DR.T.V.RAO MD 1

Dr.T.V.Rao MD

ICU INFECTIONSBASIS, DIAGNOSIS, AND PREVENTION

DR.T.V.RAO MD 2

DEFINITIONS

NOSOCOMIAL INFECTION :• An infection acquired in a patient in a

hospital or other healthcare facility in whom it was not present or incubating at the time of admission or the residual of an infection acquired during a previous admission.

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Nosocomial infections have been recognized for over a century as a critical problem affecting the quality of health care and a principal source of adverse healthcare outcomes.

BACKGROUND OF HOSPITAL INFECTIONS

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RISK OF INFECTIONS IN ICU • Patients hospitalized in ICUs are 5 to 10 times

more likely to acquire nosocomial infections than other hospital patients. The frequency of infections at different anatomic sites and the risk of infection vary by the type of ICU, and the frequency of specific pathogens varies by infection site. Contributing to the seriousness of nosocomial infections, especially in ICUs, is the increasing incidence of infections caused by antibiotic-resistant pathogens

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And why do they come to the ICU

Ventilator support – respiratory failure – pneumonia

Hemodynamic support – shock

Renal replacement therapy – renal failure, severe acidosis

Monitoring, Neurological dysfunction, Hematologic

WHY ONE MAY BE IN ICU WITH

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ICU : FACTORS THAT INCREASE CROSS-INFECTIONS

• Lack of Hand washing facilities• Patient close together or sharing rooms

• Understaffing• Preparation of IVs on the unit • Lack of isolation facilities

• No separation of clean and dirty AREAS• Excessive antibiotic use• Inadequate decontamination of items & equipment's• Inadequate cleaning of environment

DR.T.V.RAO MD

• Hospital-acquired fevers occur in one-third of all medical inpatients

• Nosocomial fevers even more common in the ICU

NOSOCOMIAL FEVERS

7

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Ventilator associated pneumonia

Catheter related blood stream infections

Urosepsis Intra-abdominal infections Sinus infections Diarrhoea

INFECTIOUS CAUSES OF FEVER WHILST IN ICU

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FEVER IN THE ICU• ICU patients have several underlying

medical/surgical conditions

• ICU patients undergo many invasive diagnostic and therapeutic procedures

• Therefore, fever in ICU patients must be thoroughly and promptly evaluated to discriminate infectious from non-infectious etiologies

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CAUSES OF FEVER IN THE ICU• Surgical site infections• Intravenous-line

infections• Nosocomial pneumonia• Nosocomial sinusitis• Intraabdominal

infections

• Urinary catheter-associated bacteriuria

• Drug fever• Post-operative fever• Neurosurgical

causes

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Community acquired pneumonia Acute CNS infection Urinary tract infection Abdominal focus of infection Wound infection / Pus collections Trauma with infection

THE OBVIOUS FOCUS

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DEVICE RELATED NOSOCOMIAL INFECTION

• A device-associated infection is an infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection. If the interval since discontinuation of the device is longer than 48 hours, there must be compelling evidence that infection was associated with device use.

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ICU PATIENTS DIFFERS FROM MANY PATIENTSPAY MORE ATTENTION

• Sickest patients (multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma)

• Move less • Malnourished • More obtunded (Glasgow coma scale)• Diabetics and Heart failure

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Ventilator associated pneumonia

Catheter related blood stream infections

Urosepsis Intra-abdominal infections Sinus infections Diarrhoea

INFECTIOUS CAUSES OF FEVER WHILST IN ICU

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Patient with an obvious focus of infection

Where is the focus?

PATIENT PRESENTING TO ICU WITH FEVER

Acute un-differentiated

fever

What is causing this fever?

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RISK FACTORS

• operative surgery• intravascular and urinary catheterization • mechanical ventilation of the respiratory tract• Other risk factors include traumatic injuries,

burns, age (elderly or neonates), immuno-suppression and existing disease

ICU CARE IS MORE INVASIVE

• More invasive life lines and procedures including surgeries

• Longer length of stay• More IV and parenteral

drugs• More tube feeding and

Parenteral nutrition• More ventilation

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FACTORS INFLUENCING INCREASED INFECTIONS IN ICU

• Hand washing facilities• Patient close together or sharing rooms• Understaffing• Preparation of IVs on the unit • Lack of isolation facilities • No separation of clean and dirty AREAS• Excessive antibiotic use• Inadequate decontamination of items & equipments• Inadequate cleaning of environment

THE INANIMATE ENVIRONMENT IS A RESERVOIR OF PATHOGENS

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive Enterococcus culture

The pathogens are ubiquitous

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• 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 malnutrition

SOME HEALTH-CARE ASSOCIATED INFECTIONS

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MANAGING FEVER IN ICU PATIENTS

• Fever in the ICU can have many infectious and noninfectious etiologies

• Crucial to identify the precise cause as some of the conditions in each groups are life-threatening, while others require no treatment

• “Routine fever work-up” not cost-effective

• If initial evaluation shows no infection, antibiotics should be withheld

• Empiric antibiotics may be started in the unstable patient, but stopped if infection is not evident later

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DEVICE RELATED NOSOCOMIAL INFECTION

• A device-associated infection is an infection in a patient with a device (i.e., central line, ventilator, or indwelling urinary catheter) that was in use within the 48-hour period before onset of infection. If the interval since discontinuation of the device is longer than 48 hours, there must be compelling evidence that infection was associated with device use.

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Intrinsic contamination of infusion fluid

Connection with administration set

Insertion siteInjection portsAdministration set

connection with IV catheter

Port for additives

Sources of Infection

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Intralumunal SpreadContaminated infusate (fluid, medication)

2. Intraluminal SpreadContaminated infusate (fluid, medication)

1. Extra luminal SpreadPatient’s own skin micro floraMicroorganism transferred by the hands of Health Care WorkerContaminated entry port, catheter tip prior or during insertionContaminated disinfectant solutionsInvading wound

3. Haematogenous SpreadInfection from distant focus

FibrinSkin

Vein

Skin attachment

Sources of Infection

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PREVENTION OF CR-BSIWritten Protocol

Must be performed by trained staff according to written guidelines

Sterile procedure

Sterile gown, Sterile gloves, Sterile large drapesDon't shave the site

Hand disinfection

With an antiseptic solution eg Chlorhexidine gluconate

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FUNGI TOO INFECTIVE IN

ICU PATIENTS

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RISK FACTORS FOR ASPERGILLOSIS

• Neutropenia

• steroids

• Environmental exposure

• Building work

• Compost heaps

• Marijuana smoking

• incidence increasing• commonest cause of

infectious death in many transplant units

• commonest cause of death in childhood leukaemia

INVASIVE ASPERGILLOSIS

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PROTECTED ENVIRONMENT

• HEPA (for allogeneic HSCT patients only)• 99.97% of all particles >3u diam)• >/=12 ACH• Pressure differential >2 Pa• Directed air flow• Sealed rooms• Respiratory protection (N95 respirator) if leaving room only during periods of building

construction

• Standard hygiene barrier precautions• No flowers, potted plants, carpets• Vacuums to have HEPA filters

HICPAC guidelines CDC 2004

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BASIC POLICIES IN MICROBIOLOGICAL

DIAGNOSIS OF ICU INFECTIONS

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CRITERIA FOR DIAGNOSIS• fever.

• cough.

• development of purulent sputum, in conjunction with radiologic evidence of a new or progressive pulmonary infiltrate.

• a suggestive Gram stain, and positive cultures of sputum, tracheal aspirate, pleural fluid, or blood.

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HOW TO DIAGNOSE?• A positive result of semi quantitative Culture ( 15 CFU per

catheter segment) Maki D, et al NEJM 1977;296:1305 or quantitative ( 102 CFU per catheter segment) catheter culture, whereby the same organism isolated from a catheter segment and a peripheral blood sample

• Simultaneous quantitative cultures of blood samples with a ratio of 5 : 1 (CVC vs. peripheral)

• Differential time to positivity :positive result of culture from a CVC is obtained at least 2 hr earlier than is a positive result of culture from peripheral blood)

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• If You put a central line in a patient with documented Bacteremia, then later next day somebody may obtain a blood culture from both the central lien and from periphery, >>>>>>> a positive blood culture from both sites, does not mean that the central lien is the source.

REMEMBER………….

DEALING WITH STAPHYLOCOCCUS AUREUS • REMOVE the central line . • Systemic antibiotics for minimal 14 days. • Failure to clear bacteremia within 72 hours Or

patient with high risk for endovascular infection or having prosthesis may be indicative for longer 3-6 weeks of treatment.

• TTE or TEE are strongly advised.• Blood Culture should be repeated during

therapy and1-2 weeks after completion of therapy, looking for relapses.

COAGULASE NEGATIVE STAPHYLOCOCCI

• CVC can be retained, if necessary, in patients with uncomplicated, catheter-related, bloodstream infection.

• If the CVC is retained, patients should be treated with systemic antibiotic therapy for 7 days.

• Treatment failure is a clear indication for removal of the catheter .

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A RANDOMIZED AND PROSPECTIVE STUDY OF 3 PROCEDURES FOR THE DIAGNOSIS OF CATHETER-RELATED BLOODSTREAM INFECTION WITHOUT

CATHETER WITHDRAWAL CID MARCH 2007

• Conclusions. CR-BSI can be assessed without catheter withdrawal in patients without neutropenia or blood disorders who have catheters inserted for a short time and are hospitalized in the intensive care unit. Because of ease of performance, low cost, and wide availability, we recommend combining semi quantitative superficial cultures and peripheral vein blood cultures to screen for CR-BSI, leaving differential quantitative blood cultures as a confirmatory and more specific technique.

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• A central line is removed and it is growing less than 15 CFU.

• Patient is not septic and blood Culture is negative.

• >>> No indication to treat the infected or colonized central line.

DO NOT TREAT COLONIZED CENTRAL LINESGET GUIDED BY MICROBIOLOGY REPORTS

• Incubation period of IPA unknown• Estimates vary from 48 hours -

3 months

• Geographical and seasonal variation in spore counts and predominant species

• Variable efficiency of different air samplers

• May not take account of surface contamination• Settle plates, contact plates,

honey jars

PROBLEMS WITH AIR SAMPLINGHAS LIMITATIONS ???

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NEW FRONTIERS ON INCREASING ICU INFECTIONS

• Emphasis on patient safety

• Move from inpatient to outpatient environment

• Increase in population age

• Persons >65yo numbered 36 million in 2004 and by 2030 there will be 72 million

• Increase in antimicrobial resistance (e.g., MRSA)

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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 fomites potentially contaminated with respiratory secretions

• Use aseptic technique

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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 contamination before use

• Keep environment clean, dry and dust free

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INFECTION CONTROL MEASURES

• 1 Identify reservoir Colonized and infected patients Environnemental contamination; Common sources

• 2. Halt transmission among patient Improve hand washing and asepsis Barrier precautions (gloves, gown) for colonized and infected Patients Eliminate any common source; disinfect environment Separate susceptible patients Close unit to new admissions if necessary

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INFECTION CONTROL MEASURES

• 3. Halt progression from colonization to infection Discontinue compromising factors when possible (eg, extubate, remove nasogastric tube, discontinue bladder catheters, as clinically indicated; rotate IV catheter sites; proper ventilator and pulmonary care)

• 4. Modify host factors Treat underlying disease and complications Control antibiotic use (rotate, restrict, or cease)

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TRADITIONAL ICP ACTIVITIES

• Surveillance• Outbreak investigations• Policy development and implementation• Environmental/infection control rounds• Education (infection control, blood borne

pathogen, TB)• Regulatory compliance• Committee participation

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NEW ICP RESPONSIBILITIES• Increased regulations (OSHA, FDA)• Emerging pathogens (avian influenza)• IHI campaign• Increase training/education requirements• Post-exposure prophylaxis (HIV, HBV)• Epidemiologic typing of outbreak pathogens• Interpreting screening cultures (MRSA, VRE)• Risk adjusted surveillance (SSI, CR-BSI, VAP)• Sentinel event analysis

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CONCLUSIONS : 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 identify problems

areas & set priorities

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GROWING CONCERNS WITH INFECTIONS IN ICU

• Nosocomial infections, especially those caused by antibiotic-resistant pathogens, represent an important source of morbidity and mortality for the patient hospitalized in an ICU. Important antibiotic-resistant nosocomial pathogens include MRSA, VRE, Gram-negative bacilli (especially, Klebsiella and Enterobacter) producing extended-spectrum b-lactamases, multiple drug-resistant M tuberculosis, and fluconazole-resistant Candida sp.

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CAN WE CONTROL ICU INFECTIONS• The key to control of antibiotic-resistant pathogens in

the ICU is rigorous adherence to infection control guidelines and prevention of antibiotic misuse. Antibiotic restriction policies clearly result in reduced drug costs. Evidence suggests that reducing use of certain antibiotics may lead to a decreased prevalence of antibiotic-resistant pathogens: vancomycin, VRE; gentamicin, gentamicin-resistant Gram-negative bacilli; and, ceftazidime, Gram-negative

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WISH WIN THE PROBLEM FACE THE CHALLENGES

• Increase infection control resources are a win-win-win investment• Reduced patient morbidity and mortality• Net cost savings to institution, society and patient• Improve patient satisfaction

• From the standpoint of the hospital and society, the benefits exceed the costs

• Hospitals should support a ratio of ICP per beds of 1:150

• The major cause of infection during the first weeks of indwelling time is from skin microorganisms.• Rannem, et. al., 1990• Maki, et. al., 1991• Maki (review), 1994 • Widmer (review), 1997

MICROBES ON SKIN PLAY A MAJOR ROLE SKIN DISINFECTION A MAJOR PREVENTIVE

MEASURE

• A meta-analysis determined that chlorhexidine gluconate significantly reduces the incidence of bacteremia in patients with central venous catheters compared to povidone-iodine for insertion-site skin disinfection.

• Chaiyakunapruk et al. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: A meta-analysis. Ann Intern Med. 2002;136:792 .

USING CHLORHEXIDINE 0.5% FOR SKIN DISINFECTION

CHLORHEXIDINE SKIN ANTISEPSIS• Prepare skin with

antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol.

• Pinch wings on the applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad.

• Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot.

• Allow antiseptic solution time to dry completely before puncturing the site (~ 2 minutes).

• Recommended by CDC basedon strong experimental, clinical, epidemiologic and microbiologic data

• Antimicrobial superiority

• Greater microbicidal effect

• Prolonged residual effect

• Ease of use and application

ALCOHOL BASED HAND SANITIZERS

AN INTERVENTION TO DECREASE CATHETER-RELATED BLOODSTREAM INFECTIONS IN THE ICU.

N ENGL J MED PRONOVOST P, ET AL: 355(26):2725-2732, 2006

• (1) hand washing, • (2) use of full-barrier precautions during placement of

catheters, • (3) cleansing of the skin with chlorhexidine,• (4) use of sites other than the femoral vein when possible,

• (5) removal of catheters that were no longer needed. The analysis included almost 2000 ICU-months and >375,750 catheter-days of data.

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WARNING

Nosocomial Infections in ICU are Waiting

BE KIND TO YOUR PATIENTS REMEMBER ONE THING

•PLEASE WASH YOUR HANDS

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• Programme created by Dr.T.V.Rao MD for Health care Workers in the Developing world

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