GUEST LECTURE AT

JIPMER , Pondicherry
INTENSIVE CARE UNITS INFECTIONS AND CONTROL (December 2012)
Dr.T.V.Rao MD Professor of Microbiology Travancore Medical College, Kollam Kerala

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A tribute to Ignaz Semmelweiss (1818-1865) ..... Ignaz Semmelweis

Obstetrician, practised in Vienna Studied puerperal (childbed) fever Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems
Reduced maternal mortality by 90%
(1818-1865)

Ignored and ridiculed by colleagues

Dr.T.V.Rao MD

What is a Intensive Care Unit

An intensive care unit (ICU) is defined as a specially staffed, specialty equipped, separate section of a hospital dedicated to the observation, care, and treatment of patients with life threatening illnesses, injuries, or complications from which recovery is possible
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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 competent infection control practices. The ICP must become knowledgeable and techniques that will motivate and sustain behavioral change.
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Why ICU patients are different

Many times very sick patients (multiple diagnoses, multi-organ failure,) immunocompromised, septic and trauma) Move less Malnourished May be associated Diabetics and Heart failure
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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 > upper extremities 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 Dis 2006
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EPIDEMIOLOGY
Contributing factors

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.
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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 being isolated with increasing frequency in ICUs
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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
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increase cross-infections Hand washing facilities are inadequate

Patient close together or sharing rooms

ICU : Factors that

Understaffing
Lack of isolation facilities No separation of clean and dirty AREAS

Excessive antibiotic use

Inadequate decontamination of
items & 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 malnutrition
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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 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 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 Unit

Prevention 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 catheter
Teflon or Polyurethane ( < infections) vs Polyvinyl chloride

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

No. of Lumen Single-lumen catheter (< infections) vs Multi-lumen catheter

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Sources of Infection
Intrinsic contamination of infusion fluid
Port for additives

Connection with administration set Insertion site Injection ports Administration set connection with IV catheter

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1. Extra luminal Spread Patients own skin micro flora Microorganism transferred by the hands of Health Care Worker Contaminated entry port, catheter tip prior or during insertion Contaminated disinfectant solutions Invading wound attachment Skin
Skin Fibrin

Sources of Infection
2. Intraluminal Spread Intralumunal Spread Contaminated infusate Contaminated (fluid, medication) infusate (fluid, medication)

Vein

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3. Haematogenous Spread Infection from distant focus

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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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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 insertion
Maki 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
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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Urinary Catheterization

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External urethral meatus & urethra

Pass catheter when bladder is full for washout 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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Intensive Care Unit Nosocomial Pneumonia

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Incidence of HAI vs. Cost

Hospital acquired Infection Urinary Tract Incidence Additional
cost

45%

13%

Surgical Wound Pneumonia

Blood Stream
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29% 9%
2%
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42 % 39%
4%
Haley, 1986 30

Prevention in ICU
Turn patients to encourage postural drainage Encourage to take deep breaths and cough. Maintain an upright position (elevate patients head to 30- 45 degree angle) to reduce reflux and aspiration of gastric bacteria.
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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 water outlet. 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 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.
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Concerns with staphylococcus

Methicillin-resistant S. aureus (MRSA) is resistant to several antibiotics. Another form of S. aureus, vancomycin-resistant S. aureus (VRSA), is resistant to one of the most powerful, last line of defence antibiotics, Dr.T.V.Rao MD vancomycin

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RESISTANT GRAM NEGATIVE ORGANISMS Resistance to multiple antibiotics

Organisms:
E .coli Proteus Enterobacter Acinetobacter Stenotrophomnonas Pseudomonas aeruginosa
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E.Coli and emerging resistance

Escherichia coli (E. coli) has gradually become resistant to different types of antibiotics. In 2003, the overall resistance of E. coli to common amino penicillin antibiotics reached 47% across Europe
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SURVEILLANCE
Important means of monitoring HAI Early detection of trends outbreaks

Laboratory Based
Microbiology Laboratory lists Gram +ve and - ve organisms ICN reviews Alert organisms reported

2. Ward Based
Ward staff monitor patients ICN reviews ICN visits wards

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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 widespread use 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 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. .
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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 OR Organism 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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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
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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 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)

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Cockroaches (Ectobius vittiventris) in an Intensive Care Unit, Switzerland

Cockroaches are capable of harboring Escherichia coli Enterobacter spp. Klebsiella spp. , Pseudomonas aeruginosa , Acinetobacter baumannii , other nonfermentative bacteria Serratia marcescens Shigella spp. Staphylococcus aureus group A streptococci , Enterococcus spp. , Bacillus spp. , various fungi , and parasites and their cysts . An outbreak of extendedspectrum -lactamaseproducing Klebsiella pneumoniae in a neonatal unit was attributed to cockroaches Emerging Infectious Diseases March 2009
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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), and the ability to detect it through an ATP bioluminometer indicates the amount of microbial and non-microbial contamination in a given test area. This is accomplished by a luminescent chemical reaction,
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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.
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WHONET - Documentation
Establishing WHONET Documentation makes the Antibiograms assessments easy by Microbiologists and Consultants at any Hospital. We are fully functional to the advantages of the WHONET documentation,
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Do remember the Reasons for Infections are Many but solutions are few

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Consequences of hospital infections ???

Hospital

Pathogen

Unhappy patients

Unhappy director

Hospital

Surveillance

Happy Patients
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Happy director 52

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 in collaboration with WHO, ICMR, DBT, NGOs; use of information technology for patient care, training and research.

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Let us support our Hospitals with clean hands

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