At least 35-50% of all healthcare-associated infections are associated with only 4 patient care practices:

1. PREVENTION OF NOSOCOMIAL
INFECTIONS
Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Ivy Hospital Sector 71 Mohali
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495

2. Principles of infection prevention
At least 35-50% of all healthcare-associated infections are
associated with only 4 patient care practices:
Hand hygiene and standard precautions.
Use and care of urinary catheters
Use and care of vascular access lines
Prevention of health care associated
pneumonia.

3. 1. System change
Alcohol-based Access to
• The 5 core
handrub at point of
care
safe, continuous
water supply, soap
and towels
components of the +
WHO Multimodal 2. Training and Education
Hand Hygiene +
3. Observation and feedback
Improvement
Strategy +
4. Reminders in the hospital
+
5. Hospital safety climate

4. Why
Don’t Staff Wash their
Hands?
(Compliance estimated less than 50%)

5. Why Not?
Skin irritation
Inaccessible hand washing facilities
Wearing gloves
Too busy
Lack of appropriate staff
Being a physician

6. Why Not?
Working in high-risk areas
Lack of hand hygiene promotion
Lack of role model
Lack of institutional priority
Lack of sanction of non-compliers

7. Decontaminate hands
before having direct contact with patients or before inserting cvls
or other invasive devices that do not require surgical procedure
after having direct contact with a patient’s skin
after having contact with body fluids, wounds or broken skin if
not visibly soiled
after touching equipment or furniture near the patient
when moving from a contaminated body site to a clean-body site
during patient care
after removing gloves

8. Successful Promotion
Education
Routine observation & feedback
Engineering controls
Location of hand basins
Possible, easy & convenient
Alcohol-based hand rubs available
Patient education

9. Successful Promotion
Reminders in the workplace
Promote and facilitate skin care
Avoid understaffing and excessive workload

10. Hand Hygiene Techniques
1. Alcohol hand rub
2. Routine hand wash 10-15 seconds
3. Aseptic procedures 1 minute
4. Surgical wash 3-5 minutes

11. Areas Most Frequently Missed

12. Routine Hand Wash

13. Alcohol Hand Rubs
Require less time
Can be strategically placed
Readily accessible
Multiple sites
All patient care areas

14. Alcohol Hand Rubs
Acts faster
Excellent bactericidal activity
Less irritating (??)
Sustained improvement

15. Visible soiling
Hands that are visibly soiled or potentially
grossly contaminated with dirt or organic
material MUST be washed with liquid soap
and water

16. Prevention of Catheter-Associated
Urinary Tract Infection (CA-UTI)
Two main principles
1 Avoid unnecessary catheterization
2 Limit the duration of catheterization

17. Catheter insertion and maintenance
Practice hand hygiene
before insertion of the catheter
before and after any manipulation of
the catheter site

18. Catheter insertion and maintenance
Insert catheters by use of aseptic technique and sterile
equipment
Cleanse the meatal area with antiseptic solutions is unnecessary
Routine hygiene is appropriate
Properly secure indwelling catheters after insertion to prevent
movement and urethral traction
Maintain a sterile, continuously closed drainage system
Do not disconnect the catheter and drainage tube unless the
catheter must be irrigated

19. What you should not do to
prevent catheter associated UTI
Do not use (avoid) catheter irrigation
Do not use systemic antimicrobials routinely as
prophylaxis
Do not change catheters routinely

20. CATHETOR ASSOCIATED BLOOD
STREAM INFECTIONS

22. Multimodal intervention strategies to reduce
catheter-associated bloodstream infections:
- Hand hygiene
- Maximal sterile barrier precaution at insertion
- Skin antisepsis with alcohol-based chlorhexidine-
containing products
- Subclavian access as the preferred insertion site
- Daily review of line necessity
- Standardized catheter care using a non-touch technique
- Respecting the recommendations for dressing change

23. Education-based, multimodal
prevention strategy of catheter related
infections

24. HEALTH CARE ASSOCIATED
PNEUMONIA

26. Prevention of Ventilator Associated
Pneumonia
1. Hand hygiene before and after patient contact, preferably
by using alcohol based handrubbing
2. Avoid endotracheal intubation if possible
3. Use of oral, rather than nasal, endotracheal tubes
4. Minimize the duration of mechanical ventilation
5. Promote tracheostomy when ventilation is needed for a longer term
6. Glove and gown use for endotracheal tube manip

27. Prevention of Ventilator
Associated Pneumonia
7. Avoid non-essential tracheal suction
8. Oral hygiene with chlorhexidine
9. Backrest elevation 30-45o
10. Maintain tracheal tube cuff pressures (>20) to prevent regurgitation from
the stomach
11. Avoid gastric overdistension
12. Promote enteral feeding
13. Careful blood sugar control in patients with diabetes
14. Selective decontamination of digestive tract (SDD )in selected cases

28. Continuous Removal of Subglottic
Secretions
 Use an ET tube with
continuous suction
through a dorsal lumen
above the cuff to
prevent drainage
accumulation

30. HOB Elevation
HOB at 30-45o

31. Intubation and ventilation
• Avoid intubation and reintubation
• Prefer non-invasive ventilation
• Prefer orotracheal intubation & orogastric tubes
• Continous subglottic aspiration
• Cuff pressure > 20 cm H2O
• Avoid entering of contaminate consendate into
tube/nebulizer
• Use sedation and weaning protocols to reduce
duration
• Use daily interruption of sedation and avoid
paralytic agents

32. Systemic and enteral antibiotics
• Selective decontamination of the digestive tract (SDD)
reduces the incidence of VAP.
• But SDD not recommended for routine use
• Prior systemic antibiotics helps to reduce VAP in
selected patient groups but increases MDR

33. Stress bleeding, transfusion, hyperglycemia
• Trend towards less VAP with sucralfate (vs H2
blockers) but increased gastric bleeding
• Prudent transfusion, leukocyte-depleted red
blood cell transfusion
• Intensive insulin therapy to keep glucose 80 -
110 mg/dl
Aspiration, body position
• Semirecumbent position (30 - 45°) especially
when receiving enteral feeding
• Enteral nutrition is preferred over parenteral
because of translocation risk

34. CLINICAL PULMONARY INFECTION SCORE
Criterion Score
Fever (°C)
38.5 but 38.9 1
>39 or < 36 2
Leukocytosis
<4000 or >11,000/L 1
Bands > 50% 1 (additional)
Oxygenation (mmHg)
PaO2/FIO2 <250 and no ARDS 2
Chest radiograph
Localized infiltrate 2
Patchy or diffuse infiltrate 1
Progression of infiltrate (no ARDS or CHF) 2
Tracheal aspirate
Moderate or heavy growth 1
Same morphology on Gram's stain 1 (additional)
Maximal scorea 12

35. "Bundled Interventions" to Prevent Common Health Care–Associated Infections and Other
Adverse Events
Prevention of Central Venous Catheter Infections
Educate personnel about catheter insertion and care.
Use chlorhexidine to prepare the insertion site.
Use maximum barrier precautions during catheter insertion.
Ask daily: Is the catheter needed?
Prevention of Ventilator-Associated Pneumonia and Complications
Elevate head of bed to 30–45 degrees.
Give "sedation vacation" and assess readiness to extubate daily.
Use peptic ulcer disease prophylaxis.
Use deep-vein thrombosis prophylaxis (unless contraindicated).

36. Prevention of Surgical-Site Infections
Administer prophylactic antibiotics within 1 h before surgery; discontinue within 24 h.
Limit any hair removal to the time of surgery; use clippers or do not remove hair at all.
Maintain normal perioperative glucose levels (cardiac surgery patients).a
Maintain perioperative normothermia (colorectal surgery patients).a
Prevention of Urinary Tract Infections
Place bladder catheters only when absolutely needed (e.g., to relieve obstruction), not solely
for the provider's convenience.
Use aseptic technique for catheter insertion and urinary tract instrumentation.
Minimize manipulation or opening of drainage systems.
Remove bladder catheters as soon as is feasible.

37. « Talking walls »

38. Thank you