3. A Patient in Intensive Care Unit is
at Risk for Many Reasons..
3/8/2014 Dr.T.V.Rao MD 3
4. 1st principle of infection
prevention
at least 35-50% of all healthcare-associated infections are
asociated with only 5 patient care practices:
• Use and care of urinary catheters
• Use and care of vascular access lines
• Therapy and support of pulmonary functions
• Surveillance of surgical procedures
• Hand hygiene and standard precautions
5. The Purpose of the Programme
• The purpose of this program
is to maintain a healthy and
safe Hospital by the
prevention and control
of health care related
infections / diseases in
particular intensive care
units. This is achieved by
surveillance and investigation
of infectious diseases and
public education.
Dr.T.V.Rao MD
5
3/8/2014
6. Educating our Health Care
Workers
•Education programs for
employees and volunteers
are one method to ensure
competent infection control
practices.
Dr.T.V.Rao MD 6
3/8/2014
7. Why ICU patients are different
• Sickest patients (multiple diagnoses, multi-
organ failure, immunocompromised, septic
and trauma)
• Move less
• Malnourished
• More obtunded (Glasgow coma scale)
• May be associated Diabetics and Heart
failure
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8. EPIDEMIOLOGY
• Contributing factors
–Patients in ICUs have more chronic
comorbid illnesses and more severe acute
physiologic derangements
–The high frequency of indwelling
catheters among ICU patients
–The use and maintenance of these
catheters necessitate frequent contact
with health care workers, which
predispose patients to colonization and
infection with nosocomial pathogens
3/8/2014 Dr.T.V.Rao MD 8
9. Multi Drug Resistant Bacteria
• Multidrug-resistant pathogens
such as methicillin-resistant
Staphylococcus aureus (MRSA)
and Vancomycin-resistant
enterococci (VRE) are being
isolated with increasing
frequency in ICUs
3/8/2014 Dr.T.V.Rao MD 9
10. ICU Care is Invasive at many
Stages
• More invasive lines and
procedures including
surgeries
• Longer length of stay
• More IV and parenteral
drugs
• More tube feeding and
Parenteral nutrition
• More ventilation
3/8/2014 Dr.T.V.Rao MD 10
11. ICU : Factors that increase
cross-infections
• Hand washing facilities are inadequate
• Patients 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
3/8/2014 Dr.T.V.Rao MD 11
12. Some Health-Care Associated
Infections May Occur in ICU Patients
• 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
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13. 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
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14. 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
3/8/2014 Dr.T.V.Rao MD 14
15. 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
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19. Incidence of CR-BSI
• Type of catheter
Teflon or Polyurethane ( < infections) vs Polyvinyl
chloride or Polyethylene
• Site of insertion
Subclavian (< infections) vs Internal Jugular & Femoral
(high risk of colonization & deep venous thrombosis)
• No. of Lumen
Single-lumen catheter (< infections)
vs Multi-lumen catheter
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20. Prevention Strategies: Core
Proper Insertion Practices
• Ensure utilization of insertion bundle:
– Chlorhexidine for skin antisepsis
– Maximal sterile barrier precautions (e.g., mask,
cap [i.e., similar to those worn in the O.R.],
gown, sterile gloves, and large sterile drape)
– Hand hygiene
• Many CLs in patients on non-ICU hospital
wards are placed outside those wards
(Emergency room, ICU, Operating room, or
Pre-operative areas)
Trick et al. Am J Infect Control 2006;34:636-41.
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21. Prevention Strategies: Core
Chlorhexidine Skin Cleansing
• Chlorhexidine is the preferred agent for skin
cleansing for both CL insertion and maintenance
– Tincture of iodine, an iodophores, or 70% alcohol are
alternatives
– Recommended application methods and contact time
should be followed for maximal effect
• Prior to use should ensure agent is
compatible with catheter
– Alcohol may interact with some polyurethane
catheters
– Some iodine-based compounds may interact
with silicone catheters
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22. 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
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23. 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
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24. 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
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25. 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
26. Prevention of CR-BSI
Skin antisepsis
• 2% Chlorhexidine gluconate has shown to
have lower BSI than 10% Povidone-iodine or
70 % Alcohol
• 2-min drying time before insertion
Maki DG et al. Lancet 1991;338:339-43
• No difference between 0.5% Chlorhexidine
gluconate or 10% Povidone-iodine
Humar A et al. Clin Infect Dis 2000;31:1001-7
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27. Prevention of CR-BSI
Dressing
• Gauze dressings every 2
days
• Transparent dressing
every 7 days on short
term catheter
• Replace dressing when
catheter is replaced or
dressing becomes damp
or loose.
Grady NP et al, HICPAC draft guidelines: 2002
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28. Prevention of CR-BSI
Catheters removal
• Don’t replace it routinely
• Replace it if:
– Inserted in an Emergency
– Non functioning
– Evidence of local or systemic infection
General handling
• Opening of hub: Use antiseptic-
impregnated pads eg Chlorhexidine
gluconate or povidone iodine
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29. Prevention of CR-BSI
Administration sets
• Replacement at 72-h intervals
• No difference in phlebitis if left for 96
hours
• Lines for lipid emulsion: replacement
at 24-h intervals
• Lines for blood product : remove
immediately after use
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30. Prevention of CR-BSI
Topical antibiotic
• Prophylactic use of topical Mupirocin (Bactroban) at
insertion site or in nose is not recommended
– Rapid development of Mupirocin resistant
– Mupirocin affect the integrity of Polyurethane catheter
Systemic antibiotic
• Prophylactic use of antibiotic is not recommended at
the time of catheter insertion
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31. Background: Prevention Strategies
Interventions
• Michigan Keystone Project
• Decrease in CLABSI in 103 ICUs in Michigan (66%
reduction)
• Basic interventions:
– Hand hygiene
– Full barrier precautions during CL insertion
– Skin cleansing with chlorhexidine
– Avoiding femoral site
– Removing unnecessary catheters
– Use of insertion checklist
– Promotion of safety culture
Pronovost et al. NEJM 2006;355:2725-32.
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33. CATHETER-ASSOCIATED UTI
• Other important risk factors for CAUTI
– Patients with other sites of active infection
– Long hospital stay
– Malnutrition
– Female sex
– Abnormal serum creatinine
– Improper catheter care (particularly
placement of the drainage tube above the
level of the bladder)
34. External urethral meatus &
urethra
• Pass catheter when bladder full for wash-out
effect.
• Before catheterization prepare urinary meatus
with an antiseptic ( e.g. povidone iodine or 0.2%
chlorhexidine aqueous solution)
• Inject single-use sterile lubricant gel (e.g. 1-2%)
lignocaine into urethra and hold there for 3 minutes
before inserting catheter.
• Use sterile catheter.
• Use non-touch technique for insertion
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35. Junction between catheter &
drainage tube
• Do not disconnect catheter unless
absolutely necessary.
• For urine specimen collection disinfect
outside of catheter proximal to junction
with drainage tube by applying alcoholic
impregnated wipe and allow it to dry
completely then aspirate urine with a
sterile needle and syringe.
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36. Junction between drainage tube
& collection bag
• Keep bag below level of bladder. If it is
necessary to raise collection bag above
bladder level for a short period, drainage
tube must be clamped temporarily.
• Empty bag every 8 hours or earlier if
full.
• Do not hold bag upside down when
emptying
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37. Tap at bottom of collection bag
• Collection bag must never touch floor.
• Always wash or disinfect hands (eg with
70% alcohol) before and after opening
tap.
• Use a separate disinfected jug to collect
urine from each bag.
• Don't put disinfectant into urinary bag.
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38. Prevention
The condom catheter is a good alternative to the indwelling
catheter for men and is associated with lower rates of
bacteriuria
Intermittent bladder catheterization has been shown to
reduce the incidence of UTI in long-term spinal cord
injury patients compared to an indwelling catheter, this
approach has not been studied in patients with shorter-
term indwelling bladder catheters
Suprapubic catheters might be more comfortable for
patients and have been shown to lower the incidence of
bacteriuria
41. Risk factors for bacterial pneumonia
Host Factors Factors that facilitate reflux
& aspiration into the lower RT
• Elderly
• Severe Illness
• Underlying Lung Disease - Mechanical ventilation
• Depressed Mental Status - Tracheostomy
• Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Position
• Viral Respiratory Tract Factors that impede normal
Infection Pulmonary Toilet
Colonisation - Abdominal or thoracic surgery
• Intensive Care Setting - Immobilisation
• Use of Antimicrobial Agents
• Contaminated hands
• Contaminated Equipment
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42. Prevention in ICU
• Turn patients to
encourage postural
drainage
• Encourage to take deep
breaths and cough.
• Maintain an upright
position (elevate
patient’s head to 30º-
45º degree angle) to
reduce reflux and
aspiration of gastric
bacteria.
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43. Gastric Ulcer Prophylaxis
• Stomach of a healthy person : Acidic pH () &
normal peristalsis movement prevent bacterial
growth
• Alkaline pH () and loss on normal peristalsis lead to
bacterial colonisation which increases the risk of
ventilator-associated pneumonia
• Mechanical ventilation patients are at increased risk
for upper GI hemorrhage from stress ulcers.
• H2 blockers or antacids are used to prevent stress
ulcers
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44. Nasogastric Tube
• May erode the mucosal surface
• Block the sinus ducts
• Regurgitation of gastric contents leading to
aspiration.
• Verify placement of the feeding tube in the
stomach or small intestine by X ray
• Elevate the head of the bed 30º- 45 º degrees
Remove NG Tube if not necessary
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45. Ventilators
• After every patient,
clean and disinfect
(high-level) or
sterilize re-usable
components of the
breathing system or
the patient circuit
according to the
manufacturer’s
instructions.
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46. Suctioning mechanically
ventilated patients
• Hand washing before and after the procedure.
• Wear clean gloves to prevent cross-
contamination
• Use a sterile single-use catheter ; if it is not
possible then rinse catheter with sterile water
and store it in a dry, clean container between
uses and change the catheter every 8 - 12
hours.
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47. Suction Bottle
Use single-use
disposable, if possible
Non-disposable bottles
should be washed with
detergent and allowed
to dry. Heat disinfect in
washing machine or
send to Sterile Service
Department.
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48. Nebulizers
• Use sterile medications and fluids for nebulization
• Fill with sterile water only.
• Change and reprocess device between patients by
using sterilization or a high level disinfection or use
single-use disposable item.
• Small hand held nebulizers
– minimise unnecessary use
– between uses for the same patient disinfect, rinse
with sterile water, or air dry and store in a clean,
dry place
• Reprocess nebulizers daily
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49. Humidifiers
• Clean and sterilize
device between
patients.
• Fill with sterile water
which must be changed
every 24 hours or
sooner, if necessary.
• Single-use disposable
humidifiers are
available but they are
expensive.
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50. Oxygen mask
• Change oxygen
mask and
tubing
between
patients and
more
frequently if
soiled
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51. The Scientific study ( SENIC )
gives guidelines
• Study of the Efficacy of Nosocomial Infection Control (SENIC)
project was published, validating the cost-benefit of infection
control programs. Data collected in 1970 and 1976-1977
suggested that one-third of all nosocomial infections could be
prevented if all the following were present:
• One infection control professional (ICP) for every 250 beds.
• An effective infection control physician.
• A program reporting infection rates back to the surgeon and
those clinically involved with the infection.
• An organized hospital-wide surveillance system.
Dr.T.V.Rao MD 51
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54. Examples of difficult to detect infections:
Uncultivable organisms
Viruses are under appreciated as causes of
nosocomial infections. Except in cases of
high morbidity viral cultures are not done
in resource scarce settings. Impact food-
borne, respiratory, water borne illnesses.
We don’t know the spectrum of anti-
microbial activity of most preservatives
and cleaners for many viruses.
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55. Examples from the NNIS
Manual
• Symptomatic Urinary Tract Infection:
– Patient must have one of the two criteria:
• Fever >38 C OR urgency OR frequency OR
dysuria OR suprapubic tenderness without
other cause
OR
• Urine culture with at least 105 organisms per
ml or no more than two species of organisms
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56. Definition of surgical site infection
(no implant)
• Occurs within 30
days of surgery
AND has one of the
following:
Purulent drainage
from drain OR
Organism isolated
from aseptically
obtained fluid in the
organ space
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57. Prior to starting any surveillance
• Agree upon a
written case
definition that is
practical given the
laboratory
facilities and
patient work load
in your facility.
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58. Our plan for future should include
• Unlike scheduled activities, occasional clusters of
patients who are colonized or infected will trigger
further investigation including a case-control study.
New laboratory methods developed and refined
within the last decade can now determine how
related the strain is at the molecular level. The QI/IC
plan should include special problem-focused studies
that describe personnel or environmental sampling,
including what circumstances and who has the
authority to order
Dr.T.V.Rao MD 58
3/8/2014
59. Hand washing
• Single most effective action to prevent HAI -
resident/transient bacteria
• Correct method - ensuring all surfaces are cleaned -
more important than agent used or length of time taken
• No recommended frequency - should be determined by
intended/completed actions
• Research indicates:
– poor techniques - not all surfaces cleaned
– frequency diminishes with workload/distance
– poor compliance with guidelines/training
Dr.T.V.Rao MD 59
3/8/2014
60. Why we are not washing hands ???
• Working in high-risk areas
• Lack of hand hygiene promotion
• Lack of role model
• Lack of institutional priority
• Lack of sanction of non-compliers
Dr.T.V.Rao MD 60
3/8/2014
61. EPIDEMIOLOGY
• A multicenter, prospective cohort surveillance study of 46
hospitals in Central and South America, India, Morocco,
and Turkey
• Rates of device-associated infection were determined
between 2002 and 2005; an overall rate of 14.7 percent or
22.5 infections per 1000 ICU days was found
• Specific devices
– Ventilator associated pneumonia VAP ; 24.1 cases/1000
ventilator days range 10.0-52.7
– CVC-related bloodstream infections; 12.5/1000 catheter days
7.8-18.5
– Catheter-associated urinary tract infections; 8.9/1000 catheter
days 1.7-12.8
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62. Our Vision to Future
• Infection control
programs must
maintain training
records of employees.
The minimum training
required is annual OSHA
blood borne pathogen,
tuberculosis prevention
and control and new
employee orientation.
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3/8/2014
63. Why we need better ICU’s
• For an incidence as well as for a
prevalence population of critically ill
patients, there is a window of critical
opportunity for admission into the ICU,
much like the golden our for the
trauma patient.
• Efforts should be made to avail ICU facilities to as
many recently deteriorated patients as possible,
especially those who could be transferred into the
ICU very early after deterioration, such as
patients on hospital wards.
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64. Do remember the Reasons for Infections
are Many but solutions are few …
3/8/2014 Dr.T.V.Rao MD 64
65. Yet No Substitute for Hand Washing
Are You Washing ?
3/8/2014 Dr.T.V.Rao MD 65
66. Let us support our Hospitals with
clean hands
Dr.T.V.Rao MD 66
3/8/2014
68. Be kind to your patients REMEMBER
ONE THING
•PLEASE WASH YOUR
HANDS
69. • The Programme Created by Dr.T.V.Rao MD for
Paramedical and Health care workers in the
Developing world
• Email
• doctortvrao@gmail.com
3/8/2014 Dr.T.V.Rao MD 69
