This document discusses infection control in healthcare settings. It begins by noting that healthcare-associated infections pose the greatest risk to patients in hospitals. It then discusses specific types of common infections like urinary tract infections, surgical site infections, pneumonia, and bloodstream infections. The document provides guidance on preventing these infections through practices like hand hygiene, maximal sterile barriers during procedures, chlorhexidine skin cleaning, and compliance with infection control bundles. It emphasizes the importance of preventing infections over treatment, and notes that following best practices can reduce infections by 20%. The role of alcohol-based hand rub, line maintenance, oral care, and isolation protocols are also summarized.

1. INFECTION CONTROL

2. INFECTION CONTROL
 Health care associated infection
greatest risk a patient faces on
admission to a hospital

3. A QUICK SURVEY
How many of you
 Have encountered Nosocomial
Infections?
 Have disclosed to families that
it is a NI?
 Analyzed root cause of NI?
 Optimized your efforts to
prevent it?

4. LET’S FACE REALITY
 Who pays for morbidity and additional
costs related to NI?
 What happens if third party payment is
denied for NI?
Medicare in USA
 Do we have benchmarks?

5. BIG FOUR…
 Urinary tract infection
 Surgical site infection
 Pneumonia
 Blood stream infection

6.  Prevention better than cure
 20% can be prevented
 Infection control is the foundation

7. WHERE TO LOOK FOR?
 Tubes- ETT, RT, Foley, TT
 Lines- peripheral, central and arterial
 Personnel-doctors,nurses, care givers

8. HOW DO WE GO ABOUT…
 Standard precaution
 Transmission barrier
 Education
 Surveillance

9. ALCOHOL BASED HAND RUB-GOLD
STANDARD
1. Terminates out breaks
2. Decreases transmission of MRSA
3. Gloves is not the answer
4. Allergic contact dermatitis
5. Generates more time

10. Routine Hand Hygiene
Ref; ISCCM 2003 guidelines
The scrub should be performed
for a minimum of 2-3 minutes

11. Procedural Hand HygiEne
Ref; ISCCM 2003 guidelines
The scrub should be
performed for a
minimum of 2-3 minutes
Hand drying - use sterile
(autoclaved) towels

12. LINES
 Peripheral
 Central
 Arterial

13. INSERTION OF PERIPHERAL IV
CATHETERS
Ref; ISCCM 2003
Guidelines
once prepared, the site of insertion should not be palpated

14. FLUSHING PERIPHERAL
LINES

15. CENTRAL LINE
 Insertion
 Maintenance
 Replacement

16. INSERTION
 Empowerment
 Insertion cart or kit
 Maximal sterile barrier
 Site

17. CENTRAL LINE INSERTION
BUNDLE
 Hand Hygiene
 Maximal Sterile Barrier Precautions
 Chlorhexidine Skin Asepsis
 Optimal Catheter Site Selection

18. MAINTENANCE
 Dressing
 Any role for systemic antibiotics
 Topical antibiotic
 Anticoagulant flush/ heparin lock

19. CENTRAL LINE MAINTENANCE
BUNDLE
 Daily review of Central Line necessity and
prompt removal of unnecessary lines
 Dedicated lumen for TPN
 Accessing the lumens aseptically
 Checking entry site during every dressing
change

20. HAND HYGIENE
strictly followed (even when gloves are worn) before and after
injection, blood sampling, dressing or any contact with the CVC or
insertion site
Ref; ISCCM 2003 Guidelines

21. TECHNIQUE OF BLOOD
SAMPLING

22. Gauze dressing
Transparent
dressing
MAINTENANCE OF CENTRAL
LINES - DRESSING CHANGE

23. POORLY MAINTAINED

24. CENTRAL LINE BUNDLE
COMPLIANCE
Intervention Compliance
Hand Hygiene 62%
Chlorhexidine antiseptic at
procedure site
100%
Draped entire patient in a sterile
fashion
85%
Used cap, mask & sterile gown 92%
Used Sterile gloves 100%
Sterile dressing applied 100%

25. REPLACEMENT
 Routine line change not needed
 Purulence
 If not needed- plastic is out
 Over the guidewire exchange- No, No
 Emergency line< 48 hrs

26. CARE OF PRESSURE MONITORING
SYSTEM
 Closed continuous flush system
 No dextrose containing solution
 Minimal manipulation
 No antibiotic lock technique

27. REPLACEMENT….
 Disposable transducer system- 96 hours
 Reusable transducer system- 48 hours

28. Chlorhexidine versus Povidone-
Iodine Solution
Ref; Chlorhexidine Compared with Povidone-Iodine Solution for Vascular Catheter–Site Care: A Meta-Analysis Nathorn
Chaiyakunapruk, PharmD, PhD; David L. Veenstra, PharmD, PhD; Benjamin A. Lipsky, MD; and Sanjay Saint, MD, MPH
Ann Intern Med. 2002;136:792-801.
Chlorhexidine is superior
 blood, serum, and other
protein-rich biomaterials can
deactivate the microbicidal
effect of povidone-iodine but
not chlorhexidine
 the residual effect defined as
the long-term antimicrobial
suppressive activity is
prolonged (at least 6 hours)
 reduces the colony counts of
coagulase-negative
staphylococci

29. URINARY CATHETER
 CAUTI – What does it mean?
 40% of all nosocomial infections
 Types of catheter
1. Short term
2. Long term indwelling

30. CAUTI
 Infection!! Why?
 Common mechanism
1. Extraluminal
2. Intraluminal

31. PREVENTION
 Closed drainage system
 Restricted catheter use
 Aseptic technique
 Unobstructed urine flow
 Catheter size

32. WHAT CAN WE DO?
 Catheter management
 Taping and anchorage
 Cleaning
 Disinfectant!!!
 Collection bag
 Discontinuation
 Transport

33.  Suprapubic catheter
 Bladder irrigation
 Antimicrobial coated catheter
 Condom catheter

34. WHEN DO YOU REPLACE?
 Suspected UTI
 Decreases bacterial load
 Antibiotic penetrate biofilm poorly

35. URINARY CATHETER
Urine sample collection
 Urine can be aspirated
from the catheter itself
or through a port
designed specifically for
that purpose, but should
not be taken from the
collection bag.
 Remove an indwelling
catheter and sample urine
using a new catheter,
when possible Ref: Thomas Fekete UpToDate 2008

36. ENDOTRACHEAL TUBE MANAGEMENT

37. Orogastric tubes also
preferred
over nasogastric
Nasal tubes obstruct
maxillary antral drainage
The orotracheal route is
preferred for intubation
Nasal route
only
as an
exception

38. SECURING THE ET TUBE
Method 1: Using standard sticking plaster
(eg. Johnsonplast®
)
Apply short strip to long 1” strip
“ sticky” side up
tails
Tail secures
tube
Tail
fixes to lip

39. Method 2: Using twill tape tie
“Cow hitch”
“Clove Hitch”
Method 3:
Commercially
manufactured holders
are now available
SECURING THE ET TUBE

40. CONFIRMING TUBE POSITION
Besides auscultation, always confirm ET tube
position on a chest radiograph
Remember! Neck position affects
ET tube tip movement.
ET tip about 4cms above carina; level of aortic knob
Always note the distance of the tube at the incisor teeth

41. VENTILATOR ASSOCIATED PNEUMONIA
 48-72 hours of ventilation
 Progressive new infiltrates in CXR
 Leukocytosis and purulent
tracheobronchial secretions

42. HOW DO YOU PREVENT
 Patient positioning
30-45 º
Semi-recumbent position

43. SUPRAGLOTTIC CARE
Continuous aspiration of supraglottic collection
will reduce VAP rates (needs special tube)
Accumulation of supraglottic
secretions; may be aspirated
with pressures not > 20 cm H2O.
Specialised tube with a channel
opening above the balloon

44. ORAL CARE
Regular mouth care to clear oral secretions &
administer antiseptics (chlorhexidine)
Preferably 8 hourly
Remove oral airway
Move ET tube to opposite corner
Clear mouth of all secretions
Paint mouth with 2% chlorhexidine
Reduces rates of VAP

45.  No evidence to prefer CSS over OSS
 Cuff pressure
 Heated Vs unheated circuit
 Artificial nose Vs humidification
 Stress ulcer prophylaxis

46. Contact isolation
 For patients with multi-drug resistant bacteria
 Consists of standard precautions plus unsterile
gloves whenever patient is touched, then
handwashing or hand rub immediately
 Plastic gowns if extensive patient contact likely
 Dedicated equipment eg stethoscope, BP apparatus
 Sign at head of bed
 Single room or cohort nursing
 One on one nursing essential
CONTACT ISOLATION

47.  Standard precautions plus contact precautions
plus:
 Private room or sharing of room with anyone
with a similar illness; if not feasible, patients
should be minimum of 3 feet apart
 Surgical masks for anyone who goes within 3
feet of patient
 Patient masked when transported outside room
 For respiratory viruses
DROPLET ISOLATION

48.  For PTb, Varicella, Rubella
 Spreads beyond 3ft
 Separate room with ante-
room
& negetive pressure
 No re-circulation of air
 6–12 exchanges per hour
 One per 100 beds
 Proper mask – N95
AIRBORNE ISOLATION

49. FUTURE IS LOOKING….
 Dramatic proliferation of MDR
organisms
 No new antibiotic in the horizon
 Mushrooming of ICUs in smaller towns
 Lack of strict adherence to protocols
MAY DAY! MAY DAY!

50. ZERO RESISTANCE – SPANISH
ARMADA
 Zero VAP and zero bacteremia
 Dedicated intensivist
 Exclusive infection control nurse
 Active surveillance
 Standardised cleaning protocol
 Built in educational modules

51. TAKE HOME MESSAGE
 Alcohol based hand rub is an eye opener
 Routine line change not needed
 Prophylactic antibiotic- definite NO
 Closed drainage system is a must
 30-40º semi-recumbent position

52.  Breaking myths , beliefs and barriers
 Advocating zero tolerance
 Rationale outlook towards local needs
YES WE CAN

53. THANK YOU