INTENSIVE CARE UNITSINFECTIONS AND CONTROL

Dr.T.V.Rao MD

04/07/2023 Dr.T.V.Rao MD 1

A Patient in Intensive Care Unit is at Risk for Many Reasons..

04/07/2023 Dr.T.V.Rao MD 2

The Purpose of the Programme

• The purpose of this program is to maintain a healthy and safe Hospital by the prevention and control of health care related infections / diseases in particular intensive care units. This is achieved by surveillance and investigation of infectious diseases and public education.

Dr.T.V.Rao MD3

04/07/2023

Educating our Health Care Workers

• Education programs for employees and volunteers are one method to ensure competent infection control practices. It is a unique challenge since employees represent a wide range of expertise and educational background. The ICP must become knowledgeable in adult education principles and use educational tools and techniques that will motivate and sustain behavioral change. Much has been written about the education of healthcare workers (HCWs). Some of the tools used to educate HCWs successfully include newsletter, posters and videos

Dr.T.V.Rao MD 404/07/2023

Why ICU patients are different

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

• Move less • Malnourished • More obtunded (Glasgow coma scale)• May be associated Diabetics and Heart

failure

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EPIDEMIOLOGY • Contributing factors

– Patients in ICUs have more chronic comorbid illnesses and more severe acute physiologic derangements.

– The high frequency of indwelling catheters among ICU patients

– The use and maintenance of these catheters necessitate frequent contact with health care workers, which predispose patients to colonization and infection with nosocomial pathogens.

– Multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE) are being isolated with increasing frequency in ICUs

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Early survival benefit for immediate ICU Care

• Early survival benefit for immediate ICU care

• Difficulty in explaining lack of ICU advantage later: could be related to the more aggressive monitoring and therapy in the ICU, which may be beneficial early by stabilizing the patient but may be deleterious afterward, due to infections, for example.04/07/2023 Dr.T.V.Rao MD 7

ICU Care is Invasive at many Stages

• More invasive lines and procedures including surgeries

• Longer length of stay• More IV and parenteral

drugs• More tube feeding and

Parenteral nutrition• More ventilation

04/07/2023 Dr.T.V.Rao MD 8

ICU : Factors that increase cross-infections

• Hand washing facilities are inadequate • 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 environment04/07/2023 Dr.T.V.Rao MD 9

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 malnutrition04/07/2023 Dr.T.V.Rao MD 10

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 technique04/07/2023 Dr.T.V.Rao MD 11

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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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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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 infection

– 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 catheter

Teflon or Polyurethane ( < infections) vs Polyvinyl chloride or Polyethylene

• Site of insertion Subclavian (< infections) vs Internal Jugular & Femoral (high risk of colonization & deep venous thrombosis)

• No. of LumenSingle-lumen catheter (< infections)

vs Multi-lumen catheter04/07/2023 Dr.T.V.Rao MD 17

Prevention Strategies: Core Proper Insertion Practices

• Ensure utilization of insertion bundle:– Chlorhexidine for skin antisepsis– Maximal sterile barrier precautions (e.g., mask, cap [i.e., similar to

those worn in the O.R.], gown, sterile gloves, and large sterile drape)

– Hand hygiene• Many CLs in patients on non-ICU hospital wards are placed

outside those wards (Emergency room, ICU, Operating room, or Pre-operative areas)

• In one study, 49% of CLs were present on admission to the ward. Rates of BSI in this study were higher in CLs placed in Emergency Room

• Define where placement occurs and review technique in those areas

Trick et al. Am J Infect Control 2006;34:636-41.

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Prevention Strategies: Core Chlorhexidine Skin Cleansing

• Chlorhexidine is the preferred agent for skin cleansing for both CL insertion and maintenance– Tincture of iodine, an iodophor, or 70% alcohol are

alternatives – Recommended application methods and contact time

should be followed for maximal effect• Prior to use should ensure agent is

compatible with catheter– Alcohol may interact with some polyurethane

catheters– Some iodine-based compounds may interact

with silicone catheters

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Intrinsic contamination of infusion fluid

Connection with administration set

Insertion site

Injection 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 flora

Microorganism 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

Fibrin

Skin

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

Hand disinfectionWith an antiseptic solution eg Chlorhexidine gluconate

04/07/2023 Dr.T.V.Rao MD 22

Prevention of CR-BSISkin 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. Lancet 1991;338:339-43

• No difference between 0.5% Chlorhexidine gluconate or 10% Povidone-iodine

Humar A et al. Clin Infect Dis 2000;31:1001-7

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Prevention of CR-BSI

Dressing

• Gauze dressings every 2 days

• Transparent dressing every 7 days on short term catheter

• Replace dressing when catheter is replaced or dressing becomes damp or loose.

Grady NP et al, HICPAC draft guidelines: 2002

04/07/2023 Dr.T.V.Rao MD 24

Prevention of CR-BSICatheters removal• Don’t replace it routinely• Replace it if:

– Inserted in an Emergency – Non functioning– Evidence of local or systemic infection

General handling• Opening of hub: Use antiseptic-impregnated pads

eg Chlorhexidine gluconate or povidone iodine

04/07/2023 Dr.T.V.Rao MD 25

Prevention of CR-BSIAdministration sets• Replacement at 72-h intervals• No difference in phlebitis if left for 96

hours• Lines for lipid emulsion: replacement

at 24-h intervals• Lines for blood product : remove

immediately after use

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Prevention of CR-BSI

Topical antibiotic • Prophylactic use of topical Mupirocin (Bactroban) at

insertion site or in nose is not recommended – Rapid development of Mupirocin resistant– Mupirocin affect the integrity of Polyurethane catheter

Systemic antibiotic• Prophylactic use of antibiotic is not recommended at

the time of catheter insertion

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Background: Prevention Strategies Interventions

• Michigan Keystone Project• Decrease in CLABSI in 103 ICUs in Michigan (66%

reduction)• Basic interventions:

– Hand hygiene– Full barrier precautions during CL insertion– Skin cleansing with chlorhexidine– Avoiding femoral site– Removing unnecessary catheters– Use of insertion checklist– Promotion of safety culture

Pronovost et al. NEJM 2006;355:2725-32.

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Urinary Catheterization

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External urethral meatus & urethra

• Pass catheter when bladder 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 unless absolutely necessary.

• For urine specimen collection disinfect outside of catheter proximal to junction with drainage tube by applying alcoholic impregnated wipe and allow it to dry completely then aspirate urine with a sterile needle and syringe.

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Junction between drainage tube & collection bag

• Keep bag below level of bladder. If it is necessary to raise collection bag above bladder level for a short period, drainage tube must be clamped temporarily.

• Empty bag every 8 hours or earlier if full.• Do not hold bag upside down when

emptying

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Tap at bottom of collection bag

• Collection bag must never touch floor.• Always wash or disinfect hands (eg with

70% alcohol) before and after opening tap.

• Use a separate disinfected jug to collect urine from each bag.

• Don't put disinfectant into urinary bag.

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Strategies for Prevention of CAUTI

Avoid unnecessary placement of indwelling urinary catheters

+++

Remove catheters as quickly as possible +++

Alternative condom catheter, intermittent bladder catheterization

+++

Aseptic technique in catheter insertion +++

Appropriate catheter maintenance ++

Antimicrobial therapy -

Different catheter composition +04/07/2023 Dr.T.V.Rao MD 34

Intensive Care Unit Nosocomial Pneumonia

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Incidence of HAI vs. Cost

Hospital acquired Infection

Incidence Additional cost

Urinary Tract 45% 13%

Surgical Wound 29% 42 %

Pneumonia 9 % 39%

Blood Stream 2% 4 %

Haley, 198604/07/2023 Dr.T.V.Rao MD 36

Risk factors for bacterial pneumoniaHost Factors Factors that facilitate reflux

& aspiration into the lower RT

• Elderly• Severe Illness• Underlying Lung Disease - Mechanical ventilation• Depressed Mental Status - Tracheostomy• Immunocompromising - Use of a Nasogastric Tube

Conditions or Treatments - Supine Position• Viral Respiratory Tract Factors that impede normal

Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgery• Intensive Care Setting - Immobilisation• Use of Antimicrobial Agents• Contaminated hands• Contaminated Equipment

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Prevention in ICU• Turn patients to

encourage postural drainage

• Encourage to take deep breaths and cough.

• Maintain an upright position (elevate patient’s head to 30º- 45º degree angle) to reduce reflux and aspiration of gastric bacteria.

04/07/2023 Dr.T.V.Rao MD 38

Gastric Ulcer Prophylaxis• Stomach of a healthy person : Acidic pH () & normal

peristalsis movement prevent bacterial growth• Alkaline pH () and loss on normal peristalsis lead to

bacterial colonisation which increases the risk of ventilator-associated pneumonia

• Mechanical ventilation patients are at increased risk for upper GI hemorrhage from stress ulcers.

• H2 blockers or antacids are used to prevent stress ulcers

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Nasogastric Tube• May erode the mucosal surface • Block the sinus ducts • Regurgitation of gastric contents leading to

aspiration. • Verify placement of the feeding tube in the

stomach or small intestine by X ray• Elevate the head of the bed 30º- 45 º degrees

Remove NG Tube if not necessary

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Ventilators• After every patient,

clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturer’s instructions.

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Suctioning mechanically ventilated patients

• Hand washing before and after the procedure.• Wear clean gloves to prevent cross-

contamination• Use a sterile single-use catheter ; if it is not

possible then rinse catheter with sterile water and store it in a dry, clean container between uses and change the catheter every 8 - 12 hours.

04/07/2023 Dr.T.V.Rao MD 42

Suction Bottle Use single-use

disposable, if possible Non-disposable bottles

should be washed with detergent and allowed to dry. Heat disinfect in washing machine or send to Sterile Service Department.

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Nebulizers• Use sterile medications and fluids for nebulization• Fill with sterile water only. • Change and reprocess device between patients by

using sterilization or a high level disinfection or use single-use disposable item.

• Small hand held nebulizers– minimise unnecessary use– between uses for the same patient disinfect, rinse

with sterile water, or air dry and store in a clean, dry place

• Reprocess nebulizers daily

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Humidifiers• Clean and sterilize device

between patients.• Fill with sterile water

which must be changed every 24 hours or sooner, if necessary.

• Single-use disposable humidifiers are available but they are expensive.

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Oxygen mask• Change oxygen

mask and tubing between patients and more frequently if soiled 04/07/2023 Dr.T.V.Rao MD 46

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 be prevented 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 and

those clinically involved with the infection. • An organized hospital-wide surveillance system.

Dr.T.V.Rao MD 4704/07/2023

Antibiotics use

Must avoid widespread use of

broad spectrum antibiotics

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Problem-Detection of Infection in the ICU’s

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Examples of difficult to detect infections: Uncultivable organisms

Viruses are under appreciated as causes of nosocomial infections. Except in cases of high morbidity viral cultures are not done in resource scarce settings. Impact food-borne, respiratory, water borne illnesses.

We don’t know the spectrum of anti-microbial activity of most preservatives and cleaners for many viruses.

04/07/2023 Dr.T.V.Rao MD 50

Examples from the NNIS Manual

• Symptomatic Urinary Tract Infection:– Patient must have one of the two criteria:

• Fever >38 C OR urgency OR frequency OR dysuria OR suprapubic tenderness without other cause

OR• Urine culture with at least 105 organisms per

ml or no more than two species of organisms

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Definition of surgical site infection (no implant)

• Occurs within 30 days of surgery

AND has one of the following:

Purulent drainage from drain OROrganism isolated from aseptically obtained fluid in the organ space

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Prior to starting any surveillance

• Agree upon a written case definition that is practical given the laboratory facilities and patient work load in your facility.

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Our plan for future should include

• Unlike scheduled activities, occasional clusters of patients who are colonized or infected will trigger further investigation including a case-control study. New laboratory methods developed and refined within the last decade can now determine how related the strain is at the molecular level. The QI/IC plan should include special problem-focused studies that describe personnel or environmental sampling, including what circumstances and who has the authority to order

Dr.T.V.Rao MD 5404/07/2023

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 by intended/completed actions

• Research indicates:– poor techniques - not all surfaces cleaned– frequency diminishes with workload/distance– poor compliance with guidelines/training

Dr.T.V.Rao MD 5504/07/2023

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

Dr.T.V.Rao MD 5604/07/2023

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 determined between 2002 and 2005; an overall rate of 14.7 percent or 22.5 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 catheter days (1.7-12.8)

04/07/2023 Dr.T.V.Rao MD 57

Our Vision to Future • Infection control

programs must maintain training records of employees. The minimum training required is annual OSHA blood borne pathogen, tuberculosis prevention and control and new employee orientation.

Dr.T.V.Rao MD 5804/07/2023

Why we need better ICU’s• For an incidence as well as for a

prevalence population of critically ill patients, there is a window of critical opportunity for admission into the ICU, much like the golden our for the trauma patient.

• Efforts should be made to avail ICU facilities to as many recently deteriorated patients as possible, especially those who could be transferred into the ICU very early after deterioration, such as patients on hospital wards.

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Do remember the Reasons for Infections are Many but solutions are few …

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Yet No Substitute for Hand Washing Are You Washing ?

04/07/2023 Dr.T.V.Rao MD 61

Let us support our Hospitals with clean hands

Dr.T.V.Rao MD 6204/07/2023

Follow me for more articles of Interest on Infections on …

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Dr.T.V.Rao MD 64

• The Programme Created by Dr.T.V.Rao MD for Medical and Paramedical

Professionals in the Developing World Email

doctortvrao@gmail.com

04/07/2023