PowerPoint Presentation

Infection Control in ICU

Muhammad Asim RanaMBBS, MRCP, FCCP, SF-CCM, EDIC

Why focus on infectionprevention and control incritical care?

Intensive care units (ICUs) 10 %of total beds, more than 20 percent of all nosocomial infections are acquired in ICUs.ICU-acquired infections account for substantial morbidity, mortality, and expense.Improving infection prevention and control in critical care acts as a catalyst for improvement in the rest of the hospital.Why Infection Control

Factors contributing in infectionsCompared to general patients, patients in ICUs have more chronic comorbidities & more severe acute physiologic derangements.The high frequency of use of catheters provide a portal of entry of organisms into the bloodstream. Multidrug-resistant pathogens MRSA and VRE are being isolated with increasing frequency in ICUs

Studies of ICU-associated infectionsMost studies of ICU-associated infections come from industrialized countries, The rates of infection may even be higher in developing countries as illustrated by a multicenter, prospective cohort surveillance study of 46 hospitals in Central and South America, India, Morocco, and Turkey.

(as reported by NNIS)Ventilator associated pneumonia (VAP)24.1 cases per 1000 ventilator days (10.0 - 52.7)

CVL-related bloodstream infections12.5 cases per 1000 catheter days ( 7.8 - 18.5)

Catheter-associated urinary tract infections8.9 cases per 1000 catheter days (1.7 - 12.8)Rate of Infection

NNIS USA 1999 Antimicrobial Resistance VRE : 24.7 % of enterococci isolates

MRSA: 53.5 % of S. aureus

ESBL : 10.4 % Klebsiella3.9 % Escherichia coli

Pseudomonas aeruginosa 16.4 % resistant to imipenem 23.0 % resistant to fluoroquinolones

Risk Factors

Presence of underlying comorbiditiesdiabetes, renal failure, malignanciespredispose patients to colonization and infection with multidrug-resistant bacteria.

Presence of indwelling devicescentral venous catheters, Foley catheters, and endotracheal tubeswhich bypass natural host defense mechanisms and serve as portals of entry for pathogens.

Risk FactorsFrequent manipulations and contact with HCWsusually concurrently caring for multiple ICU patients hands are the vehicles for transfer of pathogens from patient to patient.

Long hospital courses prior to the ICU admission, More Antibiotic Exposure ,..

Outcome of MDR ICU infectionsInfections caused by MDR pathogens are associated with increased mortality, Increased length of hospital stay, increased hospital costs.

Patients with infections due to MDR -organisms usually are chronically or acutely ill and at risk of dying from underlying serious and complex medical illnesses.

Prevention of MDR Infection in the ICUTwo Major Strategies

Strategies that attempt to improve the efficacy and utilization of antimicrobial therapy.

Infection Control Measures

Outline on Antibiotic utilization controls Antibiotic evaluation committeesProtocols and guidelines to promote appropriate antimicrobial utilizationHospital formulary restrictions of broad-spectrum agentsSubstitution of narrow-spectrum antibioticsMandatory consultations with infectious diseases specialistsAntibiotic cycling

Infection Control MeasuresGeneral principles of infection control

Specific steps involved in prevention of special MDROs

General principles of infection control

Infection control a discipline that applies epidemiologic and scientific principles and statistical analysis to the prevention or reduction in rates of nosocomial infections.

Effective infection control programs proven to reduce the rates of nosocomial infections and to be cost-effective.

Infection control is a key component of the broader discipline of hospital epidemiology.

Achieving the main goal of preventing or reducing the risk of hospital-acquired infectionsWhere to focus energy for impact

Functions and Responsibilities of a hospital Infection Control program Education Prevention of infections (eg, by hand hygiene)Prevention of infections due to devicesdisposal of infectious waste

Development of infection control policies and procedures

Surveillance : (hospital-wide Vs. targeted)

Outbreak investigations

Functions and Responsibilities of a hospital Infection Control programEvaluation of devices usedCleaning, disinfection, and sterilization of equipment Oversight on the use of new products that directly or indirectly relate to the risk of nosocomial infections

Review of antibiotic utilization and its relationship to local antibiotic resistance patterns

Functions and Responsibilities of a hospital Infection Control programHospital employee healthPre employment assessment

After exposure to either blood borne or respiratory pathogens

Areas of Infection ControlFour major areas of infection control will be reviewed here:

Standard precautions, including hand hygiene Isolation precautions Cleaning, disinfection, and sterilizationSurveillance

STANDARD PRECAUTIONSVarious forms of isolation have been used in an attempt to reduce the spread of nosocomial infections.In 1996, the CDC and Hospital Infection Control Advisory Committee (HICPAC) issued a new system of isolation precautions.

Noncritical items should be dedicated to use for a single patient if possible.

Standard precautions are recommended in the care of all hospitalized patients. The category of standard precautions combines the important features of body substance isolation policies and universal precautions, in so doing, aims to reduce the risk of transmission of infectious agents between patient and healthcare worker.

Standard precautions apply to blood, all body fluids, nonintact skin, mucous membranes and secretions and excretions except sweat.

They entailHandwashing before and after every patient contact The use of gloves, gowns and eye protection in situations in which exposure to body secretions or blood is possible Handwashing after gloves are removed The safe disposal of sharp instruments and needles in impervious containers The placement of soiled linens in impervious bags and bloody or contaminated materials such as feces or urine in sanitary toilets

The 2007 CDC guidelines included several additional componentsSafe injection practices.

Use of a mask when prolonged procedures involving puncture of the spinal canal are performed myelography, epidural anesthesia, injection of chemotherapeutic agents.

Respiratory hygiene/cough etiquette

Ignaz Philipp SemmelweisHungarian physician (1847)incidence of puerperal fever (Lack of hand washing by clinicians)Hand dips with chlorinated lime at Vienna General Hospital.These ideas evolved to form current guidelinesHand cleansing opposed to Hand washing

Hand HygieneThe surface of the skin is home of bacteria and fungi, Resident flora Transient floraEradicating microbes on the hands of hospital personnel is one of the holy crusades of infection control It is the single most important measure to reduce transmission of microorganisms from one person to another or one site to another on the same patient.

Organisms Isolated from the Hands of ICU Personnel

Gram positive cocci Staph.epidermidis 100% Staph.aureus (MSSA) 7%

Gram negative bacilli 21% Acinetobacter spp. Klebsiella spp. Enterobacter spp. Pseudomonas spp. Serratia spp.

Yeasts & Fungi 16%

Cleaning vs DecontaminationThe removal of microbes from the skin is known as decontamination, requires the application of agents that have antimicrobial activity. Antimicrobial agents that are used to decontaminate the skin are called antiseptics, while those used to decontaminate inanimate objects are called disinfectants.

Commonly Used Antiseptics

So, Do Not Forget.

Evidence for the efficacy of hand hygiene Comparative effects of a 6-minute hand scrub with 0.75% povidone-iodine and 4% chlorhexidine gluconate on microbial growth on the hands.Bacterial counts are expressed as log base 10 values.

Finger Nails

Much of the resident microflora of hands is found in the periungual and subungual areas, and fingernails are often neglected during routine hand cleansing.When the fingernails are long and when artificial fingernails are worn, there is an increase in periungual colonization with a variety of pathogensGuidelines from the CDC and Association of Operating Room Nurses (AORN) prohibit the use of artificial fingernails or extenders by health care workers

Rings

There is no consensus on the need to prohibit the wearing of rings in healthcare settings even though several studies have shown that skin beneath rings is more heavily colonized with bacteria than adjacent skin not covered by rings

GlovesThree important reasons To provide a protective barrier for the hands.To reduce the acquisition of microorganisms from a patient.To reduce the transmission of microorganisms from the hands of hospital staff to patients.However, wearing gloves does not replace the need for hand washing

Masks Three purposes in infection controlTo protect healthcare personnel from infectious material from patients.To protect healthcare personnel from infectious material from patients.To protect healthcare personnel from infectious material from patients.Masks should not be confused with particulate respirators that are used to prevent transmission by airborne droplet nuclei of infectious agents such as M. tuberculosis.

ISOLATION PRECAUTIONS Three isolation categories Contact: Contact precautions should be used in the care of patients with multidrug-resistant bacteria, and various enteric, parasitic, and viral pathogens. Droplet: Droplets are particles of respiratory secretions larger than 5 micrometers. Airborne spread: Airborne droplet nuclei, in contrast to larger droplets in the preceding section, are particles of respiratory secretions smaller than 5 micrometers.

Droplet PrecautionsLarge Droplets(>5microns)

Haemophilus influenza (type b) Epiglottitis,pneumonia,meningitis Neisseria meningitidis pneumonia & meningitidisBacterial respiratory infections Diphtheria Mycoplasma Group A strep pneumoniaViral Respiratory Infections Influenza Adenovirus Mumps RubellaPlace patient in a private room, if unavailable patient should not be within 3 feet of non infectious patients

Hospital staff and visitors should wear a surgical mask within 3 feet of the patient

Airborne PrecautionsSmall Droplets (