia

Acute CNS infection

Urinary tract infection

Abdominal focus of infection

Wound infection / Pus collections

Trauma with infection

THE OBVIOUS FOCUS

DR.T.V.RAO MD 11


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DEVICE RELATED NOSOCOMIAL INFECTION

A device-associated infection is an infection in apatient with a device (i.e., central line, ventilator, or

indwelling urinary catheter) that was in use withinthe 48-hour period before onset of infection. If theinterval since discontinuation of the device is

longer than 48 hours, there must be compellingevidence that infection was associated with deviceuse.

DR.T.V.RAO MD 12


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ICU PATIENTS DIFFERS FROM MANY PATIENTSPAY MORE ATTENTION

Sickest patients (multiple diagnoses, multi-organ failure, immunocompromised, septicand trauma)

Move less

Malnourished

More obtunded (Glasgow coma scale)

Diabetics and Heart failure

DR.T.V.RAO MD 13


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Ventilator associatedpneumonia

Catheter related bloodstream infections

Urosepsis

Intra-abdominalinfections

Sinus infections Diarrhoea

INFECTIOUS CAUSES OFFEVER WHILST IN ICU

DR.T.V.RAO MD 14


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Patient with anobvious focus ofinfection

Where is the focus?

PATIENT PRESENTING TO ICUWITH FEVER

Acute un-differentiated

fever

What is causing this

fever?

DR.T.V.RAO MD 15


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RISK FACTORS

operative surgery

intravascular and urinary catheterization

mechanical ventilation of the respiratory tract

Other risk factors include traumatic injuries,

burns, age (elderly or neonates), immuno-suppression and existing disease

DR.T.V.RAO MD 16


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ICUCARE IS MORE INVASIVE

More invasive life linesand proceduresincluding surgeries

Longer length of stay

More IV and parenteraldrugs

More tube feeding andParenteral nutrition

More ventilation

DR.T.V.RAO MD 17


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FACTORS INFLUENCING INCREASED

INFECTIONS IN ICU

Hand washing facilities

Patient close together or sharing rooms

Understaffing

Preparation of IVs on the unit

Lack of isolation facilities

No separation of clean and dirty AREAS

Excessive antibiotic use

Inadequate decontamination of items & equipments

Inadequate cleaning of environment

DR.T.V.RAO MD 18


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THE INANIMATE ENVIRONMENT IS A

RESERVOIR OF PATHOGENS

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient

Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive Enterococcus culture

The pathogens are ubiquitous


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UTI associated with Foleycatheters

Lower respiratory tract

infection (post-op and

ventilator dependent)

Skin necrosis (skin

breakdown)

Blood stream infection (and

line associated)

Surgical-site infection

Nutrition-related and

malnutrition

SOME HEALTH-CARE ASSOCIATED

INFECTIONS

DR.T.V.RAO MD 20


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MANAGING FEVER IN ICU PATIENTS

Fever in the ICU can have many infectious and

noninfectious etiologies

Crucial to identify the precise cause as some of the

conditions in each groups are life-threatening, while othersrequire no treatment

Routine fever work-up not cost-effective

If initial evaluation shows no infection, antibiotics shouldbe withheld

Empiric antibiotics may be started in the unstable patient,

but stopped if infection is not evident laterDR.T.V.RAO MD


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DEVICE RELATED NOSOCOMIAL INFECTION

A device-associated infection is an infection in apatient with a device (i.e., central line, ventilator, orindwelling urinary catheter) that was in use within

the 48-hour period before onset of infection. If theinterval since discontinuation of the device islonger than 48 hours, there must be compelling

evidence that infection was associated with deviceuse.

DR.T.V.RAO MD 22


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Intrinsic contamination ofinfusion fluid

Connection with administration set

Insertion site

Injection ports

Administration set connectionwith IV catheter

Port foradditives

Sources of Infection

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Intralumunal Spread

Contaminated infusate(fluid, medication)

2. Intraluminal SpreadContaminated infusate(fluid, medication)

1. Extra luminal Spread

Patients own skin micro floraMicroorganism transferred by the

hands of Health Care WorkerContaminated entry port, catheter tipprior or during insertionContaminated disinfectant solutionsInvading wound

3. Haematogenous SpreadInfection from distant focus

Fibrin

Skin

Vein

Skin attachment

Sources of

Infection

DR.T.V.RAO MD 24


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PREVENTION OF CR-BSIWritten Protocol

Must be performed by trained staff according towritten guidelines

Sterile procedure

Sterile gown, Sterile gloves, Sterile large drapesDon't shave the site

Hand disinfection

With an antiseptic solution eg Chlorhexidinegluconate

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DR.T.V.RAO MD 26

FUNGI TOO INFECTIVE IN

ICUPATIENTS


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RISK FACTORS FOR

ASPERGILLOSIS

Neutropenia

steroids

Environmentalexposure

Building work

Compost heaps

Marijuana smoking

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incidence increasing

commonest cause ofinfectious death inmany transplantunits

commonest cause ofdeath in childhood

leukaemia

INVASIVE ASPERGILLOSIS

DR.T.V.RAO MD 28


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PROTECTED ENVIRONMENT

HEPA (for allogeneic HSCT patients only)

99.97% of all particles >3u diam)

>/=12 ACH

Pressure differential >2 Pa Directed air flow

Sealed rooms

Respiratory protection (N95 respirator) if leaving room only during periods ofbuilding construction

Standard hygiene barrier precautions No flowers, potted plants, carpets

Vacuums to have HEPA filters

HICPAC guidelines CDC 2004

DR.T.V.RAO MD 29


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DR.T.V.RAO MD 30

BASIC POLICIES IN MICROBIOLOGICAL

DIAGNOSIS OF ICU INFECTIONS


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CRITERIA FOR DIAGNOSIS

fever.

cough.

development of purulent sputum, in conjunctionwith radiologic evidence of a new or progressive

pulmonary infiltrate.

a suggestive Gram stain, and positive culturesof sputum, tracheal aspirate, pleural fluid, or

blood.

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DR.T.V.RAO MD 32


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HOW TO DIAGNOSE?

A positive result of semi quantitative Culture ( 15 CFU percatheter segment) Maki D, et al NEJM 1977;296:1305 orquantitative( 102 CFU per catheter segment) catheter culture, whereby

the same organism isolated from a catheter segment and a peripheral

blood sample

Simultaneous quantitative cultures of blood samples with a

ratio of 5 : 1 (CVC vs. peripheral)

Differential time to positivity :positive result of culture from aCVC is obtained at least 2 hr earlierthan is a positive result of

culture from peripheral blood)

DR.T.V.RAO MD 33


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If You put a central line in apatient with documented

Bacteremia, then later next

day somebody may obtain a

blood culture from both thecentral lien and from

periphery, >>>>>>> a

positive blood culture from

both sites, does notmean

that the central lien is the

source.

REMEMBER.

DR.T.V.RAO MD 34


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DEALING WITH STAPHYLOCOCCUS AUREUS

REMOVE the central line . Systemic antibiotics for minimal 14 days.

Failure to clear bacteremia within 72 hours Or

patient with high risk for endovascular infectionor having prosthesis may be indicative for longer3-6 weeks of treatment.

TTE or TEE are strongly advised. Blood Culture should be repeated during

therapy and1-2 weeks after completion oftherapy, looking for relapses.


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COAGULASE NEGATIVE STAPHYLOCOCCI

CVC can be retained, if necessary, in patients with

uncomplicated, catheter-related, bloodstream

infection. If the CVC is retained, patients should be treated

with systemic antibiotic therapy for 7 days.

Treatment failure is a clear indication for removal ofthe catheter .


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A RANDOMIZED AND PROSPECTIVE STUDY OF 3 PROCEDURES FOR THE

DIAGNOSIS OF CATHETER-RELATED BLOODSTREAM INFECTION WITHOUT

CATHETER WITHDRAWAL CID MARCH 2007

Conclusions. CR-BSI can be assessedwithout catheter withdrawal in patients withoutneutropenia or blood disorders who have cathetersinserted for a short time and are hospitalized in the

intensive care unit. Because of ease ofperformance, low cost, and wide availability, werecommend combining semi quantitativesuperficial cultures and peripheral vein bloodcultures to screen for CR-BSI, leaving differential

quantitative blood cultures as a confirmatory andmore specific technique.

DR.T.V.RAO MD 37


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A central line is

removed and it is

growing less than 15

CFU. Patient is not septic and

blood Culture is

negative.

>>> No indication to

treat the infected or

colonized central line.

DO NOT TREAT COLONIZED CENTRAL LINES

GET GUIDED BY MICROBIOLOGY REPORTS

DR.T.V.RAO MD 38

PROBLEMS WITH AIR SAMPLING


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Incubation period of IPAunknown

Estimates vary from 48hours -3 months

Geographical and seasonal

variation in spore countsand predominant species

Variable efficiency ofdifferent air samplers

May not take account of

surface contamination Settle plates, contact plates,

honey jars

PROBLEMS WITH AIR SAMPLING

HAS LIMITATIONS ???

NEW FRONTIERS ON INCREASING


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NEW FRONTIERS ON INCREASING

ICU INFECTIONS

Emphasis on patient safety

Move from inpatient to outpatient environment

Increase in population age Persons >65yo numbered 36 million in 2004

and by 2030 there will be 72 million

Increase in antimicrobial resistance (e.g.,MRSA)

DR.T.V.RAO MD 40


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STRATEGY FOR PREVENTION

Hand washing

Use gloves to prevent contamination of the handswhen handling respiratory secretions

Wear gloves and gowns (contact precautions)during all contact with patients and fomitespotentially contaminated with respiratory

secretions Use aseptic technique

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STRATEGY FOR PREVENTION

Clean and decontaminate all equipment after use

Sterilise or use high-level disinfection for all items thatcome into direct or indirect contact with mucous

membranes Rinse and dry items that have been chemically

disinfected

Package and store items to prevent contamination beforeuse

Keep environment clean, dry and dust free

DR.T.V.RAO MD 42


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INFECTION CONTROL MEASURES

1 Identify reservoir Colonized and infected

patients Environnemental contamination;

Common sources

2. Halt transmission among patient Improve

hand washing and asepsis Barrier precautions

(gloves, gown) for colonized and infected

Patients Eliminate any common source;disinfect environment Separate susceptible

patients Close unit to new admissions if

necessaryDR.T.V.RAO MD 43


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INFECTION CONTROL MEASURES

3. Halt progression from colonization to infection

Discontinue compromising factors when possible

(eg, extubate, remove nasogastric tube,

discontinue bladder catheters, as clinicallyindicated; rotate IV catheter sites; proper

ventilator and pulmonary care)

4. Modify host factors Treat underlying diseaseand complications Control antibiotic use (rotate,

restrict, or cease)DR.T.V.RAO MD 44


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TRADITIONAL ICP ACTIVITIES

Surveillance

Outbreak investigations

Policy development and implementation

Environmental/infection control rounds

Education (infection control, blood bornepathogen, TB)

Regulatory compliance

Committee participationDR.T.V.RAO MD 45


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NEW ICP RESPONSIBILITIES

Increased regulations (OSHA, FDA)

Emerging pathogens (avian influenza)

IHI campaign

Increase training/education requirements

Post-exposure prophylaxis (HIV, HBV)

Epidemiologic typing of outbreak pathogens

Interpreting screening cultures (MRSA, VRE)

Risk adjusted surveillance (SSI, CR-BSI, VAP)

Sentinel event analysisDR.T.V.RAO MD 46


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CONCLUSIONS :

STRATEGY FOR INFECTION PREVENTION

Strict attention to Hand hygiene

Prudent Antibiotic use

Aseptic technique Disinfection/Sterilization of items and equipment

Education of staff infection control awareness

Keep Environment Clean, Dry and dust free Surveillance of nosocomial infection to identify problems

areas & set priorities

DR.T.V.RAO MD 47

GROWING CONCERNS WITH INFECTIONS IN


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GROWING CONCERNS WITH INFECTIONS IN

ICU

Nosocomial infections, especially those caused by

antibiotic-resistant pathogens, represent an important

source of morbidity and mortality for the patient

hospitalized in an ICU. Important antibiotic-resistantnosocomial pathogens include MRSA, VRE, Gram-

negative bacilli (especially, Klebsiella and Enterobacter)

producing extended-spectrum b-lactamases, multiple

drug-resistant M tuberculosis, and fluconazole-resistantCandida sp.

DR.T.V.RAO MD 48


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CAN WE CONTROL ICU INFECTIONS

The key to control of antibiotic-resistant pathogens in

the ICU is rigorous adherence to infection control

guidelines and prevention of antibiotic misuse.

Antibiotic restriction policies clearly result in reduceddrug costs. Evidence suggests that reducing use of

certain antibiotics may lead to a decreased prevalence

of antibiotic-resistant pathogens: vancomycin, VRE;

gentamicin, gentamicin-resistant Gram-negative bacilli;and, ceftazidime, Gram-negative

DR.T.V.RAO MD 49

WISH WIN THE PROBLEM


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WISH WIN THE PROBLEMFACE THE CHALLENGES

Increase infection control resources are a win-win-wininvestment

Reduced patient morbidity and mortality

Net cost savings to institution, society and patient

Improve patient satisfaction

From the standpoint of the hospital and society, the benefits

exceed the costs Hospitals should support a ratio of ICP per beds of 1:150

DR.T.V.RAO MD 50

MICROBES ON SKIN PLAY A MAJOR ROLE


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The major cause ofinfection during thefirst weeks ofindwelling time is fromskin microorganisms.

Rannem, et. al., 1990

Maki, et. al., 1991

Maki (review), 1994

Widmer (review),1997

MICROBES ON SKIN PLAY A MAJOR ROLE

SKIN DISINFECTION A MAJOR PREVENTIVE

MEASURE

USING CHLORHEXIDINE 0 5% FOR


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A meta-analysis

determined that

chlorhexidine gluconate

significantly reduces theincidence of bacteremia

in patients with central

venous catheters

compared to povidone-iodine for insertion-site

skin disinfection. Chaiyakunapruk et al. Chlorhexidine compared with

povidone-iodine solution for vascular catheter-site

care: A meta-analysis. Ann Intern Med. 2002;136:792.

USING CHLORHEXIDINE 0.5% FOR

SKIN DISINFECTION
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CHLORHEXIDINE SKIN ANTISEPSIS

Prepare skin withantiseptic/detergentchlorhexidine 2% in 70%isopropyl alcohol.

Pinch wings on the applicator

to pop the ampule. Hold theapplicator down to allow thesolution to saturate the pad.

Press sponge against skin, applychlorhexidine solution using a

back and forth friction scrub for atleast 30 seconds. Do not wipe orblot.

Allow antiseptic solution time todry completely before puncturing

the site (~ 2 minutes).


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Recommended by CDC

based

on strong experimental,

clinical, epidemiologic and

microbiologic data

Antimicrobial superiority

Greater microbicidal

effect

Prolonged residual

effect

Ease of use and application

ALCOHOL BASED HAND SANITIZERS

AN INTERVENTION TO DECREASE CATHETER-RELATED BLOODSTREAM INFECTIONS IN

THE ICU
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THE ICU.

N ENGL J MED PRONOVOST P, ET AL: 355(26):2725-2732, 2006

(1) hand washing,

(2) use of full-barrier precautions during placementof catheters,

(3) cleansing of the skin with chlorhexidine, (4) use of sites other than the femoral vein when

possible,

(5) removal of catheters that were no longer needed.The analysis included almost 2000 ICU-months and>375,750 catheter-days of data.

WARNING


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WARNING

Nosocomial Infections in ICU are Waiting

DR.T.V.RAO MD 56

BE KIND TO YOUR PATIENTS


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BE KIND TO YOUR PATIENTS

REMEMBER ONE THING

PLEASE WASH YOUR

HANDS


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Programme created by Dr.T.V.Rao MD for

Health care Workers in the Developing world

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