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7/30/2019 Guest Talk on ICU Infections
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GUEST LECTURE ATJIPMER , Pondicherry
INTENSIVE CARE UNITSINFECTIONS AND CONTROL
(December 2012)
Dr.T.V.Rao MDProfessor of Microbiology
Travancore Medical College, Kollam Kerala
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Ignaz Semmelweis(1818-1865)
Obstetrician,practised in Vienna
Studied puerperal(childbed) fever
Established that highmaternal mortalitywas due to failure ofdoctors to wash hands
after post-mortems Reduced maternal
mortality by 90%
Ignored andridiculed by
colleagues
A tribute to Ignaz Semmelweiss
(1818-1865)
. . . . .
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What is a Intensive Care Unit
An intensive care unit (ICU) is
defined as a specially staffed,
specialty equipped, separate sectionof a hospital dedicated to the
observation, care, and treatment of
patients with life threateningillnesses, injuries, or complications
from which recovery is possible12/23/2012 Dr.T.V.Rao MD 3
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A Patient in Intensive Care Unit is at
Risk for Many Reasons..
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Infection in ICU are
More in Prevention
Little in Treatment
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Educating our Health Care
Workers
Education programs for
employees and volunteers are one
method to ensure competentinfection control practices. The ICP
must become knowledgeable andtechniques that will motivate and
sustain behavioral change.12/23/2012 Dr.T.V.Rao MD 6
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Why ICU patients are different
Many times very sick patients (multiplediagnoses, multi-organ failure,)immunocompromised, septic and
trauma)
Move less
Malnourished
May be associated Diabetics and Heartfailure
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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 > upperextremities 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 Dis2006
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EPIDEMIOLOGY
Contributing factorsThe high frequency of indwelling
catheters among ICU patients
The use and maintenance of thesecatheters necessitate frequent contactwith health care workers, which
predispose patients to colonizationand infection with nosocomialpathogens.
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Drug Resistant Bacteria a threat to Life
Multidrug-resistant pathogens
such as methicillin-resistant
Staphylococcus aureus (MRSA)and Vancomycin-resistant
enterococci (VRE) are beingisolated with increasing
frequency in ICUs12/23/2012 Dr.T.V.Rao MD 10
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ICU Care is Invasive at many
Stages
More invasive lines andprocedures includingsurgeries
Longer length of stay
More IV and parenteraldrugs
More tube feeding andParenteral nutrition
More ventilation
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ICU : Factors that increasecross-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 ofitems & equipment's
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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
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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 fomitespotentially contaminated with respiratory
secretions Use aseptic techniques
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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 contaminationbefore use
Keep environment clean, dry and dust free
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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 identifyproblems areas & set priorities
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Intensive Care UnitPrevention of Blood stream
infections
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Central Venous Catheters
Indications
IV fluids and drugs
Blood and blood products Total Parenteral Nutrition (TPN) Hemodialysis
Hemodynamic monitoring
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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.
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Incidence of CR-BSI
Type of catheterTeflon or Polyurethane ( < infections) vs Polyvinylchloride
Site of insertionSubclavian (< infections) vs Internal Jugular &
Femoral (high risk of colonization & deep venousthrombosis)
No. of Lumen
Single-lumen catheter (< infections) vsMulti-lumen catheter
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Intrinsic contamination ofinfusion fluid
Connection with administrationset
Insertion site
Injection ports
Administration set connectionwith IV catheter
Port foradditives
Sources of Infection
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Intralumunal SpreadContaminatedinfusate (fluid,medication)
2. Intraluminal SpreadContaminated infusate(fluid, medication)
1. Extra luminal SpreadPatients own skin micro flora
Microorganism transferred bythe hands of Health CareWorkerContaminated entry port,catheter tip prior or duringinsertion
Contaminated disinfectantsolutionsInvading wound
3. Haematogenous SpreadInfection from distant
focus
Fibrin
Skin
Vein
Skin attachment
Sources of Infection
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Prevention Strategies: Core
Chlorhexidine Skin Cleansing
Chlorhexidine is the preferred agent for skincleansing for both CL insertion and maintenance Tincture of iodine, an iodophor, or 70% alcohol are
alternatives
Recommended application methods and contact timeshould be followed for maximal effect
Prior to use should ensure agent iscompatible with catheter Alcohol may interact with some polyurethane
catheters
Some iodine-based compounds may interactwith silicone catheters
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Prevention of CR-BSI
Skin antisepsis
2% Chlorhexidine gluconate has shown to
have lower BSI than 10% Povidone-iodine or
70 % Alcohol
2-min drying time before insertionMaki DG et al. Lancet1991;338:339-43
No difference between 0.5% Chlorhexidinegluconate or10% Povidone-iodineHumar A et al. Clin Infect Dis 2000;31:1001-7
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Prevention of CR-BSI
Topical antibiotic
Prophylactic use of topical Mupirocin (Bactroban) at
insertion site orin nose is not recommended
Rapid development of Mupirocin resistant Mupirocin affect the integrity of Polyurethane catheter
Systemic antibiotic
Prophylactic use of antibiotic is not recommendedatthe time of catheter insertion
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Urinary Catheterization
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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 insertion
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Junction between catheter & drainage
tube
Do not disconnect catheter unlessabsolutely necessary.
For urine specimen collection disinfectoutside of catheter proximal to junctionwith drainage tube by applying alcoholicimpregnated wipe and allow it to dry
completely then aspirate urine with asterile needle and syringe.
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Intensive Care Unit
Nosocomial Pneumonia
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Incidence of HAI vs. Cost
Hospital acquiredInfection
Incidence Additionalcost
Urinary Tract 45% 13%
Surgical Wound 29% 42 %
Pneumonia 9 % 39%
Blood Stream 2% 4 %
Haley, 198612/23/2012 Dr.T.V.Rao MD 30
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Prevention in ICU Turn patients to
encourage posturaldrainage
Encourage to take deep
breaths and cough. Maintain an upright
position (elevate patientshead to 30- 45 degree
angle) to reduce refluxand aspiration of gastricbacteria.
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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 wateroutlet.
All water outlets must run daily to minimize
the potential for legionella within the pipeline
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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 beprevented 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 andthose clinically involved with the infection.
An organized hospital-wide surveillance system.
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Methicillin-resistant
S. aureus (MRSA) is
resistant to several
antibiotics. Anotherform ofS. aureus,
vancomycin-resistant
S. aureus (VRSA), is
resistant to one of themost powerful, last
line of defence
antibiotics,
vancomycin
Concerns with staphylococcus
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RESISTANT GRAM NEGATIVE ORGANISMS
Resistance to multiple antibiotics
Organisms:
E .coliProteusEnterobacterAcinetobacter
StenotrophomnonasPseudomonas aeruginosa
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Escherichia coli(E.coli) has gradually
become resistant to
different types ofantibiotics. In 2003,
the overall resistance
ofE. colito common
amino penicillinantibiotics reached
47% across Europe
E.Coli and emerging resistance
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SURVEILLANCE
Dr.T.V.Rao MD 37
Important means of monitoring HAIEarly detection of trends outbreaks
Laboratory Based
Microbiology Laboratory lists Gram +ve and - veorganismsICN reviews Alert organismsreported
2. Ward BasedWard staff monitor patientsICN reviews ICN visits wards
l
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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
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Antibiotics use
Must avoid widespreaduse of
broad spectrum antibiotics
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Problems in-Detection of Infection in
the ICUs
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Examples of difficult to detect infections:
Uncultivable organisms
Viruses are under appreciated as causes ofnosocomial infections. Except in cases of highmorbidity viral cultures are not done inresource scarce settings.
Impact food-borne, respiratory, water borne
illnesses.
.
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fi i i f i l i i f i
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Definition of surgical site infection
(no implant)
Occurs within 30days of surgery
AND has one of thefollowing:
Purulent drainagefrom drain OR
Organism isolated
from asepticallyobtained fluid in theorgan space
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Prior to starting any surveillance
Agree upon a
written case
definition that is
practical given the
laboratory
facilities andpatient work load
in your facility.
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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 byintended/completed actions
Research indicates:
poor techniques - not all surfaces cleaned
frequency diminishes with workload/distance
poor compliance with guidelines/training
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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-compliers
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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 determinedbetween 2002 and 2005; an overall rate of 14.7 percent or22.5 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 catheterdays (1.7-12.8)
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k h ( bi i i i ) i
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Cockroaches (Ectobius vittiventris) in
an Intensive Care Unit, Switzerland
Cockroaches are capable of harboring Escherichia coliEnterobacter spp. Klebsiella spp. , Pseudomonasaeruginosa , Acinetobacter baumannii , othernonfermentative bacteria Serratia marcescens Shigella
spp. Staphylococcus aureus group A streptococci ,Enterococcus spp. , Bacillus spp. , various fungi , andparasites and their cysts . An outbreak of extended-spectrum -lactamaseproducing Klebsiella
pneumoniae in a neonatal unit was attributed tocockroaches
Emerging Infectious Diseases March 2009
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R id d N h d f
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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), andthe ability to detect it through an ATP
bioluminometer indicates the amount of
microbial and non-microbial contamination ina given test area. This is accomplished by a
luminescent chemical reaction,
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Our Vision to Future
Infection controlprograms must
maintain training
records of employees.The minimum training
required is annual OSHA
blood borne pathogen,
tuberculosis preventionand control and new
employee orientation.
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WHONET - Documentation
Establishing WHONET
Documentation makes
the Antibiograms
assessments easy byMicrobiologists and
Consultants at any
Hospital.
We are fully functionalto the advantages of
the WHONET
documentation,Dr.T.V.Rao MD 50
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Do remember the Reasons for Infections are
Many but solutions are few
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C f h it l i f ti
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Consequences of hospital infections
???
Hospital Pathogen Unhappy
patients
Unhappy
director
Hospital Surveillance Happy
PatientsHappy
directorDr.T.V.Rao MD 52
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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 incollaboration with WHO, ICMR, DBT, NGOs;
use of information technology for patient
care, training and research.
12/23/2012 Dr.T.V.Rao MD 53
L t t H it l ith
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Let us support our Hospitals with
clean hands
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