guest talk on icu infections

7/30/2019 Guest Talk on ICU Infections

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GUEST LECTURE ATJIPMER , Pondicherry

INTENSIVE CARE UNITSINFECTIONS AND CONTROL

(December 2012)

Dr.T.V.Rao MDProfessor of Microbiology

Travancore Medical College, Kollam Kerala

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Ignaz Semmelweis(1818-1865)

Obstetrician,practised in Vienna

Studied puerperal(childbed) fever

Established that highmaternal mortalitywas due to failure ofdoctors to wash hands

after post-mortems Reduced maternal

mortality by 90%

Ignored andridiculed by

colleagues

A tribute to Ignaz Semmelweiss

(1818-1865)

. . . . .

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What is a Intensive Care Unit

An intensive care unit (ICU) is

defined as a specially staffed,

specialty equipped, separate sectionof a hospital dedicated to the

observation, care, and treatment of

patients with life threateningillnesses, injuries, or complications

from which recovery is possible12/23/2012 Dr.T.V.Rao MD 3


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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 competentinfection control practices. The ICP

must become knowledgeable andtechniques that will motivate and

sustain behavioral change.12/23/2012 Dr.T.V.Rao MD 6


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Why ICU patients are different

Many times very sick patients (multiplediagnoses, multi-organ failure,)immunocompromised, septic and

trauma)

Move less

Malnourished

May be associated Diabetics and Heartfailure

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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 > upperextremities 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 Dis2006


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EPIDEMIOLOGY

Contributing factorsThe high frequency of indwelling

catheters among ICU patients

The use and maintenance of thesecatheters necessitate frequent contactwith health care workers, which

predispose patients to colonizationand infection with nosocomialpathogens.

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Drug Resistant Bacteria a threat to Life

Multidrug-resistant pathogens

such as methicillin-resistant

Staphylococcus aureus (MRSA)and Vancomycin-resistant

enterococci (VRE) are beingisolated with increasing

frequency in ICUs12/23/2012 Dr.T.V.Rao MD 10


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ICU Care is Invasive at many

Stages

More invasive lines andprocedures includingsurgeries

Longer length of stay

More IV and parenteraldrugs

More tube feeding andParenteral nutrition

More ventilation

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ICU : Factors that increasecross-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 ofitems & equipment's

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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 malnutrition12/23/2012 Dr.T.V.Rao MD 13


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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 fomitespotentially contaminated with respiratory

secretions Use aseptic techniques

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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 contaminationbefore 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 identifyproblems 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 catheterTeflon or Polyurethane ( < infections) vs Polyvinylchloride

Site of insertionSubclavian (< infections) vs Internal Jugular &

Femoral (high risk of colonization & deep venousthrombosis)

No. of Lumen

Single-lumen catheter (< infections) vsMulti-lumen catheter

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Intrinsic contamination ofinfusion fluid

Connection with administrationset

Insertion site

Injection ports

Administration set connectionwith IV catheter

Port foradditives

Sources of Infection

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Intralumunal SpreadContaminatedinfusate (fluid,medication)

2. Intraluminal SpreadContaminated infusate(fluid, medication)

1. Extra luminal SpreadPatients own skin micro flora

Microorganism transferred bythe hands of Health CareWorkerContaminated entry port,catheter tip prior or duringinsertion

Contaminated disinfectantsolutionsInvading 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 skincleansing for both CL insertion and maintenance Tincture of iodine, an iodophor, or 70% alcohol are

alternatives

Recommended application methods and contact timeshould be followed for maximal effect

Prior to use should ensure agent iscompatible with catheter Alcohol may interact with some polyurethane

catheters

Some iodine-based compounds may interactwith silicone catheters

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Prevention of CR-BSI

Skin 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. Lancet1991;338:339-43

No difference between 0.5% Chlorhexidinegluconate or10% Povidone-iodineHumar A et al. Clin Infect Dis 2000;31:1001-7

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Prevention of CR-BSI

Topical antibiotic

Prophylactic use of topical Mupirocin (Bactroban) at

insertion site orin nose is not recommended

Rapid development of Mupirocin resistant Mupirocin affect the integrity of Polyurethane catheter

Systemic antibiotic

Prophylactic use of antibiotic is not recommendedatthe 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

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Junction between catheter & drainage

tube

Do not disconnect catheter unlessabsolutely necessary.

For urine specimen collection disinfectoutside of catheter proximal to junctionwith drainage tube by applying alcoholicimpregnated wipe and allow it to dry

completely then aspirate urine with asterile needle and syringe.

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Intensive Care Unit

Nosocomial Pneumonia

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Incidence of HAI vs. Cost

Hospital acquiredInfection

Incidence Additionalcost

Urinary Tract 45% 13%

Surgical Wound 29% 42 %

Pneumonia 9 % 39%

Blood Stream 2% 4 %

Haley, 198612/23/2012 Dr.T.V.Rao MD 30


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Prevention in ICU Turn patients to

encourage posturaldrainage

Encourage to take deep

breaths and cough. Maintain an upright

position (elevate patientshead to 30- 45 degree

angle) to reduce refluxand aspiration of gastricbacteria.

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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 wateroutlet.

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 beprevented 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 andthose 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. Anotherform ofS. aureus,

vancomycin-resistant

S. aureus (VRSA), is

resistant to one of themost powerful, last

line of defence

antibiotics,

vancomycin

Concerns with staphylococcus

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RESISTANT GRAM NEGATIVE ORGANISMS

Resistance to multiple antibiotics

Organisms:

E .coliProteusEnterobacterAcinetobacter

StenotrophomnonasPseudomonas aeruginosa

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Escherichia coli(E.coli) has gradually

become resistant to

different types ofantibiotics. In 2003,

the overall resistance

ofE. colito common

amino penicillinantibiotics reached

47% across Europe

E.Coli and emerging resistance

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SURVEILLANCE

Dr.T.V.Rao MD 37

Important means of monitoring HAIEarly detection of trends outbreaks

Laboratory Based

Microbiology Laboratory lists Gram +ve and - veorganismsICN reviews Alert organismsreported

2. Ward BasedWard 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

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Antibiotics use

Must avoid widespreaduse of

broad spectrum antibiotics

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Problems in-Detection of Infection in

the ICUs

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Examples of difficult to detect infections:

Uncultivable organisms

Viruses are under appreciated as causes ofnosocomial infections. Except in cases of highmorbidity viral cultures are not done inresource scarce settings.

Impact food-borne, respiratory, water borne

illnesses.

.

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fi i i f i l i i f i


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Definition of surgical site infection

(no implant)

Occurs within 30days of surgery

AND has one of thefollowing:

Purulent drainagefrom drain OR

Organism isolated

from asepticallyobtained fluid in theorgan space

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Prior to starting any surveillance

Agree upon a

written case

definition that is

practical given the

laboratory

facilities andpatient 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 byintended/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 determinedbetween 2002 and 2005; an overall rate of 14.7 percent or22.5 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 catheterdays (1.7-12.8)

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k h ( bi i i i ) i


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Cockroaches (Ectobius vittiventris) in

an Intensive Care Unit, Switzerland

Cockroaches are capable of harboring Escherichia coliEnterobacter spp. Klebsiella spp. , Pseudomonasaeruginosa , Acinetobacter baumannii , othernonfermentative bacteria Serratia marcescens Shigella

spp. Staphylococcus aureus group A streptococci ,Enterococcus spp. , Bacillus spp. , various fungi , andparasites and their cysts . An outbreak of extended-spectrum -lactamaseproducing Klebsiella

pneumoniae in a neonatal unit was attributed tocockroaches

Emerging Infectious Diseases March 2009

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R id d N h d f


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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), andthe ability to detect it through an ATP

bioluminometer indicates the amount of

microbial and non-microbial contamination ina given test area. This is accomplished by a

luminescent chemical reaction,

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Our Vision to Future

Infection controlprograms must

maintain training

records of employees.The minimum training

required is annual OSHA

blood borne pathogen,

tuberculosis preventionand control and new

employee orientation.

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WHONET - Documentation

Establishing WHONET

Documentation makes

the Antibiograms

assessments easy byMicrobiologists and

Consultants at any

Hospital.

We are fully functionalto the advantages of

the WHONET

documentation,Dr.T.V.Rao MD 50


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Do remember the Reasons for Infections are

Many but solutions are few

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C f h it l i f ti


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Consequences of hospital infections

???

Hospital Pathogen Unhappy

patients

Unhappy

director

Hospital Surveillance Happy

PatientsHappy

directorDr.T.V.Rao MD 52


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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 incollaboration with WHO, ICMR, DBT, NGOs;

use of information technology for patient

care, training and research.

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L t t H it l ith


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Let us support our Hospitals with

clean hands

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