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JIPMER , Pondicherry
INTENSIVE CARE UNITS INFECTIONS 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
Dr.T.V.Rao MD
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Dr.T.V.Rao MD
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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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
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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.
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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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Understaffing
Lack of isolation facilities No separation of clean and dirty AREAS
Inadequate decontamination of
items & equipment's
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Surgical-site infection
Nutrition-related and malnutrition
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Indications
IV fluids and drugs Blood and blood products Total Parenteral Nutrition (TPN) Hemodialysis Hemodynamic monitoring
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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)
Sources of Infection
Intrinsic contamination of infusion fluid
Port for additives
Connection with administration set Insertion site Injection ports Administration set connection with IV catheter
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1. Extra luminal Spread Patients own skin micro flora Microorganism transferred by the hands of Health Care Worker Contaminated entry port, catheter tip prior or during insertion Contaminated disinfectant solutions Invading wound attachment Skin
Skin Fibrin
Sources of Infection
2. Intraluminal Spread Intralumunal Spread Contaminated infusate Contaminated (fluid, medication) infusate (fluid, medication)
Vein
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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 insertion
Maki DG et al. Lancet 1991;338:339-43
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Prevention of CR-BSI
Topical 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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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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45%
13%
29% 9%
2%
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42 % 39%
4%
Haley, 1986 30
Prevention in ICU
Turn patients to encourage postural drainage Encourage to take deep breaths and cough. Maintain an upright position (elevate patients head to 30- 45 degree angle) to reduce reflux and aspiration of gastric bacteria.
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Organisms:
E .coli Proteus Enterobacter Acinetobacter Stenotrophomnonas Pseudomonas aeruginosa
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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 patients ICN 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 widespread use of broad spectrum antibiotics
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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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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,
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Do remember the Reasons for Infections are Many but solutions are few
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Hospital
Pathogen
Unhappy patients
Unhappy director
Hospital
Surveillance
Happy Patients
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Happy director 52
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