Infec control measures in icu day in life of bacterium-mgh
1. Infection Control Measures in the ICU:
A day in the life of a bacterium in the
ICU
B. Taylor Thompson, MD
Director, MICU
Massachusetts General Hospital
Associate Professor of Medicine
Harvard Medical School
tthompson1@partners.org
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3. WHO Global Safety Challenge
First Target (2005-2006)
– Health Care Associated Infections
– Hand Hygiene as cornerstone
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4. 5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 20064
5. 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 2006
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6. 5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 20066
7. Transmission to Hands from Skin
and Environment
Pittet et al Lancet Infect Dis 2006
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8. Transfer to the hands of health
care workers (HCWs) hands: I
• “Clean Activities” (lifting, taking radial
artery pulse, measuring blood pressure)
– Up to 100-1000 cfu from HCWs hands
• HCWs intercepted before hand wash in
MRSA colonized patient
– 17% of worker’s gloves positive
Phillips, BMJ 1977; McBride, J Hosp Inf 2004
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9. Transfer to the hands of health
care workers (HCWs) hands: II
• Surveillance cultures of HCWs hands in ICU
– 21% of MDs; 5% of nurses positive (n=328)
• Serial Cultures of NSICU HCWs hands
– 100% positive for GNR and 64% positive for staph
aureus at least once
• Rings, artificial or long nails, dermatitis increase
frequency of hand contamination of HCWs
Daschner, J Hosp Inf 1988; Maki, Ann Int Med 1978; Trick, Clin Inf Dis 2003
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11. Contamination of Healthcare
Workers with VRE during Routine
Patient Examinations
At least one site 33/49 (67%)
Gloves (Hands) 31/49 (63%)
Gowns 18/49 (37%)
Stethoscopes 15/49 (31%)
All three sites 12/49 (24%)
Stethoscope after wipe 1/49 (2%)
Zachary, Infect Control Hosp Epidemiol. 2001
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12. 5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 2006
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13. Bacterial Survival times on hands
• Acinetobacter spp 60 min
• E. coli 6 min (mean)
• Klebsiella spp 2 min (mean)
• VRE 60 min
• Pseudomonas sp 30 min; 180 in sputum
• Rotavirus 16% survive 20 min;
2% survive 60 min
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15. Contamination of ICU Patient Charts
• Sterile swab of outside of binders/charts
kept outside the ICU room
Percent of ICU charts culture positive by organism
Panhotra Am J Infect Control 2005
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16. 5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 2006
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17. Hand washing compliance rates by
occupation
Occupation Compliance OR (95% CI)
Nurse 52% 1.00
Physician 30% 2.80 (1.9-4.1)
Nursing Assistant 47% 1.28 (1.0-1.5)
Other 38% 2.15 (1.4-3.2)
Pittet D et al. Ann Intern Med 1999; 130:126
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18. 5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 2006
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20. Strategies to decrease transmission
• Proven or Proposed Strategies
– Antibiotic stewardship
– Proper hand hygiene
– Cohorting patients
– Reducing LOS
– Gowns and gloves
– Isolation of patients
– Appropriate staffing ratios
– Antibiotic crop rotation
– Surveillance cultures
– Decolonization of patients (chlorhexidine body washes, muciprocin)
– Decolonization of health care worker carriers
• Paucity of RCTs on efficacy of individual approaches
• Efficacy of an individual approach may vary by pathogen
• Near eradication of a pathogen from a hospital (or a
country) requires a bundle of approaches (eg. “Search
and Destroy” in the Netherlands) 20
21. Compulsive Antibiotic Prescribing (CAP)
• CAP is a widespread and serious affliction
– First year medical students are free of the disease
– Interns and first year residents are severely afflicted…
life-long habit difficult to break
– CAP is supported by a well organized group of
antibiotic pushers
• Antibiotics Anonymous
– Self help group, available 24 hours, will talk you
through the urge to prescribe more than two
antibiotics, other abuses
Lockwood et al, NEJM p465-466, 1974
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22. Is isolation safe for the patient?
• Cases: Consecutive patients admitted and
isolated for MRSA
• Controls: Patients in the same room immediately
before and after a case
• Similar baseline characteristics
• Cases
– More likely to have unrecorded vital signs, absent MD
progress notes, and to complain about their care
– Twice the rate of preventable adverse events
– Similar mortality (17% cases vs 10% controls, p=0.16)
Stelfox , JAMA 2003 22
24. MGH Hand Hygiene (HH) Campaign
• 2000 HH Task Force (D. Hooper and P. Wright)
– Cal stat dispensers hospital wide
• 2002 Poster/Educational Campaign
• 2004
– 8% wash before contact, 48% after contact
– HH Champions on each floor -> Pizza
– New Poster Campaign
– Monitoring and feedback of HH rates by unit/floor, RN/
MD
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25. MGH Hand Hygiene Campaign
• 2005-2006
– Benchmark against peers (more peer pressure)
– “On the spot” Coffee Central coupons
– Patients as advocates: patient learning center
• 2007
– HH Quality incentive program: if rates of HH
before and after patient contact > 90% on a
given floor/ICU, monetary bonus paid at years
end to RNs, MDs. Rates/reminders sent to
units monthly
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28. Conclusions
• Nosocomial transmission of pathogenic
bacteria creates a major health burden
• Multifaceted interventions are needed for
high level control: proper hand hygiene is
the cornerstone of prevention efforts
• Isolation of patients may place them at risk
for errors of omission
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