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Premium member Presentation Transcript ICU infections basis, diagnosis, and prevention: Dr.T.V.Rao MD ICU infections basis, diagnosis, and prevention Dr.T.V.Rao MD 1DEFINITIONS : 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. Dr.T.V.Rao MD 2BACKGROUND of hospital infections: 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 Dr.T.V.Rao MD 3Risk of Infections in ICU : 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 Dr.T.V.Rao MD 4Why one may be in icu with: 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 Dr.T.V.Rao MD 5ICU : Factors that increase cross-infections: 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 6Nosocomial Fevers: Hospital-acquired fevers occur in one-third of all medical inpatients Nosocomial fevers even more common in the ICU Nosocomial Fevers 7 Dr.T.V.Rao MDInfectious causes of fever whilst in ICU: Ventilator associated pneumonia Catheter related blood stream infections Urosepsis Intra-abdominal infections Sinus infections Diarrhoea Infectious causes of fever whilst in ICU Dr.T.V.Rao MD 8Fever in the ICU: 9 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 Dr.T.V.Rao MDCauses of Fever in the ICU: 10 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 Dr.T.V.Rao MDThe obvious focus: Community acquired pneumonia Acute CNS infection Urinary tract infection Abdominal focus of infection Wound infection / Pus collections Trauma with infection The obvious focus Dr.T.V.Rao MD 11DEVICE RELATED NOSOCOMIAL INFECTION : 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. Dr.T.V.Rao MD 12ICU patients differs from many patients pay more attention: ICU patients differs from many patients pay 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 Dr.T.V.Rao MD 13Infectious causes of fever whilst in ICU: Ventilator associated pneumonia Catheter related blood stream infections Urosepsis Intra-abdominal infections Sinus infections Diarrhoea Infectious causes of fever whilst in ICU Dr.T.V.Rao MD 14Patient presenting to ICU with fever: 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? Dr.T.V.Rao MD 15RISK FACTORS : 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 Dr.T.V.Rao MD 16ICU Care is more Invasive : 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 Dr.T.V.Rao MD 17Factors influencing increased infections in ICU: 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 Dr.T.V.Rao MD 18The inanimate environment is a reservoir of pathogens: 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 ubiquitousSome Health-Care Associated Infections: 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 Dr.T.V.Rao MD 20Managing fever in ICU patients: 21 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 Dr.T.V.Rao MDDEVICE RELATED NOSOCOMIAL INFECTION : 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. Dr.T.V.Rao MD 22Slide 23: Intrinsic contamination of infusion fluid Connection with administration set Insertion site Injection ports Administration set connection with IV catheter Port for additives Sources of Infection Dr.T.V.Rao MD 23Slide 24: Intralumunal Spread Contaminated infusate (fluid, medication) 2. Intraluminal Spread Contaminated infusate (fluid, medication) 1. Extra luminal Spread Patient’s 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 3 . Haematogenous Spread Infection from distant focus Fibrin Skin Vein Skin attachment Sources of Infection Dr.T.V.Rao MD 24Prevention of CR-BSI: Prevention of CR-BSI Written Protocol Must be performed by trained staff according to written guidelines Sterile procedure Sterile gown, Sterile gloves, Sterile large drapes Don't shave the site Hand disinfection With an antiseptic solution eg Chlorhexidine gluconate Dr.T.V.Rao MD 25Fungi too infective in ICU patients: Dr.T.V.Rao MD 26 Fungi too infective in ICU patientsRisk factors for Aspergillosis: Risk factors for Aspergillosis Neutropenia steroids Environmental exposure Building work Compost heaps Marijuana smoking Dr.T.V.Rao MD 27Invasive Aspergillosis : incidence increasing commonest cause of infectious death in many transplant units commonest cause of death in childhood leukaemia Invasive Aspergillosis Dr.T.V.Rao MD 28Protected environment: 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 Dr.T.V.Rao MD 29Basic policies in microbiological diagnosis of ICU infections: Dr.T.V.Rao MD 30 Basic policies in microbiological diagnosis of ICU infectionsCriteria for Diagnosis: 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 . Dr.T.V.Rao MD 31Slide 32: Dr.T.V.Rao MD 32How To Diagnose?: 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 ( 10 2 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 ) Dr.T.V.Rao MD 33Remember………….: 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…………. Dr.T.V.Rao MD 34Dealing with Staphylococcus Aureus : 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: 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 . A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID march 2007: 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 . Dr.T.V.Rao MD 37Do not treat colonized central lines get guided by microbiology reports: 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 lines get guided by microbiology reports Dr.T.V.Rao MD 38Problems with air sampling has limitations ???: 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 sampling has limitations ???New Frontiers on increasing ICU infections: 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) Dr.T.V.Rao MD 40Strategy for Prevention: 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 Dr.T.V.Rao MD 41Strategy for Prevention: 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 Dr.T.V.Rao MD 42Infection Control Measures : 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 Dr.T.V.Rao MD 43Infection Control Measures : 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) Dr.T.V.Rao MD 44Traditional ICP Activities: 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 Dr.T.V.Rao MD 45New ICP Responsibilities: 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 Dr.T.V.Rao MD 46Conclusions : Strategy for Infection Prevention: 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 Dr.T.V.Rao MD 47Growing concerns with Infections in ICU: 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. Dr.T.V.Rao MD 48Can we control ICU Infections: 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 Dr.T.V.Rao MD 49Wish win the problem face the challenges: 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 Dr.T.V.Rao MD 50Microbes on skin play a major role skin disinfection a major preventive measure: 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 measureUsing Chlorhexidine 0.5% for skin disinfection: 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 disinfectionChlorhexidine Skin Antisepsis: 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).Alcohol Based Hand Sanitizers: Recommended by CDC based on 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 : 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 .Slide 56: WARNING Nosocomial Infections in ICU are Waiting Dr.T.V.Rao MD 56Be kind to your patients REMEMBER ONE THING: Be kind to your patients REMEMBER ONE THING PLEASE WASH YOUR HANDSSlide 58: Dr.T.V.Rao MD 58 Programme created by Dr.T.V.Rao MD for Health care Workers in the Developing world Email firstname.lastname@example.org You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.