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

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].

CHAIN OF INFECTION

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

CONTAMINATED SURFACES INCREASES CROSS- TRANSMISSION

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.

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.

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

The MOST PREVALENT INFECTIONS:

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.

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

HAND HYGIENE

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

Hands must be decontaminated:

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

• 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

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

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

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

WHO Recommended Hand Hygiene Technique

• 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

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.

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

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.

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

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

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

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

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

Prevention of Surgical Site Infections

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.

Ann Thorac Surg 2009;87:663–9

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).

• 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.

• 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.

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.

Hayek LJ, Emerson JM, Gardner AM. A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates. J Hosp Infect. 1987;10:165-172.

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.

Continue antimicrobial therapy until, at most, a few hours after the incision is closed in the operating room (OR).

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!

Antibiotic Recommendations

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.

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 the next operation .

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

• 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

• 5. Normothermia

Maintain patient normothermia. Hypothermia (core temperature <36C) 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

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

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.

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

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

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.

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.

PREDISPOSING FACTORS:

• Endotracheal Intubation

• ICU

• Receipt of antibiotics

• Surgery

• Chronic lung disease ( COPD, ILD)

• Advanced Age

• Immunosuppression

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.

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

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

MANAGEMENT STRATEGIES FOR HAP & PAP

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.

•

Preventing Contamination of Medications and Fluids

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.

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.

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

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

• 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.

Thank You!