This document discusses infection prevention strategies in cardiac surgery patients. It covers several topics: 1. Intensive care unit-acquired infections account for substantial morbidity, mortality, and costs, with infections and sepsis as a leading cause of death. Proper infection control practices can help reduce these infections. 2. Common strategies to prevent healthcare-associated infections include proper hand hygiene, surgical site infection prevention, central line-associated bloodstream infection prevention, and ventilator-associated pneumonia prevention. 3. The most prevalent healthcare-associated infections are urinary tract infections, surgical site infections, bloodstream infections, and pneumonia - together accounting for 80% of cases. Catheter-associated urinary tract infections are

1. INFECTION IN CARDIAC
SURGERY
DR NARENDRA DONGRE
MD,FIACTA,FNB
DR DIMCE SLAVESKI

2. Introduction
• Although (ICUs) account for fewer than 10% beds,
>20 percent of all nosocomial infections are
acquired in ICUs [1].
• ICU-acquired infections account for substantial
morbidity, mortality, and expense.
• Infections and sepsis are the leading cause of
death in non-cardiac ICUs and account for 40
percent of all ICU expenditures [2].

3. CHAIN OF INFECTION

5. RESERVOIRRESERVOIR
Definition:
• place in which an
infectious agent can
survive but may or may
not multiply
Common reservoirsCommon reservoirs
• humans
• animals
• Equipment & fomite
• medication/intravenous
fluid
DR.T.V.RAO MD 5

6. CONTAMINATED SURFACES
INCREASES CROSS- TRANSMISSION

8. Magnitude of the Problem
 It is estimated that 5% to 10% of hospitalized patients in
the US, or approx. 2 million people yearly,
 Acquire 1 or more healthcare-associated infections
(HAIs).
 Infection is a contributory cause in more than 90,000
deaths,
 Healthcare costs of $4.5 to $5.7 billion per annum.

9.  The etiologic organisms in 70% of these infections are
resistant to 1 or more antibiotics.
 Appropriate practices can reduce the incidence of
HOSPITAL AQUIRED INFECTIONS.

10. These infections are associated
with a variety of risk factors,
including:
• Use of indwelling medical devices
• Surgical procedures
• Injections
• Contamination of the health care environment
• Transmission of communicable diseases between
patients and healthcare workers
• Overuse or improper use of antibiotics

11. The MOST PREVALENT
INFECTIONS:

12. The 4 MOST PREVALENT INFECTIONS:
responsible for 80% of the cases of HAIs are:
 URINARY TRACT INFECTION:
accounting for 35% and generally catheter-associated, CAUTI
 SURGICAL SITE INFECTION:
20% of cases, but accounts for 1/3 of the associated costs
 BLOODSTREAM INFECTION:
15%, majority are intravascular-catheter related &
 PNEUMONIA
ventilator-associated, 15% of cases, 25% of attributable mortality.

13. Prevention of Healthcare-
Associated Infection in Patients
A. Hand Hygiene
B. Preventing Contamination of Medications
C. Prevention of Surgical Site Infection
D. Prevention of Intravascular Catheter-Related Infection
E. Prevention of Ventilator-Associated Pneumonia in the
ICU
F. Prevention of Transmission of M-D–R Organisms
G. Disinfection of Equipment

14. HAND HYGIENE

15. IGNAZ SEMMELWEIS (1818-65)
• 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

16. Hands must be decontaminated:

17. Hands must be decontaminated:
• immediately before each episode
of direct patient contact or care,
including clean/aseptic procedures;
• immediately after each episode of
direct patient contact or care;
• immediately after contact with body
fluids, mucous membranes and non-intact skin;
H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70

18. • immediately after other activities or contact with
• objects and equipment in the
immediate patient environment that
may result in the hands contaminated;
• • immediately after the removal of gloves.Class C
H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70

19. Alcohol-based hand rub
• for decontamination of hands before and after direct patient
contact and clinical care
• soap and water must be used:
• when hands are visibly soiled or
potentially contaminated with body fluids
• when patients with vomiting or diarrhoeal illness,
regardless of whether or not glove have been worn.Class A

20. Healthcare workers should ensure that
their hands can be decontaminated effectively by:
• removing all wrist and hand jewellery;
• wearing short-sleeved clothing
• making sure that fingernails are short, clean, and
free from false nails and nail polish; and
• covering cuts and abrasions with waterproof dressings.
Class D/GPP

21. Effective hand washing technique
• involves three stages: preparation,
washing and rinsing, and
drying.
• Preparation: wet hands under tepid running water before applying the recommended
amount of liquid soap or an antimicrobial preparation.
• Washing: the hand wash solution must come into contact with all of the surfaces of
the hand. The hands should be rubbed together vigorously for a minimum of 10–15 s,
paying particular attention to the tips of the fingers, the thumbs and the areas
between the fingers. Hands should be rinsed thoroughly.
• Drying: use good-quality paper towels to dry the hands thoroughly. Class D/GPP

22. WHO Recommended Hand
Hygiene Technique

23. • Alcohol-based hand rub should be made available at the point of care in all healthcare facilities.
• Regular auditing regarding adherence to HH guidelines to improve & sustain compliance.
• Regular training of healthcare workers
• Local programmes of education, social marketing, and audit and feedback should be refreshed
regularly and promoted by senior managers and clinicians to maintain focus, engage staff and
produce sustainable levels of compliance. New recommendation Class C
• Patients and relatives should be provided with information about the need for hand hygiene and
how to keep their own hands clean. New recommendation Class D/GPP
• Patients should be offered the opportunity to clean their hands before meals; after using the
toilet, commode or bedpan/urinal; and at other times as appropriate.
New recommendation Class D/GPP

24. Efficacy of Hand Hygiene Preparations
in Killing Bacteria in Health Care
Settings
*Plain or antimicrobial soap & water better than alcohol-based hand rub
if hands visibly soiled, or for spore-forming organisms (e.g. C. difficile,
anthrax),
Antimicrobial soap recommended over plain soap in health care
settings.

25. CA-UTI
EPIDEMIOLOGY:
CA-UTI is the MC HCA infection….approx. 40%
Affects 1 in 20 (5%) hospital admission.
15 to 20 % of the pts will have urethral catheter inserted at
some time during hospitalization
Incidence of UTI a/w indwelling catheterization 3-8%/day
It is MC source of Gm negative bacterimiea
Tambyah PA. Catheter associated urinary tract infection, diagnosis and prophylaxis. Int .J
.Antimicrob Agent 2004;24:44-48

26. pathogenesis
• Major Predisposing Factors:
Urinary catheterization causes
….Perturbs host defence mechanism
…..Ascension of uropathogens to the bladder
via catheter-mucosa interface.
• Catheter biofilm formation:
Exopolysaccharides entrap & protect replicating
bacteria forming microcolonies.

27. Microbiology:
• E. Coli- 33% of isolates
• Enterobacteriacceae- klebsiella species,
serratia species,
citrobacter species,
enterobacter species
• Proteus mirabilis , morganella morganni.
• Pseudomonas Aeruginossa
• Gm positive cocci – Coagulase –ve staphylococci,
Enterococcus species
• UTI ----Antibiotic resistant pathogens in ICU

28. Guidelines for preventing infections associated with
the use of short-term indwelling urethral catheters
The recommendations are divided into six distinct interventions:
• assessing the need for catheterisation;
• selection of catheter type and system;
• catheter insertion;
• catheter maintenance;
• education of patients, relatives and healthcare workers
• interventions for reducing the risk of infection.
• H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1–S70

29. Surgical Site Infections
( SSI)Burden-US
17% of all HAI; second to UTI
2%-5% of patients undergoing inpatient surgery
Mortality & Morbidity
• •3% mortality
•75% of deaths among SSI patients are directly attributable to SSI
• •~7-10 additional postoperative hospital days
Cost
• •$3000-$29,000/SSI depending on procedure & pathogen
• •Up to $10 billion annually

30. SSI Risk Factors
Endogenous
Advanced age
Malnutrition, recent weight loss
Obesity
Diabetes mellitus
Smoking
Co-existing infections other site
Bacterial colonization
Immunosuppression
Other remote site of infections

31. SSI Risk Factor Exogenous
Prolonged preoperative stay
Preoperative hair removal by shaving
Length of operation
Maintenance of body temperature
Surgical technique
Incorrect use of prophylactic antibiotics

32. Prevention of Surgical Site Infections

33. Preoperative Considerations
1. Hair removal :
No PREOP removal hair
If necessary,
remove immediately before the operation,
Preferably with electric clippers.
2. Glucose control :
Increasing levels of hemoglobin (Hg) A1c and SSI rates.
BS (>200 mg/dL)  increased SSI risk in the
Post-op period.

34. Ann Thorac Surg 2009;87:663–9

35. Glycemic Control in the
ICU Recommendation:
Class I
Patients with and without
diabetes with persistently
elevated serum glucose (180
mg/dL) should receive IV
insulin infusions to maintain
serum glucose 180 mg/dL for
the duration of their ICU care
(level of evidence A).
Glycemic Control in the
Stepdown Units and
on the Floor
Recommendations:
Class I
• A target blood glucose
level 180 mg/dL should
be achieved in the peak
postprandial state (level
of evidence B).

37. • 3. Nicotine use :
• Tobacco cessation for at least 30 days
before elective operation.
Smoking has been implicated as an
independent SSI risk factor.
Nagachinta T, Stephens M, Reitz B, Polk BF. Risk factors for surgical wound infection
following cardiac surgery. J Infect Dis. 1987;156:967-973.
Jones JK, Triplett RG. The relationship of cigarette smoking to impaired intraoral wound
healing: a review of evidence and implications for patient care. J Oral Maxillofac
Surg. 1992;50(3):237-239; discussion 239-240.

38. • 4. Transfusion
Do not withhold blood products as a means to
prevent SSI
Currently is no scientific basis to support withholding
indicated blood products from surgical patients as a
means to reduce SSI risk
Vamvakas EC, Carven JH. Transfusion of white-cell-containing allogeneic blood
components and postoperative wound infection: effect of confounding factors.
Transfus Med. 1998;8:29-36.

39. 5. Antiseptic shower
Shower with an antiseptic agent on the night
prior to surgery.
Decrease skin microbial colony counts.
povidone-iodine
triclocarban-
medicated soap
chlorhexidine gluconate
Paulson DS. Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J Infect
Control. 1993;21(4):205-209.

40. 6. Antimicrobial prophylaxis
 prophylactic antimicrobial agent when indicated ; select it based on
its efficacy against the MC pathogens causing SSI for a specific
operation and published recommendations.
 The first dose of prophylaxis should be initiated within 60 minutes prior
to incision (120 minutes for vancomycin or fluoroquinolones)
 Maintain therapeutic levels of the drug in serum and tissues throughout
the operation.

42. Relative benefit from
antimicrobial prophylaxis SSI
Rates• Operation Prophylaxis (%) Placebo (%)
• Colon 4-12 24-48
• Other (mixed) GI 4-6 15-29
• Vascular 1-4 7-17
• Cardiac 3-9 44-49
• Hysterectomy 1-16 18-38
• Craniotomy 0.5-3 4-12
• Spinal operation 2.2 5.9
Data are pretty clear – you can reduce the risk of
SSIusing antimicrobial prophylaxis for almost any
operation!

43. Antibiotic Recommendations

44. Antimicrobial Prophylaxis
• •Antibiotic selection
• –Narrowest spectrum for efficacy
• –Routine use of vancomycin for prophylaxis is not recommended
for any procedure.
• –Limit use of vancomycin to patients with known colonization with
MRSA, high risk of MRSA, or in patients with beta-lactam allergy
• –No consensus on patients colonized with other MDROs
Chambers D, et al. Glycopeptide vs. non-glycopeptide antibiotics for prophylaxis of
surgical site infections: a systematic review. Surg Infect. 2010; 11:455-62.
Murphy E, et al. MRSA colonisation and subsequent risk of infection despite effective
eradication in orthopaedic elective surgery. J Bone Joint Surg. 2011; 93:548-51.

45. Intraoperative
Considerations
1. Operating Room Ventilation
--> Maintain
positive-pressure ventilation in the operating room with
respect to the corridors
--> Keep OR doors closed except for
passage of equipment, personnel, and the patient.
--> The microbial level in OR air is directly number of people
moving about in the room.
--> All ventilation systems in
hospitals should have 2 filter
2. 2.Cleaning
-->Use an Environmental Protection Agency (EPA)–
approved hospital disinfectant to clean affected areas before

46. • 3. Surgical attire
--> Wear a surgical mask and a cap or hood that
fully covers hair on the head and face.

47. • 4. Asepsis and surgical technique

--> Asepsis when placing intravascular devices &
when dispensing and administering IV drugs.
-->Lack of strict adherence
to the principles of asepsis; reuse syringes,
contaminated infusion pumps, and
contaminated IV anesthetic have been
associated with postoperative infections SSIs.38,39

48. • 5. Normothermia 
Maintain patient normothermia.
Hypothermia (core temperature <36C) A/W an increased SSI risk.40,41
Mild hypothermia seems to increase SSI risk by causing
vasoconstriction,
decreased oxygen delivery to the wound space, and
impaired phagocytic leukocyte function.42,43

49. Postoperative
Considerations
Postoperative Incision Care
Failure of hospital personnel to use appropriate hand-
washing techniques is well-documented and has been the
cause of numerous infections.44

50. Central Venous Catheters:
prevention of infection
1. Catheter selection
Use a single lumen CVC unless more ports are essential.
Maximal barrier
precautions 2% chlorhexidine ---- skin
antisepsis Antimicrobial or antiseptic-
impregnated CVC Multi-lumen catheters A/W
with a higher risk of infection
• 2. Insertion
•  Site: A non-
tunneled CVC inserted into the subclavian vein carries a lower risk for infection than a catheter
inserted via either the jugular vein or femoral vein; The
mechanical complications are less common, with internal jugular vein insertion than with
subclavian insertion. Promptly
remove any intravascular device that is no longer essential.

51. 3. Barrier precautions
Use sterile techniques including maximal barrier precautions
sterile gown and gloves,
a mask and
a large sterile drape Use a
sterile sleeve to cover the catheter with the insertion of PAC.
4. Catheter replacement
o Do not routinely replace non-tunneled CVCs to prevent catheter-related infections. o
Use a guidewire exchange to replace
5. Pressure transducers
o Use disposable rather than reusable transducer assemblies when possible. o
Replace transducers at 96-hour intervals.
6

52. 6 Dressing regimens
 Cover catheter site with sterile gauze or sterile, transparent, semipermeable
dressing.
permit moisture to escape from beneath the dressing A/W
lower rates of skin colonization and catheter-related infection.
No topical antimicrobial ointment to the insertion site (except
with dialysis catheters).
Antibiotic ointment or creams
antimicrobial resistance and
catheter colonization with fungal species

53. HOSPITAL ACQUIRED
PNEUMONIA (HAP) &
VENTILATOR ASSOCIATED
PEUMONIA (VAP)
• HAP: Defined as peumonia that occures 48 hr or
more after admission.
• VAP: Refers to pneumonia that arises more than
48-72 hr after ET intubation.

54. EPIDEMIOLOGY:
• HAP is the 2nd
MC nosocomial infection ( 18-20%), 5-
10/1000 hospital admissions ; a/w highest mortality.
prolongation of hospital stay 8-9Day/pt + cost 40,000 dollar /pt
• HAP accounts up to 25% of all ICU infections.
• VAP occurs in 9-27% of all intubated patients.
 Cumulative incidence of VAP
 3.3% per day at day 5
 2.3% per day at day 10
 1.3% per day at day 15
Cook et al. Incidence of and risk factor for ventilator-associated pneumonia critically ill
patients.

55. PREDISPOSING FACTORS:
• Endotracheal Intubation
• ICU
• Receipt of antibiotics
• Surgery
• Chronic lung disease ( COPD, ILD)
• Advanced Age
• Immunosuppression

56. PATHOGENESIS:
• Aspiration of oropharyngeal pathogens
or leakage of secretions containing
bacterial around ETT cuff
• High rates of Gm-ve colonization in ICU
pts.
• Infected biofilm in the ETT with
embolization to distal Airways
• Gastric colonization( controversial)
Retrograde colonization of oropharynx.

57. RISK FACTORS FOR MDR
PATHOGENS
• Antibiotics in the preceding 90 days
• Hospitalization in the preceding 90 days
• Current hospitalization > 5 days
• Duration of mechanical ventilation > 7 days
• History of regular visits to dialysis centre
• Immunosuppressive disease or therapy
• High frequency of antibiotic resistance in ICU

58. MULTIDRUG RESISTANT(MDR)
PATHOGENES IN HAP & VAP
• Late onset HAP & VAP ( > 5 days)--- caused by
MDR pathogenes
• A/W increased patient’s morbidity & mortality1
• Atributable Mortality of HAP ---30-50% 2
• Increased mortality are a/w --- P. aeruginosa &
Acinatobacter,
Medical illness &
Ineffective antibi.therapy
1.Trouillet JL ChastreJ.ventilator associated pneumonia caused by potentially drug resistant bacteria. Am.J Respair crit
care med. 1998;157:531-539
• 2. Heyland DK,Cook DJ, The attributable mortality of ventilator associated peumonia in the critically ill pts. Am.J Respair
crit care med. 1999;159:1249-1256

59. MANAGEMENT STRATEGIES FOR HAP &
PAP

61. PREVENTION:
• Pulmonary Toilet:Change of position q 2 hrs,
Elevate head end of bed to 45 degree
Deep breathing ,incentive spirometry
frequent suctioning,broncoscopy to remove mucous
plugging
• Daily “sedation vacation” & assessment readiness to extubate1
• Daily oral care with chlorhexidine2
• Stress ulcer prophylaxis & intensive insulin therapy to maintain
serum glucose level 80-110gm/dl3
1.N.Engl J Med. 2000;342:1471-1477, 2.Chest 1996;109:1556-1561, 3.N.Engl J Med.
2001;345:1359-1367.

63. Preventing Contamination of
Medications and Fluids

64. Safe Injection Practices: Recommendations
• 1. Aseptic technique
Use aseptic technique to avoid contamination of sterile injection equipment.
• 2. Syringes, needles, and cannulae*
Do not administer medications from a syringe to multiple patients. Category IA
• 3. Single-dose vials (SDVs)
• Use single-dose vials for parenteral medications Category IA
• 4. Multi-dose vials (MDVs)
• If MDVs must be used i. Both the needle or cannula and syringe used must be sterile
Category IA
• 5. Fluid infusion and administration set
Use for 1 patient only and dispose appropriately after use.

65. Infusions : Recommendations
• Aseptic technique should be used when preparing and using IV infusion and
other vascular access administration sets.
• Stopcocks should be kept free of blood and covered by a sterile cap or
syringe when not in use.
• IV injection ports should be cleaned with alcohol prior to entry.

66. HOSPITAL ENVIRONMENTAL
HYGIENE
1. Hospital environmental must be visibly clean, free from non-
essential items and equipment, dust and dirt
2.Levels of cleaning should be increased in case of infections
3.The use of disinfectants should be considered for cases of infections
and colonization
4.Shared pieces of equipment used in the delivery of patient must be
cleaned and decontaminated after each use
5.All healthcare workers need to be educated about the importance of
maintaining a clean and safe care environment for patient

67. Conclusion:
• Infection control measures are important for the
effective control, prevention and treatment of
infection.
• Knowledge of emerging pathogens and resistance
profile is essential for treatment against nocosomial
infections.
• Shorter duration of treatment and correct dosage of
antibiotic therapy is recommended to reduce the
resistant isolates

68. • Hand washing is the single most important measure
to prevent nocosomial infections.
• Gloves must not be used as a substitute for hand
washing; they must be washed on glove removal.

69. Thank You!