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Infection control in icu

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  • 1. 1 VISHAL 1-12-2012
  • 2. Modes of transmission of nosocomial infections Common ICU infections  Evidence based prevention strategies 2
  • 3. 3 Pittet et al 2006 
  • 4. 4
  • 5.  Skin and oral cavity of patients colonized in hours to days Staph. aureus, Proteus mirabilis, Klebsiella spp. Acinetobacter, Enterococci present @102 -106 CFU /cm2 skin  Perineal/inguinal > axilla > trunk > upper limbs and hands  Patients on hemodialysis , diabetes, dermatitis, broad spectrum antibiotics are at increased risk  10 skin squames containing viable microorganisms are shed⁶ daily, objects in the immediate environment of the patient become contaminated with patient flora acting as fomites 5
  • 6. 6
  • 7. 7 Panhotra Am J Infect Control 2005
  • 8. 8 Pittet et al 2006  
  • 9. 9
  • 10.  “Clean Activities” like clinical examination, lifting or bed making Up to 102 -104 CFU from HCWs hands Phillips, BMJ 1977  HCWs intercepted after handling MRSA colonized patient but before hand wash 17% of worker’s gloves positive McBride, J Hosp Inf 2004 10
  • 11.  Surveillance cultures of HCWs hands in ICU 21% of MDs; 5% of nurses positive Daschner, J Hosp Inf 1988  Serial Cultures of SICU HCWs hands 100% positive for GNB and 64% positive for Staph aureus at least once Maki, Ann Int Med 1978  Rings, artificial or long nails, dermatitis increase frequency of hand contamination of HCWs Trick, Clin Inf Dis 2003 11
  • 12. 12 Zachary, Inf Control Hosp Epidem. 2001 Site Percentage positive for organism Gloves / Hands 63 Gowns 37 Stethoscopes 31 Stethoscope after wipe 2
  • 13. 13Pittet, Arch Int Med 1999
  • 14. 14 Pittet et al 2006   
  • 15. 15 Microbe Mean survival time (min) Klebsiella spp 2 E. coli 6 Rotavirus 20 Pseudomonas spp 30 Acinetobacter spp 60 VRE 60
  • 16. 16 Pittet et al 2006    
  • 17. 17 - Pittet D et al. Ann Intern Med 1999 HCW Compliance OR Nurse 52% 1 Respiratory therapist nursing attendants 47% 1.28 Others 38% 2.15 Physicians 30% 2.80 48 % - Witterick, Crit Care Med 2008
  • 18. 18 Pittet et al 2006     
  • 19. 19
  • 20.  Respiratory Tract Infections (RTI)  Blood Stream Infections (BSI)  Intraabdominal & Urosepsis (UTI)  Skin & Soft Tissue Infections (SSTI) 20
  • 21.  Advanced age  Associated co-morbidities  Increased severity of disease (APACHE score)  Prolonged ICU stay  Interinstitutional transfer  Use of invasive medical/ surgical devices  Irrational use , use of broad spectrum Abx  Poor nutrition < 6 cal/kg / day 21
  • 22.  Nosocomial Pneumonias – HCAP, HAP, VAP  Nosocomial Maxillary Sinusitis Nosocomial Pneumonia  HCAP – Health care associated Pneumonia  Hospitalised > 2 days within 90 days of RTI , or  Received parenteral therapy within 30 days, or  Received treatment in long term care facility 22
  • 23.  HAP - Hospital acquired pneumonia had Pneumonia > 48 hrs after hospitalisation and not incubating  VAP – Ventilator Acquired/ Ventilation Associated Pneumonia Pneumonia post 48 hrs of endotracheal intubation Early- < 4 days Late - > 4 days 23
  • 24.  1 out of four who get intubated develop VAP  Mortality ranges from 30- 70 %  Causes – a) Normal oropharyngeal flora changes due to loss of fibronectin due to airway ( Bacteroides -> endogenous GNB) b) Spread from contigous sites c) Blood stream infection Higher mortality seen with late VAP + Oropharyngeal secretions Valles , Int Care Med - 2007 24
  • 25.  New or worsening CXR infiltrates +  One or more of following- a) Change in secretions character b) Positive growth from specimen culture  Protected brush culture > 103 CFU/ ml  BAL > 104 CFU/ ml  ETA > 105 CFU/ ml c) Rise in antibody titres (IgM or IgG fourfold) d) Histological evidence Specific Objective Scoring scale - CPIS score >6 Procalcitonin > 0.5 ng/ml (PPV – 69-79% in VAP) 25
  • 26. 26 2003 Category IA. - Strongly recommended , supported by well designed experimental, clinical, or epidemiologic studies. Category IB. - Strongly recommended , supported by some clinical or epidemiologic studies and by strong theoretical rationale. Category IC. - Required for implementation, as mandated by federal or state regulation or standard. Category II. - Suggested for implementation , supported by suggestive clinical or epidemiologic studies or by strong theoretical rationale.
  • 27.  Several revisions have been done following these 2003 guidelines.  CDC – MMWR (Morbidity & Mortality Weekly Report) - 2004  Coffin SE, strategies to prevent VAP in ICU - Infec Control Hosp Epidem -2008  Majority of recommendations of 2003 are still valid. 27
  • 28.  Staff Education and involvement - I A  Infection and Microbiologic Surveillance  at risk critically ill patients - IB  all ICU patients not recommended - II  Sterilization of Equipment and Devices  Cleaning before sterilisation - IA  Autoclaving - IA  Use sterile water for rinsing post chemical sterilisation, if not then filter tap water f/b drying - IB 28
  • 29. Tubings and accessories  Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators - IA  Periodically drain out condensate fluid in tubings, donning gloves - IB  Dont routinely change tubings unless visibly soiled - IA  Filter at expiratory phase of tubing - Unresolved  Humidifiers fluid – only distilled water - IA 29
  • 30.  HME usage vs Heated humidifier - Unresolved HME have higher incidence of VAP than heated humidifiers (39.6% vs 15.7%) - Lorente, Critical care Forum 2006  Nebulisation  Single use aerosol / MDI - IB  With solution in nebuliser chamber - IC  Can reuse bains circuit, AMBU, Traheal or face mask, Venturimeters or reservoir bags, Tpiece - IB  after autoclaving 30
  • 31.  Hand hygiene before & after handling patient-IA  Hand wash with soap and water if dirty or  Alcohol rub if clean Wear gloves and gown - IB Suctioning of ET/ TT secretions  Multiuse closed-system suction catheter or the single-use open system suction catheter - Unresolved No difference found in either usage - Magiorre, Intensive Care Med- 2006 - Jongerden , Crit Care Med - 2007 31
  • 32.  Using sterile or clean gloves for suction – Unresolved  Single use catheter for open system - II  Sterile fluid for irrigation - II  Use of isotonic saline instillation before tracheal suctioning (ISIBTS - 8ml) in closed suctioning system is better than plain suctioning - Caruso, Crit Care Med -2009 10.8% vs 23.5% VAP rates Thins out & increase secretion, increase cough Reduces ET Biofilm 32
  • 33.  Prevention of aspiration  Use NIV if possible to avoid intubation - II  Extubate to NIV - II  Avoid repeated intubations - II  Oral preferred to nasotracheal - IB  Subglottic aspiration of secretions - II Continous better than intermittent - Bouza, Chest – 2008 Reduced VAP rates- (26.7 % vs 47.5%) Reduced Mortality - ( 44.4% Vs 52.5%) 33
  • 34.  Supraglottic suction before extubation,reintubation – II  Type of ET tube  HVLP with ultrathin (7 µm) polyurethrane cuff membrane better  Antimicrobial coated ET tubes preferred NASCENT trial – North American Silver Coated ET study – Berra , Intensive Care Med -2008 35.9% Relative risk reduction to develop VAP Reduced mortality in patients with VAP –14 % vs 36% 34
  • 35.  Prevention of aspiration associated with feeding  30-45 degree head end elevation - II (5 % vs 23 % in supine) – Drakulovik, Lancet 1999  Continous vs intermittent NG feeds - unresolved  NG vs NJ feeds - unresolved But latter a/w reduced incidence of late pneumonia in TBI patients - Acosta , Intensive Care Med- 2010  Routine verification of placement Radiologically + 35
  • 36.  Selective Oral Decontamination (SOD) – II Method for SOD(topical Abx, Chlorhex) - Unresolved  Selective Digestive tract Decontamination (SDD) - Unresolved SDD though reduced the incidence of MODS in critically ill ventilated pts,it did not reduce overall mortality. (systematic review of RCTs) - Silvestri,Int care Med 2010  DOC for prevention of SRMB – Unresolved 36
  • 37.  Physiotherapy & mobilisation  Early ambulation, incentive spirometry - IB  Chest physiotherapy routinely - Unresolved Contradictory evidences  Increased mortality in patients on ventilator for > 48 hrs - Templeton, Int Care Med , 2007  Reduced mortality (49 vs 24% )and CPIS score - Pattanshetty, Ind J Crit Care Med, 2010  Kinetic therapy or continous lateral rotation 37
  • 38. Continous lateral rotation was found to have reduced incidence of VAP - Staudinger, CCM 2010  Antibiotic prophylaxis, Empirical treatment of VAP - Unresolved  Pneumococcal vaccination for high risk groups – IB Nasomaxillary sinusitis Avoid nasotracheal intubation Semirecumbent position Xylometazoline + budesonide appplication Hand hygiene 38
  • 39.  Primary – no identifiable focus  Secondary – related to infection at other site  CRBSI / CLABSI - Catheter Related or Central Line Associated BSI  Infective endocarditis related BSI CRBSI diagnostic criteria  High clinical suspicion  Positive bloood cultures- 2 peripheral or 1 peripheral + 1 central  Colony count 3- 10 times in central than peripheral with central culture positivity > 2 hrs before peripheral Defervescence after removel of CVC line 39
  • 40. 40 2011 Educate healthcare personnel regarding - IA 1) Indications for intravascular catheter use, 2) Proper procedures for the insertion and maintenance of intravascular catheters, 3)Infection control measures to prevent CRBSI Only trained personell to do insertion - IA Maintain 1:1 or 1:2 ratio of nurses to patient - IB
  • 41. Peripheral catheters  PICC line if duration of iv treatment is anticipated to be > 6 days - II  Upper limb access better than lower - II  Daily examination for signs of phlebitis - IB  Removal the moment early features seen or malfunction noticed or catheter not needed - IB 41
  • 42. Central line / Cental venous catheter  Evaluate infective complication more over mechanical one before selecting site - IA  Avoid femoral in adults - IB  Subclavian preferred over jugular in non tunneled catheres except in CKD where otherwise - IB  Subclavian or jugular in tunneled one -Unresolved  Ultrasound guided - IB 42
  • 43.  Minimum number of ports possible – IA  Use of a designated lumen for TPN - Unresolved  When adherence to stict asepsis during insertion doubtful,(e.g casualty, emergency) remove within 48 hrs - IB  Remove CVC when not required - IA 43
  • 44. Hand hygiene and aseptic technique  Hand wash (soap/ABHR – Alcohol Based Hand Rub) before and after inserting lines - IB  clean gloves for peripheral catheters - IC  Sterile gloves for arterial and cental lines -IA  New sterile gloves before handling the new catheter when guidewire exchanges are performed. - II  Clean or sterile while changing dressing - IC  44
  • 45.  Cap , face mask, sterile gown and gloves, sterile ultrasound probe cover during  insertion,  adjustment or  guidewire exchange of PICC and CVC - IB  Skin preparation  Peripheral line – any antiseptic - IB  Central line - > 0.5 chlorhex in alcohol base - IA  Chlorhexidine vs betadine - Unresolved 45
  • 46. Catheter site dressing regimen  Sterile gauze or sterile , transparent , semipermeable dressing at insertion site - IA  Active oozing, sweating – use gauze - II  Replace if wet, soiled or loose -IB  No topical antibiotic ointments except for dialysis catheters - IB Avoid contact with water during sponging - IB 46
  • 47.  Gauze dressing change after 2 days - II  Transparent one after 7 days - IB  Regularly examine the insertion site - IB  Through dressing  While changing dressing  Permit removal of dressing for evaluation of site if high index of suspicion of CRBSI - IB 47
  • 48.  2% chlorhex daily body wash - II  Antimicrobial (minocycline / rifampicin) or antiseptic (chlorhex/ silver sulfadiazine ) impregnated CVC can be used in pts needing CVC > 5 days if only combined with so called “COMPREHENSIVE STRATEGY”  Educating HCW handling lines  Strict aseptic measures as mentioned before  > 0.5 % chlorhex with alcohol for skin preparation - IA 48
  • 49.  No systemic prophylactic antibiotics - IB  Povidone , polymixin, bacitracin ointment at the free tip of dialysis cath after dialysis - IB  Antibiotic lock or antibiotic flush - II  Replacement of catheters Peripheral - only when indicated - IB CVC / PICC - only when indicated - IB - only on basis of new onset fever, rule out non infectious or non CRBSI cause of 49
  • 50. Guidewire exchanges  Preferably to be avoided. Do not use for prevention of CRBSI . Better use new site - IB  Can use for malfunctoning catheter replacement if previous one has no evidence of infection - IB Arterial lines – Most of the guidelines are same. Replace whole assembly after 96 hrs - IB No dextrose containing solutions in pressure bag - IA 50
  • 51. Tubings replacement  Tubings for IV fluids, drug infusions to be replaced ideally every 96 hrs, max 7 days - IA  Tubings used for blood, blood products, TPN - ideally within 24 hours of their initiation for infusion - IB  Propofol infusion tubings within 12 hrs - IA 51
  • 52.  Most of them are Catheter Associated UTI (CAUTI)  2009  Use urinary catheter only if indicated  Avoid use in high risk, terminate use ASAP  Surgical patient no routine use, remove within 24 hrs if not required  Avoid use for urinary incontinence - IB 52
  • 53.  Appropriate indication-  Acute urinary retention or bladder outlet obstruction  Need for accurate measurements of output in critically ill  Perioperative use :  Urologic surgery or other surgery on contiguous structures of the genitourinary tract  Anticipated prolonged duration of surgery  Patients anticipated to receive large-volume infusions or diuretics during surgery  Need for intraoperative monitoring of urinary output 53
  • 54.  Assist in healing of open sacral or perineal wounds in incontinent patients  Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)  To improve comfort for end of life care if needed Inappropriate  As a substitute for nursing care  To obtain samples for labs, cultures 54
  • 55.  Alternatives –  External catheter use - II  Self Intermittent Bladder Catheterisation - II  Supra Pubic Catheterisation - Unresolved  Insertion -  Trained personell - IB  Strict asepsis during insertion , manipulation - IB 55
  • 56.  Properly secure over lower abd wall - IB  Choose smallest bore possible to avoid trauma - IB  Maintain a closed drainage, replace if damaged - IB  Urobag always below level of bladder but not touching the floor -IB  Clean emptying practices - IB 56
  • 57.  Do not routinely change catheter or urosac at fixed intervals - IB  Indication driven change acceptable - IB  Suspected infection  Obstuction  Breached closed drainage system  Do not use prophylactic antibiotics for CAUTI - IB  Unless obstruction highly suspected, do not flush catheter - II 57
  • 58.  Bladder irrigation or collecting bag instillation with antibiotics, antiseptics not recommended - II  Cleaning of periurethral area with antiseptics to prevent CAUTI not recommended - IB  Cleaning of glans and meatal surface while daily bath with chlorhex recommended - IB  Antibiotic, antiseptic coated catheter use - IB if associated with the “ comprehensive strategy”  Silicone catheters, one way valve use - II 58
  • 59.  In case of suspected obstruction better change catheter than flushing - IB  Use of ultrasound to decide on obstruction for cause of oliguria - unresolved  Samle collection for labs aseptically - IB  Periodic surviellance, HCW education - IB 59
  • 60. 1999  Most of the recommendations are same for asepsis  OR like asepsis, restricted personell entry in SICU - IB  15 air exchanges / hr- min 3 fresh air , filter all air - IB  >0.5 % chlorhex in alcohol for skin prep, dressing - IB  Avoid antibiotic prophylaxix for SSTI - IB 60
  • 61. Guidelines already quoted and those for -  Hand washing – 2003  Isolation of patients – 2007  Disinfection, sterilisation and housekeeping - 2008 Can be acessed and downloaded from the following link – http://www.cdc.gov/hicpac/pubs.html 61
  • 62. 62 IGNAZ SEMMELWEIS (1818 – 1865) DEFENDER OF MOTHERHOOD
  • 63. 63