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INFECTION CONTROL IN THE ICU
JOÃO MELO ALVES, MDLISBOA, PORTUGAL
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GENERAL ICUDIRECTOR: PROF. CHARLES SPRUNG, MD
DEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CAREHEAD OF DEP.: PROF. CHARLES WEISSMAN, MD
HADASSAH EIN KEREM UNIVERSITARY HOSPITAL JERUSALEM
Ignaz Semmelweis (1818 – 1865)
21% PSSA0.4% MRSA
Prospective observational study in Canterbury NZ8 years (1998-2006); n=779
Huggan PJ et al. Intern Med J 2010 (40:2)
Sir Alexander Flemming (1881 – 1955)Nobel Prize 1945
ICUsFrikdin SK et al. Infect Dis Clin North Am 1997 (11:2)
<10% HOSPITAL BEDS
>20% NOSOCOMIAL INFECTIONS
EPIC ICRBSI – OR 1.73
Pneumonia – OR 1.91
Sepsis – 3.75
Vincent JL et al. JAMA 1995 (274:8)
EPIC I >1000 ICUs
>10000 patients
17 european countries
EPIC II
60% patients infected
Infection vs mortality OR 1.51
Leading cause of mortality in ICU
40% of all ICU expenditures
Indwelling catheters
Vincent JL et al. JAMA 2009 (302:21)
EPIC II >1000 ICUs
>14000 patients
Worldwide study – 75 countries
Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)
“IA: periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters”
CDC 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections
Antibiotics control
Hand hygiene
Contact precautions
DecolonizationBathing
SOD/SDD
Nasal carriage
Device specific strategies
Antibiotics control
Hand hygiene
Contact precautions
DecolonizationBathing
SOD/SDD
Nasal carriage
Device specific strategies
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE UCI
ET & SPUTUM CULTURES
A-Lines as source of BSI
49 studies - only one study MSBP vs sterile gloves
O’Horo JC et al. Crit Care Med 2014 (42:6)
IB: aseptic technique for insertion and care of intravascular catheters
IC: clean gloves, rather than sterile, for PVC, after skin antisepsis
IA: sterile gloves for arterial and CVC catheters
IB: maximal sterile barrier precautions (incl cap, mask, sterile gown, sterile gloves, sterile full body drape) for insertion of CVC, PiCC or guidewire exchange
CDC Prevention Intravascular Catheter Related infections 2011
A-Lines as source of BSI
49 studies, 222 BSI, >30000 catheters
1.26 /1000 cath-days
O’Horo JC et al. Crit Care Med 2014 (42:6)
Arterial CRBSI
Prospective cohortn=2500, 2949 catheters
Femoral vs Radial /1000 cath-days:Local: 3.02 vs 0.75BSI: 1.92 vs 0.25
Increased durationPoor aseptic technique on insertion
Lorente L et al. Crit Care 2006 (10)
Rates of CRBSI/1000 cath-days
AL 1.7 vs. CVC 2.7
PVC 0.5
PiCC 1.1 (inpatients = CVC)
PAC 3.7
Maki DG et al. Mayo Clin Proc 2006 (81:9)
106 ICU, >300000 cath-days
18 months – The Provonost checklist
Handwashing
MSBP
Clorhexidine-ethanol
Avoidance of femoral
Removal ASAP
7.7 1.4
Pronovost P at al. NEJM 2006 (355)
n=3154, 2y cohort of catheter care
incidence rate/1000 pt-days
Exit-site infection 9.23.3 (RR 0.36)
CRBSI 11.33.8 (RR 0.33)
VAP/VAT/CAUTI no change
Global NI 52.434.0
Eggimann P et al. Lancet 2000 (355)
Routine replacement has no role
More mechanical complications
No advantage in reducing CRBSI
Cobb DK et al. NEJM 1992 (327)Eyer S et al. Crit Care Med 1990 (18)
Direct vs guidewire techniques
Less likelihood of success
Longer to perform
Used more catheters
Required more punctures
Guidewire 82% vs direct 65% success
Beards SC et al. Anaesthesia 1994 (49)Mangar D et al. Anesth Analg 1993 (76)
AL are NOT peripheral IVs
PVC are replaced routinely at 72-96h
(CDC-IB) – AL routine replacement
has no role
Risk of CRBSI increases with duration
Dedicated AL kits (e.g. Seldinger
techniques) have higher success
rates and lower complications
Infection rates are similar to CVC
1.26 – 1.92 /1000 cath-days
Maki DG et al. Mayo Clin Proc 2006 (81:9)
Transducers, tubing, flushing
device and solutions routinely
replaced every 96h
Recommendation based on CVC and
PAC studies!
Recommendations do not adress arterial lines
Insertion
Maintenance
Infection
… MSBP?
BLOOD CULTURES AND CRBSI
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE ICU
ET & SPUTUM CULTURES
1 BC = 20mL = 2 bottles
∆mL= ∆3% yield Mermel LA, Maki DG. Ann Intern Med. 1993 (119:4)
Aseptic cleaning – 70% alcohol, >0.5% clorhexidine
Should NOT be taken from IV cath at insertion9.1 vs 2.8% false positives (catheter vs. dedicated venipuncture)
Norberg A et al. JAMA 2003 (289) – >4100 BC!
Bacteremia is usually intermittent and of low quantities
One BC is rarely usefulLeads to under/overtreatment
Minimum 2 sets (4 bottles) from separate venipuncturesLow/moderate pretest – two simultaneous, one 6h later
High pretest, suspected continuous bacteremia – two setsHigh pretest, suspected pathogen a likely contaminant – four sets
Timing is neither sensitive nor specificTechnique, number, volume are more important for detection
Riedel S et al. J Clin Microbiol 2008 (46) – n=1436
CDC: CLABSI vs. CRBSI
Suspected when BSI occurs with CVC and no other apparent source
Fever: greater sensitivity, poor specificity.
Inflammation/pus at site: greater specificity, poor sensitivity
Safdar N, Maki Dg. Crit Care Med 2002 (30)
CRBSI
Paired CVC + peripheral blood cultures (labeled bottles)
Quantitative: CFU >3x CVC vs periph – most labs don’t perform
Differential time to positivity: CVC ≥2h before peripheral – sens 85%, spec 95%
Safdar et al. Ann Intern Med 2005 (142:6)Bouza E et al. Clin Infect Dis 2007 (44:6)
Diagnosis
(Same organism on tip + 2 periph culture)
Same organism on peripheral + CVC cultures
Safdar et al. Ann Intern Med 2005 (142:6)Raad I et al. Ann Intern Med 2004 (140:1)
Blot F et al. J Clin Microbiol 1998 (36:1)Blot F et al. Lancet 1999 (9184)
Criteria
Positive CVC (CNS), negative periperal
Colonization likelyIncreased risk for CRBSI
Follow closely vs. removal
Culturing Tips
Not routinely – only if CRBSI suspected
<7-10d: intradermal segment >7-10d: tip (most likely catheter colonization) Neg peripheral cultures: no antibiotherapy
O’Grady NP et al . CDC 2002 guidelines for the prev of intravascular catheter-related infections
“Risk of infection increases with duration of placement, but routine replacement does not decrease that risk”
Webster J et al. Cochrane Database Syst Ver 2013 (4)
RCT n=160, 4 replacement strategiesCRBSI/1000 cath-days
Q3d, new place – 3 Q3d, guidewire – 6 Clinical indication, new place – 2 Clinical Indication, guidewire – 3 New sites increased mechanical complications
Cobb DK et al. NEJM 1992 (327:15)
CDC guidelines IB: do not routinely replace CVCs, PiCCs, HD caths,
PACs to prevent CR-infections (new place or guidewire)
II: do not remove CVC/PiCCs on the basis of fever alone. Use clinical judgment.
IB: use guidewire exchange to replace malfunctioning catheter if no evidence of infection is present
IB: do not use guidewire exchanges to replace suspected infected catheterCDC Prevention Intravascular Catheter Related infections 2011
REMOVAL Severe sepsis/shock Endocarditis or metastatic infection Suppurative thromboplebitis >72h persistent bacteremia under atb Specific pathogens (SA, enteococci, GNR, fungi,
mycobacterium)
SALVAGE – no role in ICU Uncomplicated CRBSI with long-term catheters Salvage therapy (e.g. antibiotic lock) Except specific pathogens (…)
MONITOR, DO NOT TREAT Positive tip, no clinical signs Positive CVC BC, negative peripheral
Staphylococcus aureus 25-32% BSI develop INFECTIVE ENDOCARDITIS TEE 5-7d after +BC >72h is an ominous sign
Abraham J et al. Am Heart J 2004 (147:3)Fowler VG Jr et al. J Am Coll Cardiol 1997 (30:4)
Sullenberger AL et al. J Heart Valve Dis 2005 (14:1)
URINARY TRACT INFECTIONS IN THE ICU
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE ICU
ET & SPUTUM CULTURES
When to treat?
<5% of bacteriuric cases bacteremia
Leading cause of nosocomial BSI 17% of all HA-BSI (lower proportion in ICU)
CA-urosepsis 10% mortality
Gould CV et al. Infect Control Hosp Epidemiol 2010 (31)
Diagnosis: cultures and symptoms
Asymptomatic CA-bacteriuria: ≥105 CFU/mL of uropathogenic bacteria Pyuria >10 WBC/uL has low sensitivity but >90% specificity – doesn’t make the diagnosis Cloudy appearance and foul smell are NOT correlated with bacteriuria
Bacteriuria: 3-10%/day of catheterization
Hooton TM et al. Clin Infect Dis 2010 (50:5)Nicolle LE. Infect Dis Clin North Am 2012 (26:1)
“II: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as
INFECTION, obstruction, or when the closed system is compromised”
CDC Guideline for prevention of catheter-associated urinary tract infections 2009
Trautner BW, Darouiche RO. Am J Infect Control 2004 (32:3)Raz R et al. J Urol 2000 (164:4)
Start antibiotics and replace catheter
Fewer and later relapses
Shorter time to afebrile status
Improved clinical status at 72h p<0.001
Less rate of complications (bacteremia, pyelonephritis) p=0.015
UTIUROSEPSIS
Bacteriuria ≥105 CFU/mLFever, sepsis or bacteremia
No alternate sources
ENDOTRACHEAL TUBES & SPUTUM CULTURES
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE ICU
ET & SPUTUM CULTURES
Ventilator associated tracheobronchitis
Horan TC et al. CDC/NHSN surveillance definition. Am J Infect Control 2008 (36:5)
Fever>38ºC
No other recognizable source of infection
New/increased sputum production
Positive culture of tracheal aspirates
No radiographic infiltrate or evidence of pneumonia
Lower respiratory tract colonization ↔ VAPPseudomonas, Acinetobacter, Staph aureus
Prospective cohort VAT vs VAP (n=28 / 83)
Length of hospital stay
Duration of hospital stay
Survival rate to discharge
Need for tracheostomy
Need for antibiotics
Dallas J et al. Chest 2011 (139:3)
RCT n=58, antibiotics vs placebo (8 days)
Treatment improves outcomes
Reduced ICU mortality: 18 vs 47% – trial stopped early!
Fewer episodes of VAP: 13 vs 47%
More ventilator free days
Management of VAT=VAP
Nseir S el at, VAT Study Group. Crit Care 2008 (12:3)
Clinical importance seems to be similar to VAP
Infection control is a MAJOR issue
AL should probably be handled like CVCInsertion technique and MSBP
Never take ONE blood cultureAlways TWO OR MORE separated, dedicated venipunctures
Culture the CVC
Diagnose and treat UTIRemove the catheter – colonization is not a limitation
Don’t wait for VAP – treat the VAT
1. Antimicrobial resistance: global report on surveillance. World Health Organization 2014
2. Naomi P.O’Grady et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. HICPAC,
CDC.
3. Carolyn V Gould et al. Guideline for prevention of catheter-associated urinary tract infections 2009. HICPAC, CDC.
4. Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)
5. Australian guidelines for the prevention and control of infection in healthcare. 2010, Australian Government.
6. Healthcare Society Infection guidelines. http.//www.his..org.uk/resources-guidelines/
7. ASPIC Asia Pacific Society of Infection Control Guidelines. July 2012. http:// apsic.info/guidelines.php
8. SHEA Society for Healthcare Epidemiology of Americas. Compendium of Strategies to prevent healthcare-
associated infections in acute care hospitals (SHEA, IDSA, AHA, APIC, JC) 2014 update – several statements
published on Infection Control and Healthcare Epidemiology Journal since 2008
Executive summary 2014 updates: Infection control 2014 (35:8)
João Melo Alves – joaomeloalves@gmail.com
http://www.slideshare.net/joaomeloalves
REFERENCE BIBLIOGRAPHY
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