GUEST LECTURE AT JIPMER , Pondicherry

INTENSIVE CARE UNITSINFECTIONS AND CONTROL

(December 2012)Dr.T.V.Rao MD

Professor of Microbiology Travancore Medical College, Kollam Kerala

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Dr.T.V.Rao MD 2

Ignaz Semmelweis (1818-1865)

• Obstetrician, practised in Vienna

• Studied puerperal (childbed) fever

• Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems

• Reduced maternal mortality by 90%

• Ignored and ridiculed by colleagues

A tribute to Ignaz Semmelweiss (1818-1865)

. . . . .

What is a Intensive Care Unit• An intensive care unit (ICU) is

defined as a specially staffed, specialty equipped, separate section of a hospital dedicated to the observation, care, and treatment of patients with life threatening illnesses, injuries, or complications from which recovery is possible

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A Patient in Intensive Care Unit is at Risk for Many Reasons..

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Infection in ICU are

•More in Prevention •Little in Treatment

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Educating our Health Care Workers

• Education programs for employees and volunteers are one method to ensure competent infection control practices. The ICP must become knowledgeable and techniques that will motivate and sustain behavioral change.

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Why ICU patients are different

• Many times very sick patients (multiple diagnoses, multi-organ failure,) immunocompromised, septic and trauma)

• Move less • Malnourished • May be associated Diabetics and Heart

failure

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ICU patients are rapidly colonized with pathogenic bacteria

• Skin colonized in hours to days– Staph. aureus, Proteus mirabilis, Klebsiella spp.

present @ 100-106 CFU /cm2 skin• Perineal/inguinal > axilla > trunk > upper

extremities and hands• Dialysis/CRF, diabetes, dermatitis, broad

spectrum Abx increase risk• Patients shed 106 squames/day -> widespread

contamination of the room

Reviewed in Pittet et al Lancet Infect Dis 2006

EPIDEMIOLOGY • Contributing factors

–The high frequency of indwelling catheters among ICU patients

–The use and maintenance of these catheters necessitate frequent contact with health care workers, which predispose patients to colonization and infection with nosocomial pathogens. 04/07/2023 Dr.T.V.Rao MD 9

Drug Resistant Bacteria a threat to Life

• Multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE) are being isolated with increasing frequency in ICUs

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ICU Care is Invasive at many Stages

• More invasive lines and procedures including surgeries

• Longer length of stay• More IV and parenteral

drugs• More tube feeding and

Parenteral nutrition• More ventilation

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ICU : Factors that increase cross-infections

• Hand washing facilities are inadequate • Patient close together or sharing rooms• Understaffing• Lack of isolation facilities • No separation of clean and dirty AREAS• Excessive antibiotic use• Inadequate decontamination of

items & equipment's04/07/2023 Dr.T.V.Rao MD 12

Some Health-Care Associated Infections May Occur in ICU Patients

• UTI associated with Foley catheters• 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 malnutrition04/07/2023 Dr.T.V.Rao MD 13

Strategy for Prevention

• Hand washing• Use gloves to prevent contamination of the

hands when handling respiratory secretions• Wear gloves and gowns (contact precautions)

during all contact with patients and fomites potentially contaminated with respiratory secretions

• Use aseptic techniques04/07/2023 Dr.T.V.Rao MD 14

Strategy for Prevention• Clean and decontaminate all equipment after use• Sterilise or use high-level disinfection for all items

that come into direct or indirect contact with mucous membranes

• Rinse and dry items that have been chemically disinfected

• Package and store items to prevent contamination before use

• Keep environment clean, dry and dust free

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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

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Intensive Care UnitPrevention of Blood stream infections

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Central Venous Catheters

Indications• IV fluids and drugs• Blood and blood products• Total Parenteral Nutrition (TPN)• Hemodialysis• Hemodynamic monitoring

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Serious Infective Complications

• Blood Stream Infections (BSI)• Septic pulmonary emboli• Metastasis infections

– Acute endocarditis– Osteomyelitis– Septic arthritis

• Shock and organ failure• Poor outcome: Staph.aureus or Candida spp.

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Incidence of CR-BSI• Type of catheter

Teflon or Polyurethane ( < infections) vs Polyvinyl chloride

• Site of insertion Subclavian (< infections) vs Internal Jugular & Femoral (high risk of colonization & deep venous thrombosis)

• No. of LumenSingle-lumen catheter (< infections)

vs Multi-lumen catheter04/07/2023 Dr.T.V.Rao MD 20

Intrinsic contamination of infusion fluid

Connection with administration set

Insertion site

Injection portsAdministration set

connection with IV catheter

Port for additives

Sources of Infection

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Intralumunal SpreadContaminated infusate (fluid, medication)

2. Intraluminal SpreadContaminated infusate (fluid, medication)

1. Extra luminal SpreadPatient’s own skin micro flora

Microorganism transferred by the hands of Health Care WorkerContaminated entry port, catheter tip prior or during insertionContaminated disinfectant solutionsInvading wound

3. Haematogenous SpreadInfection from distant focus

Fibrin

Skin

Vein

Skin attachment

Sources of Infection

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Prevention Strategies: Core Chlorhexidine Skin Cleansing

• Chlorhexidine is the preferred agent for skin cleansing for both CL insertion and maintenance– Tincture of iodine, an iodophor, or 70% alcohol are

alternatives – Recommended application methods and contact time

should be followed for maximal effect• Prior to use should ensure agent is

compatible with catheter– Alcohol may interact with some polyurethane

catheters– Some iodine-based compounds may interact

with silicone catheters

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Prevention of CR-BSISkin antisepsis• 2% Chlorhexidine gluconate has shown to

have lower BSI than 10% Povidone-iodine or 70 % Alcohol

• 2-min drying time before insertionMaki DG et al. Lancet 1991;338:339-43

• No difference between 0.5% Chlorhexidine gluconate or 10% Povidone-iodine

Humar A et al. Clin Infect Dis 2000;31:1001-7

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Prevention of CR-BSITopical antibiotic • Prophylactic use of topical Mupirocin (Bactroban) at

insertion site or in nose is not recommended – Rapid development of Mupirocin resistant– Mupirocin affect the integrity of Polyurethane catheter

Systemic antibiotic• Prophylactic use of antibiotic is not recommended at

the time of catheter insertion

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Urinary Catheterization

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External urethral meatus & urethra

• Pass catheter when bladder is full for wash-out effect.

• Before catheterization prepare urinary meatus with an antiseptic ( e.g. povidone iodine or 0.2% chlorhexidine aqueous solution)

• Inject single-use sterile lubricant gel (e.g. 1-2%) lignocaine into urethra and hold there for 3 minutes before inserting catheter.

• Use sterile catheter.• Use non-touch technique for insertion 04/07/2023 Dr.T.V.Rao MD 27

Junction between catheter & drainage tube

• Do not disconnect catheter unless absolutely necessary.

• For urine specimen collection disinfect outside of catheter proximal to junction with drainage tube by applying alcoholic impregnated wipe and allow it to dry completely then aspirate urine with a sterile needle and syringe.

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Intensive Care Unit Nosocomial Pneumonia

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Incidence of HAI vs. Cost

Hospital acquired Infection

Incidence Additional cost

Urinary Tract 45% 13%

Surgical Wound 29% 42 %

Pneumonia 9 % 39%

Blood Stream 2% 4 %

Haley, 198604/07/2023 Dr.T.V.Rao MD 30

Prevention in ICU• Turn patients to

encourage postural drainage

• Encourage to take deep breaths and cough.

• Maintain an upright position (elevate patient’s head to 30º- 45º degree angle) to reduce reflux and aspiration of gastric bacteria.

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Too many Wash basins are Hazardous

• It is not necessary to have an individual hand wash basins for every bed space as there us a risk of Legionella and other infections associated with infrequently used water outlet.

• All water outlets must run daily to minimize the potential for legionella within the pipeline

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The Scientific study ( SENIC ) gives guidelines

• Study of the Efficacy of Nosocomial Infection Control (SENIC) project was published, validating the cost-benefit of infection control programs. Data collected in 1970 and 1976-1977 suggested that one-third of all nosocomial infections could be prevented if all the following were present:

• One infection control professional (ICP) for every 250 beds. • An effective infection control physician. • A program reporting infection rates back to the surgeon and

those clinically involved with the infection. • An organized hospital-wide surveillance system.

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• Methicillin-resistant S. aureus (MRSA) is resistant to several antibiotics. Another form of S. aureus, vancomycin-resistant S. aureus (VRSA), is resistant to one of the most powerful, last line of defence antibiotics, vancomycin

Concerns with staphylococcus

RESISTANT GRAM NEGATIVE ORGANISMS

• Resistance to multiple antibiotics

Organisms:E .coli Proteus Enterobacter Acinetobacter

• StenotrophomnonasPseudomonas aeruginosa

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• Escherichia coli (E. coli) has gradually become resistant to different types of antibiotics. In 2003, the overall resistance of E. coli to common amino penicillin antibiotics reached 47% across Europe

E.Coli and emerging resistance

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SURVEILLANCE• Important means of monitoring HAI

Early detection of trends outbreaks• Laboratory Based

Microbiology Laboratory lists Gram +ve and - ve organisms ICN reviews ‘Alert organisms’ reported

• 2. Ward Based Ward staff monitor patientsICN reviews ICN visits wards

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Universal precautions• Hand washing• Personal protective equipment [PPE]• Preventing/managing sharps injuries• Aseptic technique• Isolation• Staff health• Linen handling and disposal• Waste disposal• Spillages of body fluids• Environmental cleaning• Risk management/assessment

Antibiotics use

Must avoid widespread use of

broad spectrum antibiotics

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Problems in -Detection of Infection in the ICU’s

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Examples of difficult to detect infections: Uncultivable organisms

Viruses are under appreciated as causes of nosocomial infections. Except in cases of high morbidity viral cultures are not done in resource scarce settings.

Impact food-borne, respiratory, water borne illnesses.

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Definition of surgical site infection (no implant)

• Occurs within 30 days of surgery

AND has one of the following:

Purulent drainage from drain OROrganism isolated from aseptically obtained fluid in the organ space

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Prior to starting any surveillance

• Agree upon a written case definition that is practical given the laboratory facilities and patient work load in your facility.

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Hand washing• Single most effective action to prevent HAI -

resident/transient bacteria• Correct method - ensuring all surfaces are cleaned -

more important than agent used or length of time taken

• No recommended frequency - should be determined by intended/completed actions

• Research indicates:– poor techniques - not all surfaces cleaned– frequency diminishes with workload/distance– poor compliance with guidelines/training

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Why we are not washing hands ???

• Working in high-risk areas • Lack of hand hygiene promotion• Lack of role model• Lack of institutional priority• Lack of sanction of non-compliers

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EPIDEMIOLOGY• A multicenter, prospective cohort

surveillance study of 46 hospitals in Central and South America, India, Morocco, and Turkey.

• Rates of device-associated infection were determined between 2002 and 2005; an overall rate of 14.7 percent or 22.5 infections per 1000 ICU days was found.

• Specific devices: – Ventilator associated pneumonia (VAP); 24.1

cases/1000 ventilator days (range 10.0-52.7) – CVC-related bloodstream infections;

12.5/1000 catheter days (7.8-18.5) – Catheter-associated urinary tract infections;

8.9/1000 catheter days (1.7-12.8)

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Cockroaches (Ectobius vittiventris) in an Intensive Care Unit, Switzerland

• Cockroaches are capable of harboring Escherichia coli Enterobacter spp. Klebsiella spp. , Pseudomonas aeruginosa , Acinetobacter baumannii , other nonfermentative bacteria Serratia marcescens Shigella spp. Staphylococcus aureus group A streptococci , Enterococcus spp. , Bacillus spp. , various fungi , and parasites and their cysts . An outbreak of extended-spectrum β-lactamase–producing Klebsiella pneumoniae in a neonatal unit was attributed to cockroaches

• Emerging Infectious Diseases March 200904/07/2023 Dr.T.V.Rao MD 47

Rapid and Newer method of Contamination with

• ATP testing works because Adenosine Triphosphate is present in all types of organic material (i.e. food, bacteria, bodily fluids, unique proteins, allergens and even skin), and the ability to detect it through an ATP bioluminometer indicates the amount of microbial and non-microbial contamination in a given test area. This is accomplished by a luminescent chemical reaction,

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Our Vision to Future • Infection control

programs must maintain training records of employees. The minimum training required is annual OSHA blood borne pathogen, tuberculosis prevention and control and new employee orientation.

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WHONET - Documentation• Establishing WHONET

Documentation makes the Antibiograms assessments easy by Microbiologists and Consultants at any Hospital.

• We are fully functional to the advantages of the WHONET documentation,

Do remember the Reasons for Infections are Many but solutions are few …

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Consequences of hospital infections ???

Hospital Pathogen Unhappypatients

Unhappydirector

Hospital Surveillance HappyPatients

Happydirector

How successful are our Programmes

• Accreditation from competent government agency; training of ICU nurses and Intensive care physicians; technology sharing with developed countries, funding programs in collaboration with WHO, ICMR, DBT, NGOs; use of information technology for patient care, training and research.

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Let us support our Hospitals with clean hands

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