ICU INFECTIONS

BASIS, DIAGNOSIS, AND PREVENTION Dr.T.V.Rao MD

DR.T.V.RAO MD

DEFINITIONS
NOSOCOMIAL INFECTION :
An infection acquired in a patient in a hospital or other healthcare facility in whom it was not present or incubating at the time of admission or the residual of an infection acquired during a previous admission.
DR.T.V.RAO MD

BACKGROUND OF HOSPITAL INFECTIONS

Nosocomial infections have been recognized for over a century as a critical problem affecting the quality of health care and a principal source of adverse healthcare outcomes.

DR.T.V.RAO MD

RISK OF INFECTIONS IN ICU

Patients hospitalized in ICUs are 5 to 10 times

more likely to acquire nosocomial infections than other hospital patients. The frequency of
infections at different anatomic sites and the risk of infection 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 antibioticresistant pathogens
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WHY ONE MAY BE IN ICU WITH

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

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ICU : FACTORS THAT INCREASE CROSSINFECTIONS

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
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NOSOCOMIAL FEVERS
Hospital-acquired fevers occur in one-third of all medical inpatients Nosocomial fevers even more common in the ICU
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INFECTIOUS CAUSES OF FEVER WHILST IN ICU

Ventilator associated pneumonia Catheter related blood stream infections

Urosepsis
Intra-abdominal infections Sinus infections

Diarrhoea

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FEVER IN THE ICU

ICU patients have several underlying medical/surgical conditions ICU patients undergo many invasive diagnostic and therapeutic procedures Therefore, fever in ICU patients must be thoroughly and promptly evaluated to discriminate infectious from non-infectious etiologies

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CAUSES OF FEVER IN THE ICU

Surgical site infections Intravenous-line infections Nosocomial pneumonia Nosocomial sinusitis Intraabdominal infections

Urinary catheterassociated bacteriuria

Drug fever
Post-operative fever

Neurosurgical causes

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THE OBVIOUS FOCUS

Community acquired pneumonia

Acute CNS infection Urinary tract infection Abdominal focus of infection Wound infection / Pus collections

Trauma with infection

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DEVICE RELATED NOSOCOMIAL INFECTION

A device-associated infection is an infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection. If the interval since discontinuation of the device is longer than 48 hours, there must be compelling evidence that infection was associated with device use.
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ICU PATIENTS DIFFERS FROM MANY PATIENTS

PAY MORE ATTENTION

Sickest patients (multiple diagnoses, multiorgan failure, immunocompromised, septic and trauma) Move less Malnourished More obtunded (Glasgow coma scale) Diabetics and Heart failure
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INFECTIOUS CAUSES OF FEVER WHILST IN ICU

Ventilator associated pneumonia Catheter related blood stream infections Urosepsis Intra-abdominal infections Sinus infections Diarrhoea

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PATIENT PRESENTING TO ICU WITH FEVER

Patient with an obvious focus of infection Where is the focus?

Acute un-differentiated fever What is causing this fever?

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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), immunosuppression and existing disease
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ICU CARE IS MORE

More invasive life 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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INVASIVE

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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
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THE INANIMATE ENVIRONMENT IS A RESERVOIR OF PATHOGENS

X represents a positive Enterococcus culture

The pathogens are ubiquitous

~ 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.

SOME HEALTH-CARE ASSOCIATED INFECTIONS

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 malnutrition DR.T.V.RAO MD

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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 others require no treatment Routine fever work-up not cost-effective If initial evaluation shows no infection, antibiotics should be withheld Empiric antibiotics may be started in the unstable patient, but stopped if infection is not evident later 21
DR.T.V.RAO MD

DEVICE RELATED NOSOCOMIAL INFECTION A device-associated infection is an infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection. If the interval since discontinuation of the device is longer than 48 hours, there must be compelling evidence that infection was associated with device use.
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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

Sources of Infection

2. Intraluminal Spread Intralumunal Spread Contaminated infusate Contaminated infusate (fluid, medication) (fluid, medication)

Skin attachment Skin Fibrin Vein

3. Haematogenous Spread Infection from distant focus

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PREVENTION OF CR-BSI
Written Protocol

Must be performed by trained staff according to written guidelines

Sterile procedure

Sterile gown, Sterile gloves, Sterile large drapes Don't shave the site
Hand disinfection

With an antiseptic solution eg Chlorhexidine gluconate

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FUNGI TOO INFECTIVE IN

ICU PATIENTS

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RISK FACTORS FOR ASPERGILLOSIS

Neutropenia steroids Environmental exposure Building work Compost heaps Marijuana smoking
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INVASIVE ASPERGILLOSIS
incidence increasing commonest cause of infectious death in many transplant units commonest cause of death in childhood leukaemia

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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 of building construction

Standard hygiene barrier precautions No flowers, potted plants, carpets Vacuums to have HEPA filters
HICPAC guidelines CDC 2004
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BASIC POLICIES IN MICROBIOLOGICAL

DIAGNOSIS OF ICU INFECTIONS

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CRITERIA FOR DIAGNOSIS

fever. cough. development of purulent sputum, in conjunction with radiologic evidence of a new or progressive pulmonary infiltrate. a suggestive Gram stain, and positive cultures of sputum, tracheal aspirate, pleural fluid, or blood.
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HOW TO DIAGNOSE?
A positive result of semi quantitative Culture ( 15 CFU per catheter segment) Maki D, et al NEJM 1977;296:1305 or
quantitative ( 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 a CVC is obtained at least 2 hr earlier than is a positive result of culture from peripheral blood)
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REMEMBER.
If You put a central line in a patient with documented Bacteremia, then later next day somebody may obtain a blood culture from both the central lien and from periphery, >>>>>>> a positive blood culture from both sites, does not mean that the central lien is the source.

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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 infection or having prosthesis may be indicative for longer 3-6 weeks of treatment. TTE or TEE are strongly advised. Blood Culture should be repeated during therapy and1-2 weeks after completion of therapy, looking for relapses.

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 of the catheter .

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 assessed without catheter withdrawal in patients without neutropenia or blood disorders who have catheters inserted for a short time and are hospitalized in the intensive care unit. Because of ease of performance, low cost, and wide availability, we recommend combining semi quantitative superficial cultures and peripheral vein blood cultures to screen for CR-BSI, leaving differential quantitative blood cultures as a confirmatory and more specific technique.

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DO NOT TREAT COLONIZED CENTRAL LINES GET GUIDED BY MICROBIOLOGY REPORTS

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.
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PROBLEMS WITH AIR SAMPLING HAS LIMITATIONS ???

Incubation period of IPA unknown
Estimates vary from 48 hours -3 months

Geographical and seasonal variation in spore counts and predominant species Variable efficiency of different air samplers May not take account of surface contamination
Settle plates, contact plates, honey jars

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)

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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 fomites potentially 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 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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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 necessary
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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 clinically indicated; rotate IV catheter sites; proper ventilator and pulmonary care) 4. Modify host factors Treat underlying disease and complications Control antibiotic use (rotate, restrict, or cease)
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TRADITIONAL ICP ACTIVITIES

Surveillance Outbreak investigations

Policy development and implementation

Environmental/infection control rounds Education (infection control, blood borne pathogen, TB) Regulatory compliance
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Committee participation

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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 analysis
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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
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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-resistant nosocomial pathogens include MRSA, VRE, Gramnegative bacilli (especially, Klebsiella and Enterobacter) producing extended-spectrum b-lactamases, multiple drug-resistant M tuberculosis, and fluconazole-resistant Candida sp.

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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 reduced drug 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

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WISH WIN THE PROBLEM

FACE THE CHALLENGES
Increase infection control resources are a win-win-win investment 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

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MICROBES ON SKIN PLAY A MAJOR ROLE SKIN DISINFECTION A MAJOR PREVENTIVE MEASURE
The major cause of infection during the first weeks of indwelling time is from skin microorganisms. Rannem, et. al., 1990 Maki, et. al., 1991 Maki (review), 1994 Widmer (review), 1997

USING CHLORHEXIDINE 0.5% FOR SKIN DISINFECTION

A meta-analysis determined that chlorhexidine gluconate significantly reduces the incidence of bacteremia in patients with central venous catheters compared to povidoneiodine 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 .

CHLORHEXIDINE SKIN ANTISEPSIS

Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol. Pinch wings on the applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad. Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow antiseptic solution time to dry completely before puncturing the site (~ 2 minutes).

ALCOHOL BASED HAND SANITIZERS

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

AN INTERVENTION TO DECREASE CATHETER-RELATED BLOODSTREAM INFECTIONS IN 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 placement of 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

Nosocomial Infections in ICU are Waiting

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BE KIND TO YOUR PATIENTS REMEMBER ONE THING

PLEASE WASH YOUR HANDS

 Programme created by Dr.T.V.Rao MD for Health care Workers in the Developing world
Email doctortvrao@gmail.com

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