This document discusses infections in the intensive care unit (ICU). It notes that ICU patients are more susceptible to infections due to underlying illnesses and medical devices like catheters. A study found device-associated infection rates of 14.7% in ICUs internationally. Catheter-associated urinary tract infections are common, with indwelling catheters being the main risk factor. Proper hand hygiene and use of protective barriers like gloves are essential for preventing transmission of infections in the ICU. Respiratory precautions differ based on the size of infectious droplets. Blood-borne pathogens pose the greatest risk to ICU staff and needlestick injuries are a primary mode of transmission.

1. Infections in the
intensive care unit
Dr. Fatehi Hatem

2. 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 ICUs

3. 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 (1.7-12.8)

4. CATHETER-ASSOCIATED UTI
 UTI is the most common nosocomial infection (> 40%
of all nosocomial infections)
 CAUTIs are the second most common cause of
nosocomial bloodstream infection, which have an
attributable mortality
 Risk factors
 The major risk factor is an indwelling urinary catheter
 The risk increases directly with the duration of
catheterization.
 The daily incidence of catheter-associated bacteriuria is
approximately 5%
 After catheters have been in place for 1 week, bacteriuria
or candiduria develop in 25%; after 30 days, the great
majority of patients will have bacteriuria.

5. CATHETER-ASSOCIATED UTI
 Other important risk factors for CAUTI
 Patients with other sites of active infection
 Long hospital stay
 Malnutrition
 Female sex
 Abnormal serum creatinine
 Improper catheter care (particularly placement
of the drainage tube above the level of the
bladder)

6. Prevention
 The most effective method to prevent CAUTI is to
avoid unnecessary placement of indwelling urinary
catheters and to limit the duration of catheterization
once a catheter is in place.
 Use of indwelling catheters should be limited to
 patients with anatomic or physiologic urinary obstruction;
 patients undergoing surgery of the genitourinary tract;
 patients requiring accurate monitoring of urine output (ie,
critically ill or postoperative patients);
 debilitated, comatose, or paralyzed patients.
 Once a catheter is in place, it should be removed as
quickly as possible, when it is no longer needed.

7. Prevention
 The condom catheter is a good alternative to the
indwelling catheter for men and is associated with lower
rates of bacteriuria
 Intermittent bladder catheterization has been shown to
reduce the incidence of UTI in long-term spinal cord
injury patients compared to an indwelling catheter, this
approach has not been studied in patients with shorter-
term indwelling bladder catheters.
 Suprapubic catheters might be more comfortable for
patients and have been shown to lower the incidence of
bacteriuria

8. Catheter insertion and maintenance
 Aseptic technique: handwashing, sterile gloves,
a sterile drape, antiseptic solution
 Once in place,
 Maintaining a closed drainage system
 The only part of the drainage system that should
be opened is the bag drainage tube
 The number of manipulations and accesses of
the drainage system should be minimized.
 The collecting tubing and bag should always be
placed below the patient and the tubing should
be maintained at a level above the drainage bag

9. Antimicrobial therapy
 Topical antimicrobials
 Place between the catheter and urethral mucosa
 Soaking catheters in, continuous irrigation of the bladder with
an anti-infective solution,
 Placement of anti-infective solutions into the collection bag
 Not been shown to effectively prevent CAUTI
 Systemic antimicrobial prophylaxis
 Can reduce the risk for CAUTI in short-term catheterization;
 Increased long term risk for infections caused by multidrug
resistant organisms
 Treatment of asymptomatic bacteriuria does not decrease the
incidence of febrile episodes but does increase the recovery of
antibiotic-resistant bacteria

10. Different catheter composition
 Catheters impregnated with antimicrobial agents (
minocycline and rifampin) and the antiseptic agent
nitrofurazone have been demonstrated to reduce
CAUTI rates in small studies
 The potential for selection of multidrug-resistant
pathogens
 The silver-hydrogel catheter prevents adherence of
bacterial and yeast pathogens to the catheter surface.
 Catheters coated with antiseptic silver compounds have
shown promise by some investigators but have been
ineffective in other large, well-controlled trials.

11. INFECTION CONTROL
IN THE ICU

12. I. SKIN HYGIENE
Common organisms isolated from the skin of ICU
personnel are (in order of decreasing prevalence):
Staphylococcus epidermidis(over 90% of people
cultured ), gram-negative aerobic
bacilli (20%), Candid a species (15%) and
Staphylococcus aureus(5 – 10%).
Eradicating these organisms from the skin is
a major concern of infection control.

13. A. Soap and Water
 Soaps are detergents that can disperse
particulate and organic matter, but they lack
antimicrobial activity. Cleaning the skin with
plain soap and water will remove dirt and
grease but will not eradicate the microbial
flora on the skin.
 The eradication of microbes (called
decontamination) requires the application of
agents that have antimicrobial activity.

14. B. Antiseptic Agents
 Antimicrobial agents used to
decontaminate the skin are called
antiseptics, and those used to decontaminate
inanimate objects are called disinfectants.
 The antiseptic agents used most commonly
are described below:

15. Common Antiseptic Agents
Agent Major Advantage Major Disadvantage
Alcohol Broad coverage Little residual activity
Iodophors Broad coverage Inconsistent residual
activity
Chlorhexidine Good residual activity
≥6 hrs
Limited coverage

16. 1. Alcohols
 The alcohols (ethanol, propanol, isopropyl alcohol) are
germicidal against most bacteria, fungi, and viruses
(including HIV).
 a. Alcohols have a rapid onset of action, but have little
persistent (residual) activity.
 b. Repeated use of aqueous alcohol solutions can cause
drying and irritation of the skin.
This effect is minimized when a waterless alcohol gel is used.
 c. The alcohols are less effective in the presence of dirt and
organic matter, so skin that is dirty or soiled with body fluids
should be cleaned before applying alcohol.

17. 2. Iodophors
 Iodine has broad-spectrum germicidal activity
(like the alcohols), but it is irritating to the skin and soft tissues.
 Skin irritation is reduced by employing a carrier molecule to
release iodine slowly. Iodine preparations that use a carrier
molecule are called iodophors.
 The most popular iodophor in the United States is
povidone-iodine.

18. a. Since the active ingredient in iodophors (iodine) is
released slowly, iodophors must be left in contact with
the skin for a few minutes to achieve maximum
antisepsis. Prolonged contact with iodine can be
irritating,
so iodophors should be wiped from the skin after
drying. This removal limits the persistent (residual)
antiseptic activity.
b. Iodophors are neutralized by organic matter, so skin
that is soiled with blood and body fluids should be
cleaned before applying an iodophor.

19. 3. Chlorhexidine
 Chlorhexidine gluconate is a germicidal agent that is
effective against gram-positive bacteria, but has less
activity than alcohol and iodophors against
gram-negative bacilli and fungi.
 a. The major advantage of chlorhexidine is its
prolonged activity, which can last for 6 hours or
longer (2).
This activity is reduced by soaps and hand creams.
 b. Chlorhexidine is available in 0.5% to 4% aqueous
solutions. The 4% solution is most effective, but
repeated use can cause skin irritation. Chlorhexidine is
also an ocular irritant, and care should be taken to
avoid contact with the eyes.

20. 4. Spore-Forming Organism
 Antiseptic agents are not effective against
spore-forming organisms like Clostridium
difficile and Bacillus anthracis
Proper use of gloves is required to prevent the
spread of these organisms.

21. C. Handwashing
 Appropriate handwashing is the cornerstone
of infection control, and Table 1.2 presents
the guidelines for handwashing issued by the
Centers for Disease Control.

22. Recommendations forRecommendations for
HandwashingHandwashing

23. I. Handwashing with soap (plain or antiseptic) and water is recommended:
1. When hands are dirty or soiled with blood or body fluids.
2. Before eating.
3. After leaving a restroom.
II. Handwashing with an antiseptic preparation* is recommended:
1. Before direct contact with a patient.
2. After contact with a patient’s skin (intact or non intact).
3. After contact with body fluids, secretions, excretions, mucous membranes,
wound dressings, and contaminated items.
4. Before donning sterile gloves to insert central intravascular catheters or other
invasive devices that do not require a surgical procedure.
5. Before inserting urinary catheters, peripheral venous
catheters, or other invasive devices that do not require a surgical procedure.
6. After removing gloves.
7. When moving from a contaminated to a clean body site.
8. After contact with inanimate objects in the immediate vicinity of the patient.
*A waterless alcohol gel is preferred to antiseptic soaps, but the hands must be
clean prior to application.

24. 1. General Recommendations
 a. Antiseptic soaps and gels are preferred to plain soap and water for
handwashing.
 b. If the hands are not visibly soiled, a waterless alcohol gel is recommended for
handwashing (alcohol has proven more effective than iodophors or
chlorhexidine for reducing bacterial counts on the hands) The gel should be rubbed
into the hands until the hands feel dry.
 c. Antiseptic soaps are recommended when the hands are dirty or soiled with
body fluids. The soap should be rubbed over the entire surface of the hands for
at least 30 seconds .
The soap is then removed with a tap water rinse, and the hands should be dried
completely (residual moisture on the skin will promote microbial growth)
 d .Hot water is not recommended for handwashing because it is not more
effective than warm or cold water for removing skin microbes and it can be irritating
to the skin.
 e. During handwashing, special attention should be given to the subungual
areas under the finger nails , where microbes tend to congregate.

25. II. PROTECTIVE BARRIERS
 Protective barriers like gloves, gowns, masks, and
eye shields provide a physical
impediment to the transmission of infectious agents
in blood and body fluids.

26. A. Gloves
 1. Indications
The tasks that require gloves (sterile and nonsterile) are
a. Sterile gloves are required when catheters are placed in
arteries, large central veins, and closed spaces (including the
epidural and subarachnoid spaces).
 b. Non sterile gloves are used for contact with blood, body
fluids, secretions, excretions, non intact skin, and mucous
membranes.
c. Nonsterile gloves can be used for insertion of peripheral vein
catheters as long as a “no touch” technique is used
(i.e., the gloved hands do not touch the shaft of the catheter).
 2. Gloves and Handwashing
 a. The use of gloves does not eliminate the need for handwashing.
 b.Handwashing is recommended both before donning gloves, and again after
the gloves are removed.

27. Recommendations for Glove Use
in the ICU
 . Sterile gloves must be worn for the following procedures:
 1. Central venous catheterization.
 2. Peripherally-inserted central catheters.
 3. Arterial catheterization.
 4. Placement of drainage catheters in a closed space (pleural, pericardial. or
peritoneal cavities).
 5. Insertion of epidural or intraventricular catheters.
 II. Nonsterile gloves are recommended for the following situations:
 1. When there is contact with blood, body fluids, secretions, excretions,
non intact skin, and mucous membranes.
 2. Insertion of peripheral venous catheters (the gloved hands must not touch
the catheter).
 III. General recommendations:
 1. Handwashing is recommended before glove use, and again after gloves
are removed.
 2. Gloves should be changed between tasks involving the same patient if there
has been contact with potentially infectious material.
 3. Gloves should be removed immediately after use. before contact with non

28. B. Masks & Other Barriers
 Face masks, eye shields, and gowns are also
used as physical barriers to infectious agents.
These barriers are recommended for any
procedure or patient care activity that could
generate a splash of blood, body fluids,
secretions, or excretions.

29. RESPIRATORY PRECAUTIONS
FOR AIRBORNE INFECTIONS
 Large Droplets (>5µ in diameter)
 • Hemophilus influenza (type b),:
epiglottitis, pneumonia, and meningitis
*Neisseria
pneumonia, and meningitis,
Bacterial respiratory infections:
 A. Diphtheria (pharyngeal)
 B. Mycoplasma pneumonia
 C. Group A strep pharyngitis and pneumonia
• Viral respiratory infections:
 A. Influenza
 B. Adenovirus
 C. Mumps
 D. Rubella

30.  1. Place patient in private room. If
unavailable, patient should not be within 3
feet of other
noninfectious patients.
 2. Hospital staff and visitors should wear
a surgical mask when within 3 feet
of the patient.

31.  Small Droplets (≤5µ in diameter)
• Mycobacterium tuberculosis (pulmonary and
laryngeal TB)
 • Measles
 • Varicella (including disseminated zoster)

32.  1. Place patient in negative pressure isolation
room.
2. For infectious pulmonary TB,
 hospital staff and visitors should wear N95
respirator masks while in the room.
 3. For infectious measles or varicella,
those without a proven history of infection should not
enter the room, or should wear an N9 respirator
mask while in the room

33. III. BLOOD-BORNE
INFECTIONS
 The greatest infectious risk for ICU personnel
is exposure to blood-borne pathogens like
HIV, hepatitis B virus (HBV), and
Hepatitis C virus (HCV).

34. A. Needlestick Injurie
 Transmission of blood-borne infections to hospital
workers occurs primarily via needle stick injuries.
Each year, about
10% of hospital workers sustain a needle stick
injury (13), and over 50% of house staff and
medical students report a needle stick injury
at some time during their training

35. B. Human Immunodeficiency
Virus (HIV)
 The spread of HIV to hospital workers is
universally feared , but is rare. In fact, there are
only 56 cases of HIV seroconversion in
healthcare workers that can be definitely
linked to
HIV transmission in the workplace.

36.  1. Percutaneous Exposures
 Transmission of HIV via needlestick injuries is uncommon.
 a. A single needlestick injury with blood from an HIV infected
patient carries an average 0.3% risk of HIV seroconversion.
 Factors that increase the risk of transmission include:
1. a deep skin puncture
2. visible blood on the needle
3. and injury from a needle that was placed in an artery or vein of
the source patient.
 2. Mucous Membrane Exposures
 The risk of HIV transmission through mucous membranes or nonintact
skin is even less than the risk from needlestick injuries.
 a. A single exposure of broken skin or mucous membranes to blood
from an HIV-infected patient carries an average 0.09% risk of HIV seroconversion

37. 3. Postexposure Management
 When a hospital worker sustains a needlestick injury, the HIV
status of the source patient is used to determine the need for HIV
prophylaxis with antiretroviral drugs.
 a. If HIV infection is proven or suspected in the source patient,
prophylaxis with2 antiretroviral agents is started immediately.
A third drug is added if the source patient has symptomatic HIV
infection.

38.  b.If the HIV status of the source patient is unknown
and the patient is available, a rapid HIV-antibody test
can be performed on the source patient. The results of
this bedside test, which are available in minutes, can
be used to determine the need for antiretroviral
drugs.
A negative test not only eliminates the fear of
acquiring illness, it also avoids the use of drugs that
tend
to be poorly tolerated.
A positive test result must be confirmed by standard
laboratory tests (e.g., a Western Blot or immunofluorescent
antibody assay).

39.  c. The antibody responses to HIV infection
can take 4 to 6 weeks to become evident.
Therefore, anyone with documented exposure to HIV
infection should have serial tests for HIV antibodies at 6
weeks, 3 months, and 6 months post exposure

40. C. Hepatitis B Virus (HBV
 hepatitis B is the most readily transmitted blood-borne illness,
but there is a vaccine available that can produce life long immunity
to HBV
 Risk of HBV Transmission
The risk of acquiring HBV following an exposure is determined by
the immunity of the exposed individual.
a. For individuals who lack HBV immunity (unvaccinated or
unresponsive), exposure to HBV-infected blood carries a 60%
risk of acquiring HBV, and a 30% risk of developing symptomatic
hepatitis
B . For those who are vaccinated and respond appropriately,
there is virtually no risk of acquiring HBV infection

41. Management of Possible Exposure
to Hepatitis B Virus (HBV)
 a. For individuals with vaccine-induced immunity,
no treatment is necessary following HBV exposure.
 b. For possible exposure in non-immune
individuals,
proof or suspicion of HBV infection in the source patient
should prompt treatment with hepatitis B immune
globulin
(0.06 mL/ kg by intramuscular injection),
followed by HBV vaccination.

42. D. Hepatitis C Virus (HCV
 HCV is a blood-borne pathogen of some
concern because infection often leads to
chronic hepatitis.

43. 1. Risk of HCV Transmission
 a. The prevalence of anti-HCV antibodies in hospital personnel
is only 1% to 2% , which means that the risk of HCV
transmission in the hospital setting is low.
 b. Following a needle stick injury with HCV-infected
blood, the average risk of HCV transmission is only
1.8% . Transmission from mucous membrane
exposure is rare, and there are no documented cases of
HCV transmission through breaks in the skin

44. 2. Postexposure Management
 a. There is no effective prophylaxis for HCV
following exposure to infected blood.
 B . Following a documented exposure to
HCV-infected blood, serial measurements of
anti-HCV antibodies is recommended
for 6 months.

45. THE END