Intensive Care Units Infections and Contro


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Intensive Care Units Infections and Contro

  2. 2. A Patient in Intensive Care Unit is at Risk for Many Reasons..10/16/2012 Dr.T.V.Rao MD 2
  3. 3. The Purpose of the Programme• The purpose of this program is to maintain a healthy and safe Hospital by the prevention and control of health care related infections / diseases in particular intensive care units. This is achieved by surveillance and investigation of infectious diseases and public education. 3 Dr.T.V.Rao MD 10/16/2012
  4. 4. Educating our Health Care Workers• Education programs for employees and volunteers are one method to ensure competent infection control practices. It is a unique challenge since employees represent a wide range of expertise and educational background. The ICP must become knowledgeable in adult education principles and use educational tools and techniques that will motivate and sustain behavioral change. Much has been written about the education of healthcare workers (HCWs). Some of the tools used to educate HCWs successfully include newsletter, posters and videos 10/16/2012 Dr.T.V.Rao MD 4
  5. 5. Why ICU patients are different• Sickest patients (multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma)• Move less• Malnourished• More obtunded (Glasgow coma scale)• May be associated Diabetics and Heart failure10/16/2012 Dr.T.V.Rao MD 5
  6. 6. EPIDEMIOLOGY• Contributing factors – Patients in ICUs have more chronic comorbid illnesses and more severe acute physiologic derangements – 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 – Multidrug-resistant pathogens such as methicillin- resistant Staphylococcus aureus MRSA and Vancomycin-resistant enterococci VRE are being isolated with increasing frequency in ICUs10/16/2012 Dr.T.V.Rao MD 6
  7. 7. Early survival benefit for immediate ICU Care• Early survival benefit for immediate ICU care• Difficulty in explaining lack of ICU advantage later: could be related to the more aggressive monitoring and therapy in the ICU, which may be beneficial early by stabilizing the patient but may be deleterious afterward, due to infections, for example.10/16/2012 Dr.T.V.Rao MD 7
  8. 8. ICU Care is Invasive at many Stages• More invasive lines and procedures including surgeries• Longer length of stay• More IV and parenteral drugs• More tube feeding and Parenteral nutrition• More ventilation10/16/2012 Dr.T.V.Rao MD 8
  9. 9. ICU : Factors that increase cross-infections• Hand washing facilities are inadequate• 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 environment10/16/2012 Dr.T.V.Rao MD 9
  10. 10. 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 malnutrition10/16/2012 Dr.T.V.Rao MD 10
  11. 11. 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 technique10/16/2012 Dr.T.V.Rao MD 11
  12. 12. 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 free10/16/2012 Dr.T.V.Rao MD 12
  13. 13. 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 priorities10/16/2012 Dr.T.V.Rao MD 13
  14. 14. Intensive Care Unit Prevention of Blood stream infections10/16/2012 Dr.T.V.Rao MD 14
  15. 15. Central Venous CathetersIndications• IV fluids and drugs• Blood and blood products• Total Parenteral Nutrition (TPN)• Hemodialysis• Hemodynamic monitoring10/16/2012 Dr.T.V.Rao MD 15
  16. 16. Serious Infective Complications• Blood Stream Infections (BSI)• Septic pulmonary emboli• Metastasis infection – Acute endocarditis – Osteomyelitis – Septic arthritis• Shock and organ failure• Poor outcome: Staph.aureus or Candida spp.10/16/2012 Dr.T.V.Rao MD 16
  17. 17. Incidence of CR-BSI• Type of catheter Teflon or Polyurethane ( < infections) vs Polyvinyl chloride or Polyethylene• Site of insertion Subclavian (< infections) vs Internal Jugular & Femoral (high risk of colonization & deep venous thrombosis)• No. of Lumen Single-lumen catheter (< infections) vs Multi-lumen catheter10/16/2012 Dr.T.V.Rao MD 17
  18. 18. Prevention Strategies: Core Proper Insertion Practices • Ensure utilization of insertion bundle: – Chlorhexidine for skin antisepsis – Maximal sterile barrier precautions (e.g., mask, cap [i.e., similar to those worn in the O.R.], gown, sterile gloves, and large sterile drape) – Hand hygiene • Many CLs in patients on non-ICU hospital wards are placed outside those wards (Emergency room, ICU, Operating room, or Pre-operative areas) • In one study, 49% of CLs were present on admission to the ward. Rates of BSI in this study were higher in CLs placed in Emergency Room • Define where placement occurs and review technique in those areas Trick et al. Am J Infect Control 2006;34:636-41.10/16/2012 Dr.T.V.Rao MD 18
  19. 19. Prevention Strategies: Core Chlorhexidine Skin Cleansing • Chlorhexidine is the preferred agent for skin cleansing for both CL insertion and maintenance – Tincture of iodine, an iodophor, or 70% alcohol are alternatives – Recommended application methods and contact time should be followed for maximal effect • Prior to use should ensure agent is compatible with catheter – Alcohol may interact with some polyurethane catheters – Some iodine-based compounds may interact with silicone catheters10/16/2012 Dr.T.V.Rao MD 19
  20. 20. Sources of Infection Intrinsic contamination of infusion fluid Port for additives Connection with administration set Insertion site Injection ports Administration set connection with IV catheter10/16/2012 Dr.T.V.Rao MD 20
  21. 21. 1. Extra luminal Spread Sources of Infection Patient’s own skin micro flora Microorganism transferred by the hands of Health Care 2. Intraluminal Spread Intralumunal Spread Worker Contaminated infusate Contaminated Contaminated entry port, (fluid, medication) infusate (fluid, catheter tip prior or during medication) insertion Contaminated disinfectant solutions Invading wound attachment Skin Skin Fibrin Vein 3. Haematogenous Spread Infection from distant10/16/2012 Dr.T.V.Rao MD focus 21
  22. 22. Prevention of CR-BSIWritten Protocol Must be performed by trained staff according to written guidelinesSterile procedure Sterile gown, Sterile gloves, Sterile large drapes Dont shave the siteHand disinfection With an antiseptic solution eg Chlorhexidine gluconate10/16/2012 Dr.T.V.Rao MD 22
  23. 23. Prevention of CR-BSISkin 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• No difference between 0.5% Chlorhexidine gluconate or 10% Povidone-iodine Humar A et al. Clin Infect Dis 2000;31:1001-710/16/2012 Dr.T.V.Rao MD 23
  24. 24. Prevention of CR-BSIDressing• Gauze dressings every 2 days• Transparent dressing every 7 days on short term catheter• Replace dressing when catheter is replaced or dressing becomes damp or loose. Grady NP et al, HICPAC draft guidelines: 200210/16/2012 Dr.T.V.Rao MD 24
  25. 25. Prevention of CR-BSICatheters removal• Don’t replace it routinely• Replace it if: – Inserted in an Emergency – Non functioning – Evidence of local or systemic infectionGeneral handling• Opening of hub: Use antiseptic- impregnated pads eg Chlorhexidine gluconate or povidone iodine10/16/2012 Dr.T.V.Rao MD 25
  26. 26. Prevention of CR-BSIAdministration sets• Replacement at 72-h intervals• No difference in phlebitis if left for 96 hours• Lines for lipid emulsion: replacement at 24-h intervals• Lines for blood product : remove immediately after use10/16/2012 Dr.T.V.Rao MD 26
  27. 27. Prevention of CR-BSITopical 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 catheterSystemic antibiotic• Prophylactic use of antibiotic is not recommended at the time of catheter insertion10/16/2012 Dr.T.V.Rao MD 27
  28. 28. Background: Prevention Strategies Interventions • Michigan Keystone Project • Decrease in CLABSI in 103 ICUs in Michigan (66% reduction) • Basic interventions: – Hand hygiene – Full barrier precautions during CL insertion – Skin cleansing with chlorhexidine – Avoiding femoral site – Removing unnecessary catheters – Use of insertion checklist – Promotion of safety culturePronovost et al. NEJM 2006;355:2725-32.10/16/2012 Dr.T.V.Rao MD 28
  29. 29. Urinary Catheterization10/16/2012 Dr.T.V.Rao MD 29
  30. 30. External urethral meatus & urethra• Pass catheter when bladder 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 insertion10/16/2012 Dr.T.V.Rao MD 30
  31. 31. 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.10/16/2012 Dr.T.V.Rao MD 31
  32. 32. Junction between drainage tube & collection bag• Keep bag below level of bladder. If it is necessary to raise collection bag above bladder level for a short period, drainage tube must be clamped temporarily.• Empty bag every 8 hours or earlier if full.• Do not hold bag upside down when emptying10/16/2012 Dr.T.V.Rao MD 32
  33. 33. Tap at bottom of collection bag• Collection bag must never touch floor.• Always wash or disinfect hands (eg with 70% alcohol) before and after opening tap.• Use a separate disinfected jug to collect urine from each bag.• Dont put disinfectant into urinary bag.10/16/2012 Dr.T.V.Rao MD 33
  34. 34. Strategies for Prevention of CAUTIAvoid unnecessary placement of indwelling urinary +++cathetersRemove catheters as quickly as possible +++Alternative condom catheter, intermittent bladder +++catheterizationAseptic technique in catheter insertion +++Appropriate catheter maintenance ++Antimicrobial therapy -Different catheter composition 10/16/2012 Dr.T.V.Rao MD + 34
  35. 35. Intensive Care Unit Nosocomial Pneumonia10/16/2012 Dr.T.V.Rao MD 35
  36. 36. Incidence of HAI vs. Cost Hospital acquired Incidence Additional Infection cost Urinary Tract 45% 13% Surgical Wound 29% 42 % Pneumonia 9% 39% Blood Stream 2% 4%10/16/2012 Dr.T.V.Rao MD Haley, 1986 36
  37. 37. Risk factors for bacterial pneumonia Host Factors Factors that facilitate reflux & aspiration into the lower RT • Elderly • Severe Illness • Underlying Lung Disease - Mechanical ventilation • Depressed Mental Status - Tracheostomy • Immunocompromising - Use of a Nasogastric Tube Conditions or Treatments - Supine Position • Viral Respiratory Tract Factors that impede normal Infection Pulmonary Toilet Colonisation - Abdominal or thoracic surgery • Intensive Care Setting - Immobilisation • Use of Antimicrobial Agents • Contaminated hands • Contaminated Equipment10/16/2012 Dr.T.V.Rao MD 37
  38. 38. Prevention in ICU• Turn patients to encourage postural drainage• Encourage to take deep breaths and cough.• Maintain an upright position (elevate patient’s head to 30º- 45º degree angle) to reduce reflux and aspiration of gastric bacteria.10/16/2012 Dr.T.V.Rao MD 38
  39. 39. Gastric Ulcer Prophylaxis • Stomach of a healthy person : Acidic pH () & normal peristalsis movement prevent bacterial growth • Alkaline pH () and loss on normal peristalsis lead to bacterial colonisation which increases the risk of ventilator-associated pneumonia • Mechanical ventilation patients are at increased risk for upper GI hemorrhage from stress ulcers. • H2 blockers or antacids are used to prevent stress ulcers10/16/2012 Dr.T.V.Rao MD 39
  40. 40. Nasogastric Tube• May erode the mucosal surface• Block the sinus ducts• Regurgitation of gastric contents leading to aspiration.• Verify placement of the feeding tube in the stomach or small intestine by X ray• Elevate the head of the bed 30º- 45 º degrees Remove NG Tube if not necessary10/16/2012 Dr.T.V.Rao MD 40
  41. 41. Ventilators• After every patient, clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturer’s instructions.10/16/2012 Dr.T.V.Rao MD 41
  42. 42. Suctioning mechanically ventilated patients• Hand washing before and after the procedure.• Wear clean gloves to prevent cross- contamination• Use a sterile single-use catheter ; if it is not possible then rinse catheter with sterile water and store it in a dry, clean container between uses and change the catheter every 8 - 12 hours.10/16/2012 Dr.T.V.Rao MD 42
  43. 43. Suction Bottle Use single-use disposable, if possible Non-disposable bottles should be washed with detergent and allowed to dry. Heat disinfect in washing machine or send to Sterile Service Department.10/16/2012 Dr.T.V.Rao MD 43
  44. 44. Nebulizers• Use sterile medications and fluids for nebulization• Fill with sterile water only.• Change and reprocess device between patients by using sterilization or a high level disinfection or use single-use disposable item.• Small hand held nebulizers – minimise unnecessary use – between uses for the same patient disinfect, rinse with sterile water, or air dry and store in a clean, dry place• Reprocess nebulizers daily10/16/2012 Dr.T.V.Rao MD 44
  45. 45. Humidifiers• Clean and sterilize device between patients.• Fill with sterile water which must be changed every 24 hours or sooner, if necessary.• Single-use disposable humidifiers are available but they are expensive.10/16/2012 Dr.T.V.Rao MD 45
  46. 46. Oxygen mask• Change oxygen mask and tubing between patients and more frequently if soiled10/16/2012 Dr.T.V.Rao MD 46
  47. 47. 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 be prevented 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 and those clinically involved with the infection.• An organized hospital-wide surveillance system. 10/16/2012 Dr.T.V.Rao MD 47
  48. 48. Antibiotics use Must avoid widespread use ofbroad spectrum antibiotics10/16/2012 Dr.T.V.Rao MD 48
  49. 49. Problem-Detection of Infection in the ICU’s10/16/2012 Dr.T.V.Rao MD 49
  50. 50. Examples of difficult to detect infections: Uncultivable organismsViruses are under appreciated as causes of nosocomial infections. Except in cases of high morbidity viral cultures are not done in resource scarce settings. Impact food-borne, respiratory, water borne illnesses.We don’t know the spectrum of anti-microbial activity of most preservatives and cleaners for many viruses.10/16/2012 Dr.T.V.Rao MD 50
  51. 51. Examples from the NNIS Manual• Symptomatic Urinary Tract Infection: – Patient must have one of the two criteria:• Fever >38 C OR urgency OR frequency OR dysuria OR suprapubic tenderness without other cause OR• Urine culture with at least 105 organisms per ml or no more than two species of organisms10/16/2012 Dr.T.V.Rao MD 51
  52. 52. Definition of surgical site infection (no implant) • Occurs within 30 days of surgery AND has one of the following: Purulent drainage from drain OR Organism isolated from aseptically obtained fluid in the organ space10/16/2012 Dr.T.V.Rao MD 52
  53. 53. Prior to starting any surveillance• Agree upon a written case definition that is practical given the laboratory facilities and patient work load in your facility.10/16/2012 Dr.T.V.Rao MD 53
  54. 54. Our plan for future should include• Unlike scheduled activities, occasional clusters of patients who are colonized or infected will trigger further investigation including a case-control study. New laboratory methods developed and refined within the last decade can now determine how related the strain is at the molecular level. The QI/IC plan should include special problem-focused studies that describe personnel or environmental sampling, including what circumstances and who has the authority to order10/16/2012 Dr.T.V.Rao MD 54
  55. 55. 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 10/16/2012 Dr.T.V.Rao MD 55
  56. 56. 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-compliers10/16/2012 Dr.T.V.Rao MD 56
  57. 57. 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 1.7-12.810/16/2012 Dr.T.V.Rao MD 57
  58. 58. Our Vision to Future• Infection control programs must maintain training records of employees. The minimum training required is annual OSHA blood borne pathogen, tuberculosis prevention and control and new employee orientation.10/16/2012 Dr.T.V.Rao MD 58
  59. 59. Why we need better ICU’s• For an incidence as well as for a prevalence population of critically ill patients, there is a window of critical opportunity for admission into the ICU, much like the golden our for the trauma patient.• Efforts should be made to avail ICU facilities to as many recently deteriorated patients as possible, especially those who could be transferred into the ICU very early after deterioration, such as patients on hospital wards.10/16/2012 Dr.T.V.Rao MD 59
  60. 60. Do remember the Reasons for Infections are Many but solutions are few …10/16/2012 Dr.T.V.Rao MD 60
  61. 61. Yet No Substitute for Hand Washing Are You Washing ?10/16/2012 Dr.T.V.Rao MD 61
  62. 62. Let us support our Hospitals with clean hands10/16/2012 Dr.T.V.Rao MD 62
  63. 63. Follow me for more articles of Interest on Infections on …10/16/2012 Dr.T.V.Rao MD 63
  64. 64. • The Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World Email doctortvrao@gmail.com10/16/2012 Dr.T.V.Rao MD 64