ICU infections AND PREVENTION

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ICU- AQUIRED INFECTIONS&PREVENTION : 

ICU- AQUIRED INFECTIONS&PREVENTION Dr. P.SREENIVASULU REDDY MD Professor of MICROBIOLOGY NARAYANA MEDICAL COLLEGE NELLORE-2 ANDHRA PRADESH

ICU Admission : 

ICU Admission PURPOSE To receive life - saving therapy. PARADOXICALLY Life threatening complications. RESPONSIBILITY Intensive care specialist & Microbiologist.

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Infection rates are 3 to 4 times higher than in General Wards. Infection rates vary between different types of ICUs within a single hospital. Cardiac surgery 0.8 % Paediatric & Neonatal 8 % Surgical 35 % Medical procedures 24 %

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Types of ICU infections: Pneumonia & LRTI 52 % Sepsis & Blood stream 18 % Urinary tract & related 17 % Wound infections 06 % ENT & URTI 04 % Skin & Soft tissue 03 %

MORTALITY : 

MORTALITY So many workups were done. Depends on underlying disease. Ventilator associated Pneumonia is important cause of death in ICUs .

Common pathogens – ICU : 

Common pathogens – ICU Gram positive cocci Staph. aureus 30 % Enterococci 12 % Pneumococci 3 % Str.pyogenes 9 %

ICU pathogens contd…. : 

ICU pathogens contd…. Gram negative bacilli Pseudomonas spp. 32 % E.coli 13 % Klebsiella spp 9 % H.influenzae 4 % Moraxella spp. 1 % Legionella spp. 0.5 %

Viruses 0.5 % HIV , HCV HBV Fungi & Protozoa 18 % Aspergillosis Candididiasis Mucormycosis Plasmodium spp. ICU pathogens contd….

Organisms responsible for UTI in ICU : 

Organisms responsible for UTI in ICU E.coli Others Klebsiella spp. Candida spp. Enterococci. Pseudomonas

Organisms responsible for surgical wound infections : 

Organisms responsible for surgical wound infections Others Staph.aureus Enterococci. Co N Staphylococci. E.coli Ps.aeruginosa

Organisms responsible for Pneumonia in ICU : 

Organisms responsible for Pneumonia in ICU Others Ps.aeruginosa Staph.aureus. Enterobacter spp. S.pneumoniae H.influenzae

Organisms responsible for Blood stream infections in ICU : 

Organisms responsible for Blood stream infections in ICU Others Co N Staphylococci. Staph.aureus. Enterococci. Candida spp. E.coli

Risk factors for ICU Pneumonia: : 

Risk factors for ICU Pneumonia: Prolonged Mechanical ventilation. Prolonged stay in ICU. Malnutrition in ill patients. COPD Antacids & H2 blockers Elderly age. Obesity. Impaired airway reflexes. Smoking

Mechanisms of RT colonisation & infection : 

Mechanisms of RT colonisation & infection Host factors Surgery Medications Invasive Respiratory devices therapy equipment. Oropharyngeal Gastric colonisation Colonisation Aspiration of virulent bacteria Bacteraemia Affects Lung defences Translocation Mechanisms (Cellular / Humoral) PNEUMONIA

Risk factors for Blood stream & UT infections : 

Risk factors for Blood stream & UT infections Paediatric & Elderly patients. Patients with Trauma or burns. Metabolic, Neoplastic diseases. Immunodeficiency disorders. Indwelling Catheters and other devices. Implantation of prosthetic devices. Chemotherapy & Immunosuppressive agents.

Pathogen specific risk factors : 

Pathogen specific risk factors Co N Staphylococci. Hickman catheters. CV nutrition catheters. Peripheral IV catheters. Prosthetic heart valves. IV lipid emulsions. MRSA Severe underlying disease. Poor prognosis. Prolonged hospitalization. Prior antibiotic therapy. Extensive burns.

Pathogen specific risk factors contd…. : 

Pathogen specific risk factors contd…. Enterococci. Severe underlying disease Recent major surgery. Full-thickness burn. Usage of many antibiotics. Prolongedhospitalisation. Candida spp. Many antibiotics. Haemodialysis. Hickman catheters. Azotaemia. Diarrhoea. Candiduria. Total parenteral nutrition.

DIAGNOSIS of ICU INFECTIONS. : 

DIAGNOSIS of ICU INFECTIONS. PNEUMONIA: Intubated patient. Don’t inject lignocaine. Sedation, short acting paralytic agent. Position FOB close to bronchial orifice Collect the desired sample ( BAL , Biopsy ) Giemsa / Gram’s staining. Intracellular organisms in > 5% of cells : PNEUMONIA Intracellular organisms in < 2% of cells: Ruled out.

DIAGNOSIS contd… : 

DIAGNOSIS contd… BLOOD SAMPLING: Avoid from in situ arterial / venous cannula. 5 -10 ml from 3 different sites on different times. Send for culture & sensitivity in the biphasic medium. Always summon the laboratory in charge for sample collection

DIAGNOSIS contd… : 

DIAGNOSIS contd… URINE SAMPLING: Do not collect from Uri bags. Do not collect from in situ catheters. Collect by catheterisation , SP puncture. Culture and sensitivity.

DIAGNOSIS contd… : 

DIAGNOSIS contd… WOUND SEPSIS: Clean the area with Normal saline. Sorroundings with Absolute alcohol. Specimen from the Depths of wound. Use sterile swab and Transport medium.

In vitro activity of selected antibiotics against ICU pathogens. : 

In vitro activity of selected antibiotics against ICU pathogens. Antibiotic Non fermentors . Staphylococci Enterobacter ( Pseudomonas spp. Acinetobacter ) Cefpirome 67% 60% 94% Ceftazidime 70% 51% 70% Ceftriaxone 36% 37% 65% Pipercillin 45% 50% 66% Imipenum 95% 97% 98%

SELECTION OF INITIAL THERAPY: : 

SELECTION OF INITIAL THERAPY: Based on: Species of bacteria. Hospital specific antibiotic resistance pattern. Clinical condition of the patient. Patient’s risk factors. Previous antibiotic therapy.

SELECTION OF INITIAL THERAPY contd…. : 

SELECTION OF INITIAL THERAPY contd…. Preferably…. Severe ICU infections: Clinical success Bacteriological success. Cefpirome 82% 76% Ceftazidime 81% 77% Septicaemia cases : Clinical success Bacteriological success. Cefpirome 97% 89% Ceftazidime 90% 90%

PREVENTION OF ICU INFECTIONS : 

PREVENTION OF ICU INFECTIONS 1. BASIC HYGEINE: a. Isolation of patients with infections. b. Hand washing. c. Usage of gloves and gowns. 2. PREVENTION OF ‘LINE’ ASSOCIATED INFECTIONS: “Early in and early out” should be the rule.

PREVENTION …….. contd… : 

PREVENTION …….. contd… 3.Prevention of device associated infections: a. Arterial pressure transducers. with non disposable domes. cracks by repeated autoclavings. contamination of dome by staff. b. Ventilator tubing Change every 48 hrs. c. Usage of bacterial filters in ventilation circuits. Contraversial.

PREVENTION …….. contd… : 

PREVENTION …….. contd… 4.GUT protection strategies: a. Avoid H2 antagonists & antacids. b. Selective digestive decontamination. Regimen : ICU stay: Polymyxin B, Tobramycin and Amphotericin B As sticky base in Oropharynx. Instilled into stomach through nasogastric tube. Optional for first few days: Parenteral Cefotaxime.

PREVENTION …… contd… : 

PREVENTION …… contd… 5. EARLY ENTERAL NUTRITION: ( If no contraindications ) Maintains mucosal integrity. Reduces bacterial translocation. Enhances autoregulation of blood flow to the gut.

Surveillance at various levels. In 1960s CDC in USA initiated. National Nosocomial Infection Survey (NNIS ) Study on Efficacy of Nosocomial Infection Control ( SENIC ) Monitor local resistance pattern. Develop rational antibiotic policy for ICU.

CONCLUSIONS : 

CONCLUSIONS Empirical therapy with Broad spectrum antibiotics is justified. Consider invasive diagnostic techniques for Pneumonia. Treat sepsis empirically. Negative blood cultures do not guarantee the absence of infection.

CONCLUSIONS contd…… : 

CONCLUSIONS contd…… Ventilatory & haemodynamic support. consider new, non-invasive monitoring techniques. Prevent and correct gut ischaemia. Avoid H2 blockers and antacids. Sucralfate preferred to prevent stress ulcers. Institute enteral nutrition as early as possible. Practice scrupulous infection control. Hand washing . Disinfection of catheterisation sites. Care about the invasive devices.

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THAN Q

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