A very important aspect of intensive care

1. Infection Control in ICU
Muhammad Asim Rana
MBBS, MRCP, FCCP, SF-CCM, EDIC

2. Why focus on infection
prevention and control in
critical care?

3. Intensive care units (ICUs) 10 %of total
beds, more than 20 percent of all
nosocomial infections are acquired in ICUs.
 ICU-acquired infections account for
substantial morbidity, mortality, and
expense.
 Improving infection prevention and control
in critical care acts as a catalyst for
improvement in the rest of the hospital.


4. Factors contributing in infections
1.
Compared to general patients,
patients in ICUs have more chronic
comorbidities & more severe acute
physiologic derangements.
2.
The high frequency of use of catheters
provide a portal of entry of organisms into
the bloodstream.
3.
Multidrug-resistant pathogens
MRSA and VRE are being isolated with
increasing frequency in ICUs

5. Studies of ICU-associated infections

Most studies of ICUassociated infections come
from industrialized countries,
The rates of infection may even be
higher in developing countries as
illustrated by a
multicenter,
prospective
cohort surveillance study of 46 hospitals
in Central and South America, India,
Morocco, and Turkey.


6. (as reported by NNIS)

Ventilator associated pneumonia (VAP)


CVL-related bloodstream infections


24.1 cases per 1000 ventilator days (10.0 - 52.7)
12.5 cases per 1000 catheter days ( 7.8 - 18.5)
Catheter-associated urinary tract infections

8.9 cases per 1000 catheter days
(1.7 - 12.8)

7. NNIS USA 1999 Antimicrobial Resistance

VRE : 24.7 % of enterococci isolates

MRSA: 53.5 % of S. aureus

ESBL :



10.4 % Klebsiella
3.9 % Escherichia coli
Pseudomonas aeruginosa


16.4 % resistant to imipenem
23.0 % resistant to fluoroquinolones

8. Risk Factors

Presence of underlying comorbidities



diabetes, renal failure, malignancies
predispose patients to colonization and infection with
multidrug-resistant bacteria.
Presence of indwelling devices


central venous catheters, Foley catheters, and
endotracheal tubes
which bypass natural host defense mechanisms and
serve as portals of entry for pathogens.

9. Risk Factors

Frequent manipulations and contact with
HCWs
usually concurrently caring for multiple ICU
patients
 hands are the vehicles for transfer of pathogens
from patient to patient.


Long hospital courses prior to the ICU
admission, More Antibiotic Exposure ,…..

10. Outcome of MDR ICU infections
1.
Infections caused by MDR pathogens are
associated with
1.
2.
3.
2.
increased mortality,
Increased length of hospital stay,
increased hospital costs.
Patients with infections due to MDR organisms usually are chronically or acutely
ill and at risk of dying from underlying
serious and complex medical illnesses.

11. Prevention of MDR Infection
in the ICU
Two Major Strategies
1.
Strategies that attempt to improve the
efficacy and utilization of antimicrobial
therapy.
2.
Infection Control Measures

12. Outline on
Antibiotic utilization controls
1.
2.
3.
4.
5.
6.
Antibiotic evaluation committees
Protocols and guidelines to promote
appropriate antimicrobial utilization
Hospital formulary restrictions of broadspectrum agents
Substitution of narrow-spectrum antibiotics
Mandatory consultations with infectious
diseases specialists
Antibiotic cycling

13. Infection Control Measures
1.
General principles of infection control
2.
Specific steps involved in prevention of
special MDROs

14. General principles of infection control

Infection control


a discipline that applies epidemiologic and scientific
principles and statistical analysis to the prevention or
reduction in rates of nosocomial infections.
Effective infection control programs

proven to reduce the rates of nosocomial infections
and to be cost-effective.
Infection control is a key component of the
broader discipline of hospital epidemiology.

15. Achieving the main goal of
preventing or reducing the risk of
hospital-acquired infections
Where to focus energy for impact

16. Functions and Responsibilities of a
hospital Infection Control program

Education



Prevention of infections (eg, by hand hygiene)
Prevention of infections due to devices
disposal of infectious waste

Development of infection control policies and
procedures

Surveillance : (hospital-wide Vs. targeted)

Outbreak investigations

17. Functions and Responsibilities of a
hospital Infection Control program

Evaluation of devices used



Cleaning, disinfection, and sterilization of
equipment
Oversight on the use of new products that
directly or indirectly relate to the risk of
nosocomial infections
Review of antibiotic utilization and its
relationship to local antibiotic resistance
patterns

18. Functions and Responsibilities of a
hospital Infection Control program

Hospital employee health

Pre employment assessment

After exposure to either blood borne or
respiratory pathogens

19. Areas of Infection Control

Four major areas of infection control will
be reviewed here:
1.
Standard precautions, including hand
hygiene
Isolation precautions
Cleaning, disinfection, and sterilization
Surveillance
2.
3.
4.

20. STANDARD PRECAUTIONS
Various forms of isolation have been used
in an attempt to reduce the spread of
nosocomial infections.
 In 1996, the CDC and Hospital Infection
Control Advisory Committee (HICPAC)
issued a new system of isolation
precautions.


22. Noncritical items should be dedicated to use for a single
patient if possible.

25. 
Standard precautions are recommended in
the care of all hospitalized patients.

The category of standard precautions
combines the important features of
body substance isolation policies and
universal precautions,
in so doing,
aims to reduce the risk of transmission of
infectious agents between patient and
healthcare worker.

26. 
Standard precautions apply to
blood,
 all body fluids,
 nonintact skin,
 mucous membranes and
 secretions
 and excretions

except sweat.

27. They entail
Handwashing before and after every
patient contact
 The use of gloves, gowns and eye
protection in situations in which exposure
to body secretions or blood is possible
 Handwashing after gloves are removed
 The safe disposal of sharp instruments
and needles in impervious containers
 The placement of soiled linens in
impervious bags and bloody or
contaminated materials such as feces or
urine in sanitary toilets


28. The 2007 CDC guidelines included
several additional components

Safe injection practices.

Use of a mask when prolonged procedures
involving puncture of the spinal canal are
performed
myelography,
 epidural anesthesia,
 injection of chemotherapeutic agents.


Respiratory hygiene/cough etiquette

29. Ignaz Philipp Semmelweis
Hungarian physician (1847)
 incidence of puerperal fever
(Lack of hand washing by clinicians)
 Hand dips with chlorinated lime at Vienna
General Hospital.
 These ideas evolved to form current
guidelines
 Hand cleansing opposed to Hand washing


30. Hand Hygiene
The surface of the skin is home of
bacteria and fungi,
Resident flora
Transient flora
Eradicating microbes on the hands of hospital
personnel is one of the holy crusades of
infection control
It is the single most important measure to
reduce transmission of microorganisms
from one person to another or one site to
another on the same patient.

31. Organisms Isolated from the Hands of ICU Personnel
Gram positive cocci
Staph.epidermidis
100%
Staph.aureus (MSSA) 7%
Gram negative bacilli 21%
Acinetobacter spp.
Klebsiella spp.
Enterobacter spp.
Pseudomonas spp.
Serratia spp.
Yeasts & Fungi
16%

32. Cleaning vs Decontamination

The removal of microbes from the skin is
known as decontamination,


requires the application of agents that have
antimicrobial activity.
Antimicrobial agents that are used to
decontaminate the skin are called antiseptics,
 while those used to decontaminate inanimate
objects are called disinfectants.


33. Commonly Used Antiseptics

39. Evidence for the efficacy of hand hygiene


Comparative
effects of a 6minute hand
scrub with 0.75%
povidone-iodine
and 4%
chlorhexidine
gluconate on
microbial growth
on the hands.
Bacterial counts
are expressed as
log base 10

40. Finger Nails



Much of the resident microflora of hands is found in
the periungual and subungual areas, and fingernails
are often neglected during routine hand cleansing.
When the fingernails are long and when artificial
fingernails are worn, there is an increase in
periungual colonization with a variety of pathogens
Guidelines from the CDC and Association of
Operating Room Nurses (AORN) prohibit the use of
artificial fingernails or extenders by health care
workers

41. Rings

There is no consensus on the need to
prohibit the wearing of rings in healthcare
settings even though several studies have
shown that skin beneath rings is more
heavily colonized with bacteria than
adjacent skin not covered by rings

42. Gloves
Three important reasons
To provide a protective barrier for the hands.
 To reduce the acquisition of microorganisms
from a patient.
 To reduce the transmission of microorganisms
from the hands of hospital staff to patients.

However, wearing gloves does not replace the need for hand washing

43. Masks
Three purposes in infection control
To protect healthcare personnel from
infectious material from patients.
 To protect healthcare personnel from
infectious material from patients.
 To protect healthcare personnel from
infectious material from patients.

Masks should not be confused with particulate respirators that are
used to prevent transmission by airborne droplet nuclei of
infectious agents such as M. tuberculosis.

44. ISOLATION PRECAUTIONS
Three isolation categories

Contact:
Contact precautions should be used in the care of patients with
multidrug-resistant bacteria, and various enteric, parasitic, and viral
pathogens.

Droplet:
Droplets are particles of respiratory secretions larger than 5
micrometers.

Airborne spread:
Airborne droplet nuclei, in contrast to larger droplets in the preceding
section, are particles of respiratory secretions smaller than 5
micrometers.

45. Droplet Precautions
Large Droplets(>5microns)
Haemophilus influenza (type b)
Epiglottitis,pneumonia,meningitis

Place patient in a
private room, if
unavailable patient
should not be within 3
feet of non infectious
patients

Hospital staff and
visitors should wear a
surgical mask within 3
feet of the patient
Neisseria meningitidis
pneumonia & meningitidis
Bacterial respiratory infections
Diphtheria
Mycoplasma
Group A strep pneumonia
Viral Respiratory Infections
Influenza
Adenovirus
Mumps
Rubella

46. Airborne Precautions
Small Droplets (<5micron)



Mycobacterium TB
Measels
Varicella (including
dissemenated Zoster)



Place patient in negative
pressure isolation room
Hospital staff and visitors
should wear N95 respirator
Those who are without a
history of infection or pregnant
ladies, immunocompromised
should not enter the room,
others should wear N95

47. ENVIRONMENTAL CLEANING

Cleaning


Cleaning is the removal of all foreign material (eg,
soil, organic material) from objects. It is normally
accomplished with water, mechanical action, and
detergents or enzymatic products.
Disinfection

Disinfection describes a process that eliminates many
or all pathogenic microorganisms from inanimate
objects, except for bacterial spores.

48. 
Sterilization
Sterilization is the complete elimination or
destruction of all forms of microbial life by
Steam under pressure
Dry heat
Low temperature sterilization processes
(ethylene oxide gas, plasma sterilization)
Liquid chemicals

49. SURVEILLANCE

Cornerstone of all successful hospital
infection control programs.

Surveillance is only the starting point and
benchmark for assessing the need for
intervention strategies.

Effective surveillance involves




counting cases and then
calculating rates of various infections,
analyzing these data,
reporting the data in an appropriate way to personnel
involved in patient care

50. Epidemiology and prevention and
control of vancomycin-resistant
enterococci

51. INTRODUCTION
Vancomycin-resistant enterococci (VRE)
are an increasingly common and difficult to
treat cause of hospital-acquired infection.
 2006 report from the Clinical and
Laboratory Standards Institute
Vancomycin susceptible — ≤ 4 mcg/mL
Vancomycin resistant — ≥ 32 mcg/mL
An MIC of 8 to 16 mcg/mL was considered
vancomycin intermediate


52. TRANSMISSION

VRE colonize the gastrointestinal tract and
can be found on the skin due to fecal
shedding.

Colonization with VRE generally precedes
infection, but not all patients with
colonization become infected.

Persons either colonized or infected with
VRE can serve as sources for secondary
transmission.

53. 
Transmission can occur by both
Direct contact (eg, the hands of health care
workers)
 Indirectly

 From
instruments eg, rectal probes
 From environmental surfaces.

The following observations come from
different studies that have evaluated VRE
transmission:

54. 
In a study in which VRE were inoculated in
different places, the strains survived for

Five to seven days on patients tables

24 hours without a reduction in counts on bedrails

60 minutes on a telephone handpiece

30 minutes on the diaphragmatic surface of stethoscopes

55. RISK FACTORS

Previous antimicrobial therapy

Patient characteristics

Colonization pressure

Exposure to contaminated surfaces

Residence in long-term care facilities

56. INFECTION CONTROL
Prevention of infection with VRE, requires a multifaceted
approach including

General infection prevention (eg, optimal management
of vascular and urinary catheters)

Accurate and prompt diagnosis and treatment,

Prudent use of antimicrobial drugs,

Prevention of transmission

57. Healthcare Infection Control Practices Advisory
Committee (HICPAC) guideline recommendations

Hand hygiene (Grade 1A)

Contact precautions (Grade 1A)

Cohorting (Grade 1A)


Not to attempt Decolonization (Grade 1B)
Surveillance cultures

Not applicable everywhere

three negative stool/rectal cultures obtained at weekly intervals are required to remove a
previously colonized patient from contact precautions if patient is not on antimicrobials

58. General principles of the treatment
and prevention of Acinetobacter
infection

59. INTRODUCTION

The genus Acinetobacter consists of
ubiquitous Gram negative bacilli that were
originally identified in the 1930s

Gram negative coccobacilli

non-motile, strictly aerobic, catalase-positive,
and oxidase-negative.

60. PREVENTION AND CONTROL

In an era of
rising antimicrobial resistance rates
 and limited therapeutic options,


the control of multidrug resistant pathogens
such as Acinetobacter relies heavily upon
preventive measures

61. Infection control
Apply standards precautions


at all times in contact with any patients

Apply contact precautions with MDRO infected patients

Use antibiotics appropriately

In the setting of an outbreak :

should be careful adherence to infection control measures.
1.
Compliance with hand hygiene and should be strictly enforced.
2.
Colonized and infected patients should be isolated or cohorted
3.
Contact precautions should be used consistently.

62. Infection control (Continued)

In the setting of an outbreak :
Environmental surfaces
1.

should be appropriately cleaned with an approved hospital
disinfectant.
Equipment that comes in contact with mucous membranes
or nonintact skin (semi-critical items)
2.

should undergo high level disinfection.
Proper investigations should be conducted
3.
•
•
attempt to identify a common source of infection
to prevent further dissemination of the infecting strain

63. Prevention and control of
methicillin-resistant
Staphylococcus aureus in adults

64. INTRODUCTION

Prevention and control of methicillin-resistant Staphylococcus
aureus (MRSA) cross-infection


Some European countries have managed to contain MRSA at
a low prevalence Netherlands, Finland, and France




the most important challenges of infection control.
using active surveillance cultures
contact precautions
with or without decolonization
Other countries:


Germany and Canada
did not implement early MRSA surveillance and control measures
subsequently have struggled to control MRSA epidemics

65. SURVEILLANCE AND PRECAUTIONS

High MRSA prevalence has been
correlated with inadequate adherence to
infection control principles; (the countries with
greatest MRSA prevalence include the United States and Japan.)

Active surveillance cultures (ASC)

facilitate identification of patients with MRSA
colonization to be placed on contact
precautions

The goal is to minimize MRSA spread to other
patients.

66. Active surveillance cultures (ASC)
In the setting of hospital outbreaks

Among patients at high risk for MRSA
infection, such as









patients in intensive care units (ICUs),
immunocompromised patients,
long-term care facility residents,
Patients on hemodialysis
Patients with history of MRSA colonization
Patients hospitalized in the previous twelve months
Received antibiotic therapy in the last three months
Patients with skin or soft tissue infection at admission

67. Prevention & Control

HAND HYGIENE

ENVIRONMENTAL CLEANING

ANTIBIOTIC STEWARDSHIP

COMMUNITY PREVENTION

INFORMATION FOR PATIENTS

68. So far today…
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

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I’ve changed 24 beds.
Dressed 25 wounds.
Emptied 20 bedpans.
Washed and dressed 16 patients.
Given 6 enemas.
Bandaged 3 sores.
Helped 10 people in toilet.
You Are Next…

69. Thank You