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GUEST LECTURE AT               JIPMER , Pondicherry                INTENSIVE CARE UNITS              INFECTIONS AND CONTRO...
A tribute to Ignaz Semmelweiss                 (1818-1865)Ignaz Semmelweis                    .....  (1818-1865)• Obstetri...
What is a Intensive Care Unit• An intensive care unit (ICU) is  defined as a specially staffed,  specialty equipped, separ...
A Patient in Intensive Care Unit is at         Risk for Many Reasons..12/23/2012         Dr.T.V.Rao MD            4
Infection in ICU are             •More in Prevention             •Little in Treatment12/23/2012           Dr.T.V.Rao MD   5
Educating our Health Care               Workers• Education programs for  employees and volunteers are one  method to ensur...
Why ICU patients are different• Many times very sick patients (multiple  diagnoses, multi-organ failure,)  immunocompromis...
ICU patients are rapidly colonized with           pathogenic bacteria• Skin colonized in hours to days  – Staph. aureus, P...
EPIDEMIOLOGY• Contributing factors     –The high frequency of indwelling      catheters among ICU patients     –The use an...
Drug Resistant Bacteria a threat to Life• Multidrug-resistant pathogens  such as methicillin-resistant  Staphylococcus aur...
ICU Care is Invasive at many                 Stages• More invasive lines and  procedures including  surgeries• Longer leng...
ICU : Factors that                            increase            cross-infections• Hand washing facilities are inadequate...
Some Health-Care Associated Infections         May Occur in ICU Patients• UTI associated with Foley catheters• Lower respi...
Strategy for Prevention• Hand washing• Use gloves to prevent contamination of the  hands when handling respiratory secreti...
Strategy for Prevention• Clean and decontaminate all equipment after use• Sterilise or use high-level disinfection for all...
Strategy for Infection                  Prevention•   Strict attention to Hand hygiene•   Prudent Antibiotic use•   Asepti...
Intensive Care Unit             Prevention of Blood stream                     infections12/23/2012             Dr.T.V.Rao...
Central Venous CathetersIndications• IV fluids and drugs• Blood and blood products• Total Parenteral Nutrition (TPN)• Hemo...
Serious Infective Complications• Blood Stream Infections (BSI)• Septic pulmonary emboli• Metastasis infections     – Acute...
Incidence of CR-BSI• Type of catheter        Teflon or Polyurethane ( < infections) vs Polyvinyl        chloride• Site of ...
Sources of Infection                     Intrinsic contamination of                            infusion fluid  Port for  a...
1. Extra luminal Spread                  Sources of Infection        Patient’s own skin micro flora        Microorganism t...
Prevention Strategies: Core             Chlorhexidine Skin Cleansing  • Chlorhexidine is the preferred agent for skin    c...
Prevention of CR-BSISkin antisepsis• 2% Chlorhexidine gluconate has shown to  have lower BSI than 10% Povidone-iodine or  ...
Prevention of CR-BSITopical antibiotic• Prophylactic use of topical Mupirocin (Bactroban) at  insertion site or in nose is...
Urinary Catheterization12/23/2012   Dr.T.V.Rao MD    26
External urethral meatus &                 urethra• Pass catheter when bladder is full for wash-  out effect.• Before cath...
Junction between catheter & drainage                    tube• Do not disconnect catheter unless  absolutely necessary.• Fo...
Intensive Care Unit             Nosocomial Pneumonia12/23/2012           Dr.T.V.Rao MD   29
Incidence of HAI vs. Cost   Hospital acquired         Incidence Additional        Infection                           cost...
Prevention in ICU• Turn patients to  encourage postural  drainage• Encourage to take deep  breaths and cough.• Maintain an...
Too many Wash basins are Hazardous• It is not necessary to have an individual hand  wash basins for every bed space as the...
The Scientific study ( SENIC )                    gives guidelines• Study of the Efficacy of Nosocomial Infection Control ...
Concerns with staphylococcus• Methicillin-resistant  S. aureus (MRSA) is  resistant to several  antibiotics. Another  form...
RESISTANT GRAM NEGATIVE ORGANISMS• Resistance to multiple antibiotics             Organisms:             E .coli          ...
E.Coli and emerging resistance                       • Escherichia coli (E.                         coli) has gradually   ...
SURVEILLANCE• Important means of monitoring HAI  Early detection of trends outbreaks•   Laboratory Based    Microbiology L...
Universal precautions•   Hand washing•   Personal protective equipment [PPE]•   Preventing/managing sharps injuries•   Ase...
Antibiotics use  Must avoid widespread          use ofbroad spectrum antibiotics12/23/2012         Dr.T.V.Rao MD   39
Problems in -Detection of Infection in         the ICU’s12/23/2012   Dr.T.V.Rao MD   40
Examples of difficult to detect infections:        Uncultivable organisms    Viruses are under appreciated as causes of   ...
Definition of surgical site infection           (no implant)   • Occurs within 30      days of surgery   AND has one of th...
Prior to starting any surveillance• Agree upon a  written case  definition that is  practical given the  laboratory  facil...
Hand washing• Single most effective action to prevent HAI -  resident/transient bacteria• Correct method - ensuring all su...
Why we are not washing hands ???  •    Working in high-risk areas  •    Lack of hand hygiene promotion  •    Lack of role ...
EPIDEMIOLOGY• A multicenter, prospective cohort surveillance study of 46  hospitals in Central and South America, India, M...
Cockroaches (Ectobius vittiventris) in  an Intensive Care Unit, Switzerland• Cockroaches are capable of harboring Escheric...
Rapid and Newer method of                 Contamination with• ATP testing works because Adenosine  Triphosphate is present...
Our Vision to Future• Infection control    programs must    maintain training    records of employees.    The minimum trai...
WHONET - Documentation• Establishing WHONET  Documentation makes  the Antibiograms  assessments easy by  Microbiologists a...
Do remember the Reasons for Infections are         Many but solutions are few …12/23/2012           Dr.T.V.Rao MD         ...
Consequences of hospital infections              ???     Hospital     Pathogen          Unhappy          Unhappy          ...
How successful are our Programmes• Accreditation from competent government  agency; training of ICU nurses and Intensive  ...
Let us support our Hospitals with                  clean hands12/23/2012           Dr.T.V.Rao MD         54
12/23/2012   Dr.T.V.Rao MD   55
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Guest talk icu infections

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Guest talk on ICU infections

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Guest talk icu infections

  1. 1. GUEST LECTURE AT JIPMER , Pondicherry INTENSIVE CARE UNITS INFECTIONS AND CONTROL (December 2012) Dr.T.V.Rao MD Professor of Microbiology Travancore Medical College, Kollam Kerala12/23/2012 Dr.T.V.Rao MD 1
  2. 2. A tribute to Ignaz Semmelweiss (1818-1865)Ignaz Semmelweis ..... (1818-1865)• Obstetrician, practised in Vienna• Studied puerperal (childbed) fever• Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems• Reduced maternal mortality by 90%• Ignored and ridiculed by colleagues Dr.T.V.Rao MD 2
  3. 3. What is a Intensive Care Unit• An intensive care unit (ICU) is defined as a specially staffed, specialty equipped, separate section of a hospital dedicated to the observation, care, and treatment of patients with life threatening illnesses, injuries, or complications from which recovery is possible12/23/2012 Dr.T.V.Rao MD 3
  4. 4. A Patient in Intensive Care Unit is at Risk for Many Reasons..12/23/2012 Dr.T.V.Rao MD 4
  5. 5. Infection in ICU are •More in Prevention •Little in Treatment12/23/2012 Dr.T.V.Rao MD 5
  6. 6. Educating our Health Care Workers• Education programs for employees and volunteers are one method to ensure competent infection control practices. The ICP must become knowledgeable and techniques that will motivate and sustain behavioral change.12/23/2012 Dr.T.V.Rao MD 6
  7. 7. Why ICU patients are different• Many times very sick patients (multiple diagnoses, multi-organ failure,) immunocompromised, septic and trauma)• Move less• Malnourished• May be associated Diabetics and Heart failure12/23/2012 Dr.T.V.Rao MD 7
  8. 8. ICU patients are rapidly colonized with pathogenic bacteria• Skin colonized in hours to days – Staph. aureus, Proteus mirabilis, Klebsiella spp. present @ 100-106 CFU /cm2 skin• Perineal/inguinal > axilla > trunk > upper extremities and hands• Dialysis/CRF, diabetes, dermatitis, broad spectrum Abx increase risk• Patients shed 106 squames/day -> widespread contamination of the room Reviewed in Pittet et al Lancet Infect Dis 8 2006
  9. 9. EPIDEMIOLOGY• Contributing factors –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 pathogens12/23/2012 Dr.T.V.Rao MD 9
  10. 10. Drug Resistant Bacteria a threat to Life• Multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE) are being isolated with increasing frequency in ICUs12/23/2012 Dr.T.V.Rao MD 10
  11. 11. 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 ventilation12/23/2012 Dr.T.V.Rao MD 11
  12. 12. ICU : Factors that increase cross-infections• Hand washing facilities are inadequate• Patient close together or sharing rooms• Understaffing• Lack of isolation facilities• No separation of clean and dirty AREAS• Excessive antibiotic use• Inadequate decontamination of items & equipments12/23/2012 Dr.T.V.Rao MD 12
  13. 13. 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 malnutrition12/23/2012 Dr.T.V.Rao MD 13
  14. 14. 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 techniques12/23/2012 Dr.T.V.Rao MD 14
  15. 15. 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 free12/23/2012 Dr.T.V.Rao MD 15
  16. 16. 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 priorities12/23/2012 Dr.T.V.Rao MD 16
  17. 17. Intensive Care Unit Prevention of Blood stream infections12/23/2012 Dr.T.V.Rao MD 17
  18. 18. Central Venous CathetersIndications• IV fluids and drugs• Blood and blood products• Total Parenteral Nutrition (TPN)• Hemodialysis• Hemodynamic monitoring12/23/2012 Dr.T.V.Rao MD 18
  19. 19. Serious Infective Complications• Blood Stream Infections (BSI)• Septic pulmonary emboli• Metastasis infections – Acute endocarditis – Osteomyelitis – Septic arthritis• Shock and organ failure• Poor outcome: Staph.aureus or Candida spp.12/23/2012 Dr.T.V.Rao MD 19
  20. 20. Incidence of CR-BSI• Type of catheter Teflon or Polyurethane ( < infections) vs Polyvinyl chloride• 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 catheter12/23/2012 Dr.T.V.Rao MD 20
  21. 21. Sources of Infection Intrinsic contamination of infusion fluid Port for additives Connection with administration set Insertion site Injection ports Administration set connection with IV catheter12/23/2012 Dr.T.V.Rao MD 21
  22. 22. 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 distant12/23/2012 Dr.T.V.Rao MD focus 22
  23. 23. 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 catheters12/23/2012 Dr.T.V.Rao MD 23
  24. 24. 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;31:1001-712/23/2012 Dr.T.V.Rao MD 24
  25. 25. 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 insertion12/23/2012 Dr.T.V.Rao MD 25
  26. 26. Urinary Catheterization12/23/2012 Dr.T.V.Rao MD 26
  27. 27. External urethral meatus & urethra• Pass catheter when bladder is 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 insertion12/23/2012 Dr.T.V.Rao MD 27
  28. 28. 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.12/23/2012 Dr.T.V.Rao MD 28
  29. 29. Intensive Care Unit Nosocomial Pneumonia12/23/2012 Dr.T.V.Rao MD 29
  30. 30. 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%12/23/2012 Dr.T.V.Rao MD Haley, 1986 30
  31. 31. 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.12/23/2012 Dr.T.V.Rao MD 31
  32. 32. Too many Wash basins are Hazardous• It is not necessary to have an individual hand wash basins for every bed space as there us a risk of Legionella and other infections associated with infrequently used water outlet.• All water outlets must run daily to minimize the potential for legionella within the pipeline12/23/2012 Dr.T.V.Rao MD 32
  33. 33. 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. 12/23/2012 Dr.T.V.Rao MD 33
  34. 34. Concerns with staphylococcus• Methicillin-resistant S. aureus (MRSA) is resistant to several antibiotics. Another form of S. aureus, vancomycin-resistant S. aureus (VRSA), is resistant to one of the most powerful, last line of defence antibiotics, vancomycin Dr.T.V.Rao MD 34
  35. 35. RESISTANT GRAM NEGATIVE ORGANISMS• Resistance to multiple antibiotics Organisms: E .coli Proteus Enterobacter Acinetobacter• Stenotrophomnonas Pseudomonas aeruginosa12/23/2012 Dr.T.V.Rao MD 35
  36. 36. E.Coli and emerging resistance • Escherichia coli (E. coli) has gradually become resistant to different types of antibiotics. In 2003, the overall resistance of E. coli to common amino penicillin antibiotics reached 47% across Europe Dr.T.V.Rao MD 36
  37. 37. SURVEILLANCE• Important means of monitoring HAI Early detection of trends outbreaks• Laboratory Based Microbiology Laboratory lists Gram +ve and - ve organisms ICN reviews ‘Alert organisms’ reported• 2. Ward Based Ward staff monitor patients ICN reviews ICN visits wards Dr.T.V.Rao MD 37
  38. 38. Universal precautions• Hand washing• Personal protective equipment [PPE]• Preventing/managing sharps injuries• Aseptic technique• Isolation• Staff health• Linen handling and disposal• Waste disposal• Spillages of body fluids• Environmental cleaning• Risk management/assessment Dr.T.V.Rao MD 38
  39. 39. Antibiotics use Must avoid widespread use ofbroad spectrum antibiotics12/23/2012 Dr.T.V.Rao MD 39
  40. 40. Problems in -Detection of Infection in the ICU’s12/23/2012 Dr.T.V.Rao MD 40
  41. 41. Examples of difficult to detect infections: Uncultivable organisms Viruses 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..12/23/2012 Dr.T.V.Rao MD 41
  42. 42. 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 space12/23/2012 Dr.T.V.Rao MD 42
  43. 43. 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.12/23/2012 Dr.T.V.Rao MD 43
  44. 44. 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 12/23/2012 Dr.T.V.Rao MD 44
  45. 45. 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-compliers12/23/2012 Dr.T.V.Rao MD 45
  46. 46. 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 1.7-12.812/23/2012 Dr.T.V.Rao MD 46
  47. 47. Cockroaches (Ectobius vittiventris) in an Intensive Care Unit, Switzerland• Cockroaches are capable of harboring Escherichia coli Enterobacter spp. Klebsiella spp. , Pseudomonas aeruginosa , Acinetobacter baumannii , other nonfermentative bacteria Serratia marcescens Shigella spp. Staphylococcus aureus group A streptococci , Enterococcus spp. , Bacillus spp. , various fungi , and parasites and their cysts . An outbreak of extended- spectrum β-lactamase–producing Klebsiella pneumoniae in a neonatal unit was attributed to cockroaches• Emerging Infectious Diseases March 200912/23/2012 Dr.T.V.Rao MD 47
  48. 48. Rapid and Newer method of Contamination with• ATP testing works because Adenosine Triphosphate is present in all types of organic material (i.e. food, bacteria, bodily fluids, unique proteins, allergens and even skin), and the ability to detect it through an ATP bioluminometer indicates the amount of microbial and non-microbial contamination in a given test area. This is accomplished by a luminescent chemical reaction,12/23/2012 Dr.T.V.Rao MD 48
  49. 49. 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.12/23/2012 Dr.T.V.Rao MD 49
  50. 50. WHONET - Documentation• Establishing WHONET Documentation makes the Antibiograms assessments easy by Microbiologists and Consultants at any Hospital.• We are fully functional to the advantages of the WHONET documentation, Dr.T.V.Rao MD 50
  51. 51. Do remember the Reasons for Infections are Many but solutions are few …12/23/2012 Dr.T.V.Rao MD 51
  52. 52. Consequences of hospital infections ??? Hospital Pathogen Unhappy Unhappy patients directorHospital Surveillance Happy Happy Patients Dr.T.V.Rao MD director 52
  53. 53. How successful are our Programmes• Accreditation from competent government agency; training of ICU nurses and Intensive care physicians; technology sharing with developed countries, funding programs in collaboration with WHO, ICMR, DBT, NGOs; use of information technology for patient care, training and research.12/23/2012 Dr.T.V.Rao MD 53
  54. 54. Let us support our Hospitals with clean hands12/23/2012 Dr.T.V.Rao MD 54
  55. 55. 12/23/2012 Dr.T.V.Rao MD 55

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