Infection control and prevention in ICU

DR OHAGWU I.C
Outline
• Introduction

• Risk factors

• Architectural design

• Isolation

• Standard precautions

• Transmission based precautions

• Extra-measures

• Conclusion
Introduction
• Nosocomial infection describes hospital acquired infections that develop 48h following admission

• Also called health care associated infections (HCAIs)

• Major safety concern for both health care providers and the patients considering its demerits ,

• Burden to health care and leading cause of death ICUs

• About 15% of all hospitalised patient suffer these infections

• Incidence in ICU is 10 - 50%

• Duty of health care providers to minimise the spread of infection among patients
• Bacterial are the most common pathogens for nosocomial
infection
• Acinetobacter is the genre of bacteria responsible for most
infections in ICUs
• Viruses and fungal parasites are also implicated
Risk factors
• More than 70yrs

• Coma

• Mechanical ventilation

• Prolonged ICU (intensive care unit ) stay - more than 3days

• Immunosuppressants

• Prior antibiotics

• Major trauma - RTA, burns

• Acute renal failure

• Shock

• Indwelling catheters
 Architectural layout of icu

• Situated close to the operating theatre and emergency department for easy
accessibility, but should be away from the main ward areas

• Central air-conditioning systems are designed in such a way that recirculated air
must pass through appropriate filters

• All air should be filtered to 99% efficiency down to 5 μm

• Clearly demarcated routes of traffic flow through the ICU are required

• Adequate space around beds is ideally 2.5-3 m

• Electricity, air, vacuum outlets/connections should not hamper access around the
bed
• Adequate number of washbasins should be installed

• Alcohol gel dispensers are required at the ICU entry, exits, every bed space and
every workstation

• There should be separate medication and meal preparation area

• There should be separate areas for clean storage and soiled and waste storage
and disposal

• Adequate toilet facilities should be provided

• Isolation facility should be made available

Isolation
• Assess the need for isolation - Neutropenia and immune compromise, Diarrhoea, Skin rashes ,
known communicable diseases and carriers of epidemic strain of bacterium

• Types of isolation

• Protective isolation - for neutropenic or other immunocompromised patients to reduce the

risks of acquiring opportunistic infections

• Source isolation - colonised or infected patients to minimise potential transmission to other

patients or staff

• Isolation rooms should have tight-fitting doors , glass partitions for observation and both negative
pressure ( for source isolation ) and positive pressure ( for protective isolation) ventilations
Standard precautions
• Designed to reduce the risk of micro-organism transmission

• Applies to all patients regardless of their diagnosis

Hand hygiene

•Single most effective means of preventing the horizontal transmission of infections

•Increasing hand washing compliance by 2 folds would reduce HCAIs by 25-50%

WHO’s five moments of hand hygiene ;

– Before touching patient

– Before aseptic procedures

– After body fluid exposure

– After touching the patient

– After touching the patient’s surrounding

Caption
• Wash hands with soap and water when soiled or visibly dirty

• Use alcohol based hand rub(e.g 0.5% Chlorhexidine with 70% ethanol), if hands are not visibly dirty

• Scrub for at least 15 s

• During surgical hand preparation , remove all hand jewelries

• Trim finger nails

• Avoid wearing long sleeves

• Tuck in ties

• House coats are discouraged

Personal protective equipments (PPE)

Gloves

– Hand hygiene before putting on gloves , and after removing them

– Change gloves between tasks and procedures in the same patient

– Never wear the same pair of gloves for the care of more than one patient

– Remove gloves after caring for patients

Gown

– Prevents soiling of clothing and skin during procedures likely to generate splashes of blood and or body fluids

– Sterile gown for aseptic procedures and a clean , non sterile gown is sufficient for other procedures
 Mask, eye protection/ face shield

– Relatives and health care workers with respiratory symptoms should use surgical masks

N95 respirators

– Specifically designed to filter small airborne particles

– Used in aerosol generating procedures

Respiratory hygiene / cough etiquette

• Cover mouth/noses when coughing or sneezing . Should perform hand hygiene

• Wear surgical mask if tolerated or maintain spatial separation

Sharps safety

Immunisation against vaccine-preventable diseases

Environmental measures
•High-quality cleaning and disinfection of all patient-care areas is important,
especially surfaces close to the patient (e.g. bedrails, bedside tables, doorknobs and
equipment)

•Frequent cleaning of surfaces , such as walls, floor and terminal cleaning (patient
bed area) after discharge or death

•Ensure reusable equipment is cleaned and sterilised

•Used and soiled patient-care equipment should be carefully handled

•Adequate waste disposal

Transmission based precautions
Airborne precautions

• Isolate with negative pressure ventilation

• Use of N95 respirator mask

Contact precautions

• Isolate and limit transportation

• Non- critical patient care equipment should be of single use

• For reusable equipment , clean and disinfect before using on another patient

Droplet precautions

• Isolatie and limit transportation

• Use of N95 respirator mask

MAJOR hCai IN ICU

• Catheter associated urinary tract infection (CAUTI)

• Catheter related blood stream infection (CRBSI)
• Ventilator associated pneumonia (VAP)
• Surgical site infection (SSI)
 CATHETER safety bundle

• Insert catheter only when necessary

• Follow aseptic measures during insertion

• Maintain a closed drainage system

• Maintain unobstructed flow - rid of kinking and the urine bag be kept below the level of the bladder

• Urine bag should never have floor contact

• Remove catheter when it is no longer needed

• Change indwelling catheters or drainage bags only when there are clinical indications
CRSBI(catheter related blood stream infection) safety bundle
• Use maximal sterile barrier precautions

• Clean skin with alcohol based preparations

• For CVC , the upper extremity is preferred

• Use antibiotic impregnated CVC if catheter is expected to remain in for more than 5 days

• Use either sterile gauze or sterile, transparent , semipermeable dressing to cover the catheter

• Insertion date should be put on all vascular access devices

• Evaluate the insertion site daily and replace dressing when necessary

• Routine replacement of catheters is not required

• Frequent replacement of fluid giving sets

• Clean injection ports with appropriate antiseptic

VAP safety bundle
• Avoid intubation and invasive ventilation whenever possible

• Keep head elevated at 30- 45

• Prefer oral to nasal intubations

• Daily oral care with antiseptic solution

• Avoid reintubation whenever possible

• Daily sedation vacation if feasible and assessment of readiness to extubate

• Prefer endotracheal tubes with subglottic suction port

• Keep endotracheal tube cuff pressure above 20cm H20

• Avoid acid prophylaxis for patients who are not high risk for developing stress ulcers

• Periodically drain and discard any condensate that collects in tubing of ventilator

• Closed endotracheal suction systems are better

Ssi safety bundle
• Administer prophylactic antibiotics when indicated

• Do not remove hair preoperatively unless it will interfere with the incision

• If hair needs to be removed , it should be done immediately before the

operation

• Antiseptic agent for skin preparation and should be done in a centrifugal

manner

• Use sterile techniques when handling wound dressing

• Skin care
• Prompt identification and treatment of infection from other
sources
Antibiotic stewardship
• Effort to measure and improve how antibiotics are prescribed by clinicians and
used by patients

• Allows close collaboration between the antimicrobial stewardship team ,

microbiology lab, pharmacy and infection control team

• Allows evidence based prescriptions that incorporates local microbiology and

resistance patten thereby improving antibiotic utilisation

• Decreases nosocomial outbreak of resistant infections

• Fast-tracks antibiotic de-escalation

 conclusion

• 80% of disease spread through unclean hands

• Hand washing is the single most important measure in infection
control, particularly in the ICU
• In addition, stringent measures for monitoring care bundles and
other standard precautions should be implemented
References

• Morgan text book of anesthesia, 5th ed (pg 1314-1316)

• Ncdc guidelines
• Journal of Critical Care Medicine
• Journal of Tropical Biomedicine
Thank you