Infection control in ICU /

Hospital
Speaker : Dr Vidit Joshi
Nosocomial Infections
• 5-10% of patients admitted to acute care
hospitals acquire infections
• 2 million patients/year
• 70% are due to antibiotic-resistant organisms
• ¼ of nosocomial infections occur in ICUs
• 90,000 deaths/year
• Attributable annual cost: 25k– 40k Cr

Weinstein RA. Emerg Infect Dis 1998;4:416-420.

Jarvis WR. Emerg Infect Dis 2001;7:170-173.
Shifting Vantage Points on Nosocomial
Infections

Many infections are Each infection is potentially

inevitable , although some preventable unless proven
can be prevented otherwise

Gerberding JL. Ann Intern Med 2002;137:665-670.

Source of microorganism
• Exogenous (such as bacteria, fungi, virus etc)
• From other patient, health care worker or visitors.
• Endogenous flora (flora from skin, mucous membrane, GI
tract or respiratory tract)
• Inanimate object (e.g. patient bed surface, equipment or other
devices or objects used in ICU)
• Intrinsic risk factors - Immunocompromised state, severity of
illness, extremes of age, inadequate nutrition, and
immobilization make ICU patient more susceptible.
• Extrinsic risk factors include invasive procedure, catheters,
mechanical ventilation & other therapeutic interventions in
ICU
CONTRIBUTING FACTORS
1. Acuity of illness – reduced patient’s ability to resist colonization,
Decrease energy stores and Supressed immune system
2. Response to physiological stressors (noise. Pain,
anxiety, and isolation)
3. Age and associated comorbidity
4. Indiscriminate use of antibiotics promoting the development of
antibiotics- resistant organisms.
5. Drug therapies for stress ulcer
6. Sleep deprivation
7. protein-energy malnutrition, and understaffing.
Major types of infections in ICU

• BSI
• Catheter type, insertion, maintenance
• UTI
• Catheter use and insertion, maintenance
• VAP
• Duration of intubation, gastric pH, HOB elevation
• SSI
• Site, pressure sore
Sadly, we as medical
professionals frequently do
not practice well known
nosocomial infection risk
reduction practices
Most frequent mode of transmission is-
Contact transmission (30%-40% of all
Nosocomial Infections )
5 Essential Steps for Cross
Transmission

Pittet et al Lancet Infect Dis 2006 9

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The inanimate environment is a
reservoir of pathogens
Recovery of MRSA, VRE, C.diff, CNS and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:849-869
Transfer to the hands of health care workers
(HCWs) hands: I

• “Clean Activities” (lifting, taking radial artery

pulse, measuring blood pressure)
• Up to 100-1000 cfu from HCWs hands
• Rings, artificial or long nails increase frequency
of hand contamination of HCWs

Phillips, BMJ 1977; McBride, J Hosp Inf 2004

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Contamination of ICU Patient Charts

• Sterile swab of outside of binders/charts kept

outside the ICU room

Percent of ICU charts culture positive by organism

Panhotra Am J Infect Control 2005 13

Bacterial Survival times on hands

• Acinetobacter spp 60 min

• E. coli 6 min (mean)
• Klebsiella spp 2 min (mean)
• VRE 60 min
• Pseudomonas sp 30 min; 180 in sputum
• Rotavirus 16% survive 20 min;
2% survive 60 min

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 Hand Hygiene
Single most effective method to limit cross
transmission

Hand Hygiene Comment

Typical Observational studies of hand hygiene report

Compliance compliance rates of 5-81%

Common Insufficient time, understaffing, patient

Reported Barriers overcrowding, lack of knowledge of hand
To Compliance hygiene guidelines, skepticism about hand
washing efficacy, inconvenient location of
sinks and hand disinfectants and lack of hand
hygiene promotion by the institution
 Alcohol Based Hand Sanitizers
• CDC/SHEA hand antiseptic agents of choice
• 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 hygiene
solutions Easy to use
Quick: 5- 15 seconds

Very effective antisepsis due to bactericidal properties of alcohol

Hand washing compliance rates by
occupation

Occupation Compliance OR (95% CI)

Nurse 52% 1.00

Physician 30% 2.80 (1.9-4.1)

Nursing Assistant 47% 1.28 (1.0-1.5)

Other 38% 2.15 (1.4-3.2)

Pittet D et al. Ann Intern Med 1999; 130:126

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Contact
Precautions for
drug resistant
pathogens.

Gowns and gloves must be worn

upon entry into the patient’s
room
 Glove Use for Infection Control
Variable Rationale Comment

Gloves
Prevent healthcare Remove
worker exposure to
bloodborne gloves after
pathogens caring for
Prevent patient
contamination of
hands with drug
resistant pathogens
during patient care
activities
Gown Use for Infection Control
Variable Rationale

Gowns

Several studies have

documented
colonization of
healthcare worker
apparel and
instruments during
patient care activities
without the use of
gowns
 The CVC is the
The risk factors interact in a
dynamic fashion greatest risk factor
for Nosocomial BSI
The CVC:
Subclavian,
El Host
Femoral and
IJ sites

The intensity
of the
Catheter
Manipulation
As the host cannot be altered, preventive measures are focused on risk factor
modification of catheter use, duration, placement and manipulation
Prevention of Nosocomial BSIs
• Limit duration of use of intravascular catheters
• No advantage to changing catheters routinely
• Hand hygiene prior to procedure
• Maximal barrier precautions for insertion
• Sterile gloves, gown, mask, cap, full-size drape, Maintenance
of sterile field during procedure
• Chlorhexidine prep for catheter insertion
• Significantly decreases catheter colonization
• Disadvantages: possibility of skin sensitivity to chlorhexidine
• Transparent dressing
• Daily inspection & changing CVC if signs of local
infections appear
 Eliminating catheter-related bloodstream
infections in the intensive care unit

Staff Education
Creation of a catheter insertion cart
Promotion of daily catheter Removal

Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.

Compulsive Antibiotic Prescribing (CAP)

• CAP is a widespread and serious affliction

• First year medical students are free of the disease
• Interns and first year residents are severely
afflicted…life-long habit difficult to break
• CAP is supported by a well organized group of
antibiotic pushers

Lockwood et al, NEJM p465-466, 1974

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URINARY TRECT INFECTION
• Most common organism is E.coli
• Risk factors
• Female gender
• Postpartum status.
• Older age
• Severe underlying illness
• High creatinine level.
• The wrong reason for catheterization,
• Contamination during insertion,
• Errors in catheter care
• Use of antibiotics
Mechanism of UTI
• Backward flow of urine in the catheter (More in males)
• backward flow of urine in the catheter (More in females)
Prevention of UTI
• Remove the catheter as soon as possible.
• The Catheter collection systems should remain closed unless
absolutely necessary for diagnosis or therapeutic reasons.
• Caution the patient against pulling on the catheter.
• Urine flow through the catheter should be checked regularly
to ensure that the catheter is not blocked.
• Avoid raising the collection bag above the level of the patient’s
bladder.
• Avoid back-and- forth movement of the catheter
Prevention of UTI
• Before the patient stand up, drain all urine from the tubing into the
bag.
• Replace bags with new or clean containers when needed.
• If the drainage tubing becomes disconnected, do not touch the ends of
the catheter or tubing.
• Wipe the ends of the catheter and tubing with an antiseptic solution before
re connecting them.
• Wash the head of the penis and urethral opening (men) or the
tissue around the urethral
opening (women) after a bowel movement or if the patient is incontinent.
• Avoid irrigation, if frequent irrigation is required, the catheter should be
changed.
SURGICAL SITE INFECTION /Bed sore
• Change gloves during patient care if moving from a
contaminated body site to a clean body site or operational site.
• Maintain sterility protocol
VENTILATOR ASSOCIATED PNEUMONIA

Definition : Pneumonia after 48 hours of intubation

Criteria include
New or progressive infiltrates, Consolidation, cavitation or pleural effusion on
chest X ray
And
At Least one of the following -
New onset of purulent sputum or change of character of sputum.
Fever
Increased WBC counts
Organism cultured
VENTILATOR ASSOCIATED
PNEUMONIA
• Develop VAP prevention protocol
• Awareness & Training
• Shorten the duration of intubation and invasive ventilation.
• Consider use of noninvasive ventilation.
• Avoid continues use of paralytics as far as possible.
• Ensure appropriate dosages of sedation or narcotics
• Consider use of sedation scale to avoid over-sedation.
• Daily Interruption of sedation to assess readiness for
extubation.
• Wean patient off invasive ventilation as soon as possible.
• Prevent unplanned extubation e.g. patient self extubation.
VENTILATOR ASSOCIATED
PNEUMONIA
• Perform tracheal suction properly with aseptic precaution
& avoid routine saline instillation during suctioning.
• Ensure appropriate disinfection, sterilization, and maintenance of
respiratory equipment
• Prevent leakage of oral or subglottic secretion into lower airway.
• Place the ventilated patient in semi- upright position around 45
degrees.
• Consider use of antiseptic oral rinse such as 0.12% Aq.
Chlorhexidine at set interval for maintenance of oral hygiene.
Strategies to decrease transmission

• Proven or Proposed Strategies

• Antibiotic stewardship
• Proper hand hygiene
• Cohorting patients
• Gowns and gloves
• Isolation of patients
• Appropriate staffing ratios
• Surveillance cultures
• Decolonization of patients (chlorhexidine body
washes)

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THANK
YOU

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