This document discusses infection control in the intensive care unit (ICU). It begins with an overview of general ICU organization and leadership at Hadassah Ein Kerem University Hospital in Jerusalem. It then reviews the history and importance of infection control, citing studies that ICUs account for over 20% of nosocomial infections while using less than 10% of hospital beds. Specific strategies for infection control are discussed, including antibiotic stewardship, hand hygiene, and device-specific protocols. Guidelines from various international organizations are referenced throughout.

1. INFECTION CONTROL IN THE ICU
JOÃO MELO ALVES, MD
LISBOA, PORTUGAL
--
GENERAL ICU
DIRECTOR: PROF. CHARLES SPRUNG, MD
DEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CARE
HEAD OF DEP.: PROF. CHARLES WEISSMAN, MD
HADASSAH EIN KEREM UNIVERSITARY HOSPITAL
JERUSALEM
Ignaz Semmelweis (1818 – 1865)

4. 21% PSSA
0.4% MRSA
Prospective observational study in Canterbury NZ
8 years (1998-2006); n=779
Huggan PJ et al. Intern Med J 2010 (40:2)
Sir Alexander Flemming (1881 – 1955)
Nobel Prize 1945

5. ICUs
Frikdin SK et al. Infect Dis Clin North Am 1997 (11:2)
<10% HOSPITAL BEDS
>20% NOSOCOMIAL INFECTIONS
EPIC I
CRBSI – OR 1.73
Pneumonia – OR 1.91
Sepsis – 3.75
Vincent JL et al. JAMA 1995 (274:8)
EPIC I
 >1000 ICUs
 >10000 patients
 17 european countries
EPIC II
60% patients infected
Infection vs mortality OR 1.51
Leading cause of mortality in ICU
40% of all ICU expenditures
Indwelling catheters
Vincent JL et al. JAMA 2009 (302:21)
EPIC II
 >1000 ICUs
 >14000 patients
 Worldwide study – 75 countries

7. Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)

9. Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)
“IA: periodically assess knowledge of and adherence to guidelines for
all personnel involved in the insertion and maintenance of intravascular catheters”
CDC 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections

10. Antibiotics control
Hand hygiene
Contact precautions
Decolonization
Bathing
SOD/SDD
Nasal carriage
Device specific strategies

11. Antibiotics control
Hand hygiene
Contact precautions
Decolonization
Bathing
SOD/SDD
Nasal carriage
Device specific strategies
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE UCI
ET & SPUTUM CULTURES

12. A-LINES (vs. CVC)
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE ICU
ET & SPUTUM CULTURES

13. A-Lines as source of BSI
49 studies - only one study MSBP vs sterile gloves
O’Horo JC et al. Crit Care Med 2014 (42:6)
IB: aseptic technique for insertion and care of intravascular catheters
IC: clean gloves, rather than sterile, for PVC, after skin antisepsis
IA: sterile gloves for arterial and CVC catheters
IB: maximal sterile barrier precautions (incl cap, mask, sterile gown, sterile gloves,
sterile full body drape) for insertion of CVC, PiCC or guidewire exchange
CDC Prevention Intravascular Catheter Related infections 2011

14. A-Lines as source of BSI
49 studies, 222 BSI, >30000 catheters
1.26 /1000 cath-days
O’Horo JC et al. Crit Care Med 2014 (42:6)
Arterial CRBSI
Prospective cohort
n=2500, 2949 catheters
Femoral vs Radial /1000 cath-days:
Local: 3.02 vs 0.75
BSI: 1.92 vs 0.25
Increased duration
Poor aseptic technique on insertion
Lorente L et al. Crit Care 2006 (10)
Rates of CRBSI/1000 cath-days
AL 1.7 vs. CVC 2.7
PVC 0.5
PiCC 1.1 (inpatients = CVC)
PAC 3.7
Maki DG et al. Mayo Clin Proc 2006 (81:9)

15. 106 ICU, >300000 cath-days
18 months – The Provonost checklist
 Handwashing
 MSBP
 Clorhexidine-ethanol
 Avoidance of femoral
 Removal ASAP
7.7  1.4
Pronovost P at al. NEJM 2006 (355)
n=3154, 2y cohort of catheter care
incidence rate/1000 pt-days
 Exit-site infection 9.23.3 (RR 0.36)
 CRBSI 11.33.8 (RR 0.33)
 VAP/VAT/CAUTI no change
 Global NI 52.434.0
Eggimann P et al. Lancet 2000 (355)

17. Routine replacement has no role
More mechanical complications
No advantage in reducing CRBSI
Cobb DK et al. NEJM 1992 (327)
Eyer S et al. Crit Care Med 1990 (18)
Direct vs guidewire techniques
Less likelihood of success
Longer to perform
Used more catheters
Required more punctures
Guidewire 82% vs direct 65% success
Beards SC et al. Anaesthesia 1994 (49)
Mangar D et al. Anesth Analg 1993 (76)

18. AL are NOT peripheral IVs
 PVC are replaced routinely at 72-96h
(CDC-IB) – AL routine replacement
has no role
 Risk of CRBSI increases with duration
 Dedicated AL kits (e.g. Seldinger
techniques) have higher success
rates and lower complications
Infection rates are similar to CVC
 1.26 – 1.92 /1000 cath-days
Maki DG et al. Mayo Clin Proc 2006 (81:9)
Transducers, tubing, flushing
device and solutions routinely
replaced every 96h
 Recommendation based on CVC and
PAC studies!
Recommendations do not adress arterial lines
Insertion
Maintenance
Infection
… MSBP?

19. BLOOD CULTURES AND CRBSI
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE ICU
ET & SPUTUM CULTURES

20. 1 BC = 20mL = 2 bottles
∆mL= ∆3% yield
Mermel LA, Maki DG. Ann Intern Med. 1993 (119:4)
Aseptic cleaning – 70% alcohol, >0.5% clorhexidine
Should NOT be taken from IV cath at insertion
9.1 vs 2.8% false positives (catheter vs. dedicated venipuncture)
Norberg A et al. JAMA 2003 (289) – >4100 BC!
Bacteremia is usually intermittent and of low quantities
One BC is rarely useful
Leads to under/overtreatment
Minimum 2 sets (4 bottles) from separate venipunctures
Low/moderate pretest – two simultaneous, one 6h later
High pretest, suspected continuous bacteremia – two sets
High pretest, suspected pathogen a likely contaminant – four sets
Timing is neither sensitive nor specific
Technique, number, volume are more important for detection
Riedel S et al. J Clin Microbiol 2008 (46) – n=1436

21. CDC: CLABSI vs. CRBSI
Suspected when BSI occurs with CVC and no other apparent source
 Fever: greater sensitivity, poor specificity.
 Inflammation/pus at site: greater specificity, poor sensitivity
Safdar N, Maki Dg. Crit Care Med 2002 (30)
CRBSI
Paired CVC + peripheral blood cultures (labeled bottles)
 Quantitative: CFU >3x CVC vs periph – most labs don’t perform
 Differential time to positivity: CVC ≥2h before peripheral – sens 85%, spec 95%
Safdar et al. Ann Intern Med 2005 (142:6)
Bouza E et al. Clin Infect Dis 2007 (44:6)
Diagnosis
(Same organism on tip + 2 periph culture)
Same organism on peripheral + CVC cultures
Safdar et al. Ann Intern Med 2005 (142:6)
Raad I et al. Ann Intern Med 2004 (140:1)
Blot F et al. J Clin Microbiol 1998 (36:1)
Blot F et al. Lancet 1999 (9184)
Criteria
Positive CVC (CNS), negative periperal
Colonization likely
Increased risk for CRBSI
Follow closely vs. removal
Culturing Tips
Not routinely – only if CRBSI suspected
 <7-10d: intradermal segment
 >7-10d: tip (most likely catheter colonization)
 Neg peripheral cultures: no antibiotherapy
O’Grady NP et al . CDC 2002 guidelines for the prev of intravascular catheter-related infections

22. “Risk of infection increases with duration of placement,
but routine replacement does not decrease that risk”
Webster J et al. Cochrane Database Syst Ver 2013 (4)
RCT n=160, 4 replacement strategies
CRBSI/1000 cath-days
 Q3d, new place – 3
 Q3d, guidewire – 6
 Clinical indication, new place – 2
 Clinical Indication, guidewire – 3
 New sites increased mechanical complications
Cobb DK et al. NEJM 1992 (327:15)
CDC guidelines
 IB: do not routinely replace CVCs, PiCCs, HD caths,
PACs to prevent CR-infections (new place or
guidewire)
 II: do not remove CVC/PiCCs on the basis of fever
alone. Use clinical judgment.
 IB: use guidewire exchange to replace malfunctioning
catheter if no evidence of infection is present
 IB: do not use guidewire exchanges to replace
suspected infected catheter
CDC Prevention Intravascular Catheter Related infections 2011
REMOVAL
 Severe sepsis/shock
 Endocarditis or metastatic infection
 Suppurative thromboplebitis
 >72h persistent bacteremia under atb
 Specific pathogens (SA, enteococci, GNR, fungi,
mycobacterium)
SALVAGE – no role in ICU
 Uncomplicated CRBSI with long-term catheters
 Salvage therapy (e.g. antibiotic lock)
 Except specific pathogens (…)
MONITOR, DO NOT TREAT
 Positive tip, no clinical signs
 Positive CVC BC, negative peripheral
Staphylococcus aureus
 25-32% BSI develop INFECTIVE ENDOCARDITIS
 TEE 5-7d after
 +BC >72h is an ominous sign
Abraham J et al. Am Heart J 2004 (147:3)
Fowler VG Jr et al. J Am Coll Cardiol 1997 (30:4)
Sullenberger AL et al. J Heart Valve Dis 2005 (14:1)

23. URINARY TRACT INFECTIONS IN THE ICU
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE ICU
ET & SPUTUM CULTURES

24. When to treat?
<5% of bacteriuric cases  bacteremia
Leading cause of nosocomial BSI
17% of all HA-BSI (lower proportion in ICU)
CA-urosepsis 10% mortality
Gould CV et al. Infect Control Hosp Epidemiol 2010 (31)
Diagnosis: cultures and symptoms
Asymptomatic CA-bacteriuria: ≥105 CFU/mL of uropathogenic bacteria
 Pyuria >10 WBC/uL has low sensitivity but >90% specificity – doesn’t make the diagnosis
 Cloudy appearance and foul smell are NOT correlated with bacteriuria
Bacteriuria: 3-10%/day of catheterization
Hooton TM et al. Clin Infect Dis 2010 (50:5)
Nicolle LE. Infect Dis Clin North Am 2012 (26:1)

25. “II: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended.
Rather, it is suggested to change catheters and drainage bags based on clinical indications such as
INFECTION, obstruction, or when the closed system is compromised”
CDC Guideline for prevention of catheter-associated urinary tract infections 2009
Trautner BW, Darouiche RO. Am J Infect Control 2004 (32:3)
Raz R et al. J Urol 2000 (164:4)
Start antibiotics and replace catheter
Fewer and later relapses
Shorter time to afebrile status
Improved clinical status at 72h p<0.001
Less rate of complications (bacteremia, pyelonephritis) p=0.015
UTI
UROSEPSIS
Bacteriuria ≥105 CFU/mL
Fever, sepsis or bacteremia
No alternate sources

26. ENDOTRACHEAL TUBES & SPUTUM CULTURES
A-LINES (vs. CVC)
BLOOD CULTURES & CRBSI
UTI IN THE ICU
ET & SPUTUM CULTURES

27. Ventilator associated tracheobronchitis
Horan TC et al. CDC/NHSN surveillance definition. Am J Infect Control 2008 (36:5)
 Fever>38ºC
 No other recognizable source of infection
 New/increased sputum production
 Positive culture of tracheal aspirates
 No radiographic infiltrate or evidence of pneumonia
Lower respiratory tract colonization ↔ VAP
Pseudomonas, Acinetobacter, Staph aureus
Prospective cohort VAT vs VAP (n=28 / 83)
Length of hospital stay
Duration of hospital stay
Survival rate to discharge
Need for tracheostomy
Need for antibiotics
Dallas J et al. Chest 2011 (139:3)
RCT n=58, antibiotics vs placebo (8 days)
Treatment improves outcomes
Reduced ICU mortality: 18 vs 47% – trial stopped early!
Fewer episodes of VAP: 13 vs 47%
More ventilator free days
Management of VAT=VAP
Nseir S el at, VAT Study Group. Crit Care 2008 (12:3)
Clinical importance seems to be similar to VAP

28. Infection control is a MAJOR issue
AL should probably be handled like CVC
Insertion technique and MSBP
Never take ONE blood culture
Always TWO OR MORE separated, dedicated venipunctures
Culture the CVC
Diagnose and treat UTI
Remove the catheter – colonization is not a limitation
Don’t wait for VAP – treat the VAT

29. 1. Antimicrobial resistance: global report on surveillance. World Health Organization 2014
2. Naomi P.O’Grady et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. HICPAC,
CDC.
3. Carolyn V Gould et al. Guideline for prevention of catheter-associated urinary tract infections 2009. HICPAC, CDC.
4. Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)
5. Australian guidelines for the prevention and control of infection in healthcare. 2010, Australian Government.
6. Healthcare Society Infection guidelines. http.//www.his..org.uk/resources-guidelines/
7. ASPIC Asia Pacific Society of Infection Control Guidelines. July 2012. http:// apsic.info/guidelines.php
8. SHEA Society for Healthcare Epidemiology of Americas. Compendium of Strategies to prevent healthcare-
associated infections in acute care hospitals (SHEA, IDSA, AHA, APIC, JC) 2014 update – several statements
published on Infection Control and Healthcare Epidemiology Journal since 2008
 Executive summary 2014 updates: Infection control 2014 (35:8)
João Melo Alves – joaomeloalves@gmail.com
http://www.slideshare.net/joaomeloalves
REFERENCE BIBLIOGRAPHY