intensive care unit infections. icu patients sickest patients (multiple diagnoses, multi-organ...

Intensive Care Unit infections

ICU patientsICU patientsSickest patients (multiple diagnoses, Sickest patients (multiple diagnoses, multi-organ failure, multi-organ failure, immunocompromised, septic and immunocompromised, septic and trauma) trauma) Move less Move less Malnourished Malnourished More obtunded (Glasgow coma scale)More obtunded (Glasgow coma scale)Diabetics and Heart failureDiabetics and Heart failure

04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 22

ICU Care is Invasive ICU Care is Invasive More invasive lines and More invasive lines and procedures including procedures including surgeriessurgeries

Longer length of stayLonger length of stayMore IV and parenteral More IV and parenteral drugsdrugs

More tube feeding and More tube feeding and Parenteral nutritionParenteral nutrition

More ventilationMore ventilation04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 33

ICU : Factors that increase cross-ICU : Factors that increase cross-infectionsinfections

Hand washing facilitiesHand washing facilitiesPatient close together or sharing roomsPatient close together or sharing roomsUnderstaffingUnderstaffingPreparation of IVs on the unit Preparation of IVs on the unit Lack of isolation facilities Lack of isolation facilities

No separation of clean and dirty AREASNo separation of clean and dirty AREASExcessive antibiotic useExcessive antibiotic use

Inadequate decontamination of items & equipmentsInadequate decontamination of items & equipmentsInadequate cleaning of environmentInadequate cleaning of environment04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 44

Some Health-Care Associated Some Health-Care Associated Infections that May OccurInfections that May Occur

UTI associated with Foley cathetersUTI associated with Foley catheters

Lower respiratory tract infection (post-op Lower respiratory tract infection (post-op and ventilator dependent)and ventilator dependent)

Skin necrosis (skin breakdown)Skin necrosis (skin breakdown)

Blood stream infection (and line associated)Blood stream infection (and line associated)

Surgical-site infection Surgical-site infection

Nutrition-related and malnutritionNutrition-related and malnutrition04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 55

Strategy for PreventionStrategy for PreventionHandwashingHandwashing

Use gloves to prevent contamination of Use gloves to prevent contamination of the hands when handling respiratory the hands when handling respiratory secretionssecretions

Wear gloves and gowns (contact Wear gloves and gowns (contact precautions) during all contact with precautions) during all contact with patients and fomites potentially patients and fomites potentially contaminated with respiratory secretionscontaminated with respiratory secretions

Use aseptic techniqueUse aseptic technique


Strategy for PreventionStrategy for Prevention

Clean and decontaminate all equipment after useClean and decontaminate all equipment after use

Sterilise or use high-level disinfection for all items Sterilise or use high-level disinfection for all items that come into direct or indirect contact with that come into direct or indirect contact with mucous membranesmucous membranes

Rinse and dry items that have been chemically Rinse and dry items that have been chemically disinfecteddisinfected

Package and store items to prevent contamination Package and store items to prevent contamination before usebefore use

Keep environment clean, dry and dust freeKeep environment clean, dry and dust free


Conclusions : Conclusions : Strategy for Infection Strategy for Infection PreventionPrevention

Strict attention to Hand hygiene Strict attention to Hand hygiene Prudent Antibiotic usePrudent Antibiotic useAseptic technique Aseptic technique Disinfection/Sterilization of items and equipmentDisinfection/Sterilization of items and equipment

Education of staff infection control awareness Education of staff infection control awareness

Keep Environment Clean, Dry and dust freeKeep Environment Clean, Dry and dust freeSurveillance of nosocomial infection to identify Surveillance of nosocomial infection to identify problems areas & set priorities problems areas & set priorities


Intensive Care UnitIntensive Care UnitPrevention of Blood stream infectionsPrevention of Blood stream infections

Central Venous CathetersCentral Venous Catheters

IndicationsIndications

IV fluids and drugsIV fluids and drugsBlood and blood productsBlood and blood productsTotal Parenteral Nutrition (TPN)Total Parenteral Nutrition (TPN)HaemodialysisHaemodialysisHaemodynamic monitoringHaemodynamic monitoring


Serious Infective Serious Infective ComplicationsComplications

Blood Stream Infections (BSI)Blood Stream Infections (BSI)

Septic pulmonary emboliSeptic pulmonary emboli

Metastasis infectionMetastasis infection– Acute endocarditisAcute endocarditis– OsteomyelitisOsteomyelitis– Septic arthritisSeptic arthritis

Shock and organ failureShock and organ failure

Poor outcome: Poor outcome: Staph.aureusStaph.aureus or or CandidaCandida..04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 1111

Incidence of CR-BSIIncidence of CR-BSIType of catheter Type of catheter

Teflon or Polyurethane ( < infections) Teflon or Polyurethane ( < infections) vsvs Polyvinyl chloride or Polyvinyl chloride or PolyethylenePolyethylene

Site of insertionSite of insertion Subclavian (< infections) Subclavian (< infections) vsvs Internal Jugular & Femoral Internal Jugular & Femoral (high risk of colonization & deep venous thrombosis)(high risk of colonization & deep venous thrombosis)

No. of LumenNo. of LumenSingle-lumen catheter (< infections) Single-lumen catheter (< infections) vsvs Multi-lumen Multi-lumencathetercatheter


Intrinsic contamination of infusion fluid

Connection with administration set

Insertion site

Injection portsAdministration set

connection with IV catheter

Port for additives

Sources of Sources of InfectionInfection


Intralumunal SpreadContaminated infusate (fluid, medication)

2. Intraluminal SpreadContaminated infusate (fluid, medication)

1. Extraluminal SpreadPatient’s own skin micro floraMicroorganism transferred by the hands of Health Care WorkerContaminated entry port, catheter tip prior or during insertionContaminated disinfectant solutionsInvading wound

3. Haematogenous SpreadInfection from distant focus

Fibrin

Skin

Vein

Skin attachment

Sources of Sources of InfectionInfection


Prevention of CR-BSIPrevention of CR-BSIWritten ProtocolWritten Protocol

Must be performed by Must be performed by trained stafftrained staff according to according to written guidelineswritten guidelines

Sterile procedureSterile procedureSterile gown, Sterile gloves, Sterile large drapesSterile gown, Sterile gloves, Sterile large drapesDon't shave the siteDon't shave the site

Hand disinfectionHand disinfectionWith an antiseptic solution egWith an antiseptic solution eg Chlorhlexidine gluconate Chlorhlexidine gluconate


Prevention of CR-BSIPrevention of CR-BSI

Skin antisepsisSkin antisepsis2% Chlorhlexidine gluconate has shown 2% Chlorhlexidine gluconate has shown totohave lower BSI than 10% Povidone-iodine have lower BSI than 10% Povidone-iodine or 70 % Alcohol or 70 % Alcohol 2-min drying time before insertion2-min drying time before insertionChlorhlexidine gluconate Chlorhlexidine gluconate oror 10% Povidone- 10% Povidone-

iodineiodine



DressingDressing

Gauze dressings every 2 daysGauze dressings every 2 daysTransparent dressing every 7 days on short term catheterTransparent dressing every 7 days on short term catheter

Replace dressing when catheter is replaced Replace dressing when catheter is replaced or or dressing dressing becomes damp or loose.becomes damp or loose.



CathetersCatheters removalremovalDon’t replace it routinelyDon’t replace it routinelyReplace it if:Replace it if:– Inserted in an Emergency Inserted in an Emergency – Non functioningNon functioning– Evidence of local Evidence of local oror systemic infection systemic infection

General handlingGeneral handlingOpening of hubOpening of hub: : Use antiseptic-impregnated pads eg Use antiseptic-impregnated pads eg Chlorhexidine gluconate Chlorhexidine gluconate oror povidone iodine povidone iodine



Administration setsAdministration sets

Replacement at 72-h intervalsReplacement at 72-h intervalsNo difference in phlebitis if left for 96 hoursNo difference in phlebitis if left for 96 hoursLines for lipid emulsion: replacement at Lines for lipid emulsion: replacement at 24-h intervals24-h intervalsLines for blood product : remove Lines for blood product : remove immediately after useimmediately after use



Topical antibiotic Topical antibiotic Prophylactic use of topical Mupirocin Prophylactic use of topical Mupirocin (Bactroban)(Bactroban) at insertion site at insertion site oror in nose is in nose is not not recommendedrecommended – Rapid development of Mupirocin resistantRapid development of Mupirocin resistant– Mupirocin affect the integrity of Polyurethane catheterMupirocin affect the integrity of Polyurethane catheter

Systemic antibioticSystemic antibioticProphylactic use of antibiotic is Prophylactic use of antibiotic is notnot recommendedrecommended at the time of catheter insertion at the time of catheter insertion


Urinary CatheterizationUrinary Catheterization

External urethral meatus & External urethral meatus & urethraurethra

Pass catheter when bladder full for wash-out Pass catheter when bladder full for wash-out effect.effect.

Before catheterization prepare urinary meatus Before catheterization prepare urinary meatus with an antiseptic ( e.g. povidone iodine or 0.2% with an antiseptic ( e.g. povidone iodine or 0.2% chlorhexidine aqueous solution)chlorhexidine aqueous solution)

Inject single-use sterile lubricant gel (e.g. 1-2%) Inject single-use sterile lubricant gel (e.g. 1-2%) lignocaine into urethra and hold there for 3 lignocaine into urethra and hold there for 3 minutes before inserting catheter.minutes before inserting catheter.

Use sterile catheter.Use sterile catheter.

Use non-touch technique for insertionUse non-touch technique for insertion 04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 2222

Junction between catheter & Junction between catheter & drainage tubedrainage tube

Do not disconnect catheter unless Do not disconnect catheter unless absolutely necessary.absolutely necessary.

For urine specimen collection disinfect For urine specimen collection disinfect outside of catheter proximal to junction outside of catheter proximal to junction with drainage tube by applying alcoholic with drainage tube by applying alcoholic impregnated wipe and allow it to dry impregnated wipe and allow it to dry completely then aspirate urine with a completely then aspirate urine with a sterile needle and syringe.sterile needle and syringe.


Junction between drainage tube Junction between drainage tube & collection bag& collection bag

Keep bag below level of bladder. If it is Keep bag below level of bladder. If it is necessary to raise collection bag above necessary to raise collection bag above bladder level for a short period, drainage bladder level for a short period, drainage tube must be clamped temporarily.tube must be clamped temporarily.

Empty bag every 8 hours or earlier if full.Empty bag every 8 hours or earlier if full.

Do not hold bag upside down when Do not hold bag upside down when emptyingemptying


Tap at bottom of collection Tap at bottom of collection bagbag

Collection bag Collection bag mustmust never touch floor. never touch floor.

Always wash or disinfect hands (eg with Always wash or disinfect hands (eg with 70% alcohol) before and after opening tap.70% alcohol) before and after opening tap.

Use a separate disinfected jug to collect Use a separate disinfected jug to collect urine from each bag.urine from each bag.

Don't put disinfectant into urinary bag.Don't put disinfectant into urinary bag.


Intensive Care UnitIntensive Care Unit Nosocomial PneumoniaNosocomial Pneumonia

Risk factors for bacterial Risk factors for bacterial pneumoniapneumonia

Host FactorsHost Factors

ElderlyElderlySevere IllnessSevere IllnessUnderlying Lung DiseaseUnderlying Lung DiseaseDepressed Mental StatusDepressed Mental StatusImmunocompromisingImmunocompromisingConditions or TreatmentsConditions or TreatmentsViral Respiratory Tract Viral Respiratory Tract InfectionInfection04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 2727


ColonisationColonisationIntensive Care SettingIntensive Care SettingUse of Antimicrobial AgentsUse of Antimicrobial AgentsContaminated handsContaminated handsContaminated EquipmentContaminated Equipment



Factors that facilitate Factors that facilitate refluxreflux

& aspiration into the lower RT& aspiration into the lower RT

- - Mechanical ventilationMechanical ventilation- Tracheostomy- Tracheostomy

- Use of a Nasogastric Tube- Use of a Nasogastric Tube- Supine Position- Supine Position

Factors that impede normal Factors that impede normal Pulmonary ToiletPulmonary Toilet

- Abdominal or thoracic surgery- Abdominal or thoracic surgery- Immobilisation- Immobilisation


Prevention in ICUPrevention in ICUTurn patients to encourage postural Turn patients to encourage postural drainagedrainage

Encourage to take deep breaths and Encourage to take deep breaths and cough.cough.

Maintain an upright position (elevate Maintain an upright position (elevate patient’s head to 30º- 45º degree angle) to patient’s head to 30º- 45º degree angle) to reduce reflux and aspiration of gastric reduce reflux and aspiration of gastric bacteria.bacteria.


Gastric Ulcer ProphylaxisGastric Ulcer Prophylaxis

Stomach of a healthy person : Acidic pH (Stomach of a healthy person : Acidic pH () & ) & normal peristalsis movement prevent bacterial normal peristalsis movement prevent bacterial growthgrowth

Alkaline pH (Alkaline pH () and loss on normal ) and loss on normal peristalsisperistalsis lead to bacterial colonisation which increases the lead to bacterial colonisation which increases the risk of ventilator-associated pneumoniarisk of ventilator-associated pneumonia

Mechanical ventilation patients are at increased Mechanical ventilation patients are at increased risk for upper GI haemorrhage from stress ulcers.risk for upper GI haemorrhage from stress ulcers.

HH22 blockers or antacids are used to prevent blockers or antacids are used to prevent stress stress

ulcersulcers


Nasogastric TubeNasogastric TubeMay erode the mucosal surface May erode the mucosal surface

Block the sinus ducts Block the sinus ducts

Regurgitation of gastric contents leading to Regurgitation of gastric contents leading to aspiration. aspiration.

Verify placement of the feeding tube in the Verify placement of the feeding tube in the stomach or small intestine by X raystomach or small intestine by X ray

Elevate the head of the bed 30Elevate the head of the bed 30ºº- 45 - 45 ºº degrees degrees

Remove NG Tube if not necessaryRemove NG Tube if not necessary


VentilatorsVentilatorsAfter every patient, clean and disinfect After every patient, clean and disinfect (high-level) or sterilize re-usable (high-level) or sterilize re-usable components of the breathing system or the components of the breathing system or the patient circuit according to the patient circuit according to the manufacturer’s instructions.manufacturer’s instructions.


Suctioning mechanically Suctioning mechanically ventilated patientsventilated patients

Handwashing Handwashing before and after the before and after the procedure.procedure.

Wear Wear cleanclean gloves to prevent cross- gloves to prevent cross-contaminationcontamination

Use a sterile single-use catheter ; if it is not Use a sterile single-use catheter ; if it is not possible then rinse catheter with possible then rinse catheter with sterile sterile waterwater and store it in a dry, clean container and store it in a dry, clean container between uses and change the catheter between uses and change the catheter every 8 - 12 hours.every 8 - 12 hours.


Suction BottleSuction Bottle

Use single-use disposable, if possibleUse single-use disposable, if possible

Non-disposable bottles should be washed Non-disposable bottles should be washed with detergent and allowed to dry. Heatwith detergent and allowed to dry. Heat disinfect in washing machine or send to disinfect in washing machine or send to

Sterile Service Department. Sterile Service Department.


NebulizersNebulizersUse sterile medications and fluids for nebulizationUse sterile medications and fluids for nebulizationFill with sterile water only. Fill with sterile water only.

Change and reprocess device between patients by Change and reprocess device between patients by using sterilization or a high level disinfection using sterilization or a high level disinfection oror use use single-use disposable item. single-use disposable item.

Small hand held nebulizersSmall hand held nebulizers– minimise unnecessary useminimise unnecessary use– between uses for the same patient disinfect, rinse between uses for the same patient disinfect, rinse

with sterile water, or air dry and store in a clean, dry with sterile water, or air dry and store in a clean, dry placeplace

Reprocess nebulizers dailyReprocess nebulizers daily04/21/2304/21/23 dr yrkefallah-phd of nursing-2015dr yrkefallah-phd of nursing-2015 3636

HumidifiersHumidifiers

Clean and sterilize device between Clean and sterilize device between patients.patients.

Fill with sterile water which must be Fill with sterile water which must be changed every 24 hours or sooner, if changed every 24 hours or sooner, if necessary. necessary.

Single-use disposable humidifiers are Single-use disposable humidifiers are available but they are expensive.available but they are expensive.


Oxygen maskOxygen mask

Change oxygen mask and Change oxygen mask and tubing between patients and tubing between patients and more frequently if soiledmore frequently if soiled


Antibiotics useAntibiotics use

Must avoid widespread Must avoid widespread use of use of

broad spectrum broad spectrum antibiotics antibiotics


Problem-DetectionProblem-Detection in in the ICU’sthe ICU’s

Examples illustrating difficult to Examples illustrating difficult to detect infections: detect infections:

Long Incubation periodLong Incubation period

• Hard to detect HIV, Hep B or Hep C due to Hard to detect HIV, Hep B or Hep C due to long incubation periodlong incubation period

• Easier to detect Staph aureus food borne Easier to detect Staph aureus food borne illness, or toxic shock due to re-use of illness, or toxic shock due to re-use of medication vial. medication vial.

• These infections occur 1 hr to days post These infections occur 1 hr to days post event. event.


Examples of difficult to detect Examples of difficult to detect infections: infections:

Uncultivable organismsUncultivable organismsViruses are under appreciated as causes of Viruses are under appreciated as causes of

nosocomial infections. Except in cases of high nosocomial infections. Except in cases of high morbidity viral cultures are not done in resource morbidity viral cultures are not done in resource scarce settings. Impact food-borne, respiratory, scarce settings. Impact food-borne, respiratory, water borne illnesses. water borne illnesses.

We don’t know the spectrum of anti-microbial We don’t know the spectrum of anti-microbial activity of most preservatives and cleaners for activity of most preservatives and cleaners for many viruses. many viruses.


Define the problem to trackedDefine the problem to tracked

Advantages:Advantages:

– The occurrence then can be compared in The occurrence then can be compared in different facilities and in different time periodsdifferent facilities and in different time periods

– Definitions can be suspect, probable orDefinitions can be suspect, probable or– confirmed depending upon the information confirmed depending upon the information

that is available that is available


Examples from the NNIS Examples from the NNIS Manual Manual

Symptomatic Urinary Tract Infection:Symptomatic Urinary Tract Infection:– Patient must have one of the two criteria:Patient must have one of the two criteria:

Fever >38 C OR urgency OR frequency OR Fever >38 C OR urgency OR frequency OR dysuria OR suprapubic tenderness without dysuria OR suprapubic tenderness without other cause other cause

ORORUrine culture with at least 10Urine culture with at least 105 5 organisms per organisms per ml or no more than two species of organismsml or no more than two species of organisms


Definition of surgical site Definition of surgical site infection (no implant)infection (no implant)

Occurs within 30 days of surgeryOccurs within 30 days of surgery

AND has one of the following:AND has one of the following:

Purulent drainage from drain ORPurulent drainage from drain OR

Organism isolated from aseptically Organism isolated from aseptically obtained fluid in the organ spaceobtained fluid in the organ space


Example of lab-confirmed Example of lab-confirmed blood stream infectionblood stream infection

Patient has a recognized pathogen cultured from Patient has a recognized pathogen cultured from one or more blood culturesone or more blood cultures

ANDAND

Organism cultured is not related to another Organism cultured is not related to another infection at another site infection at another site


Prior to starting any Prior to starting any surveillancesurveillance

Agree upon a written case definition that is Agree upon a written case definition that is practical given the laboratory facilities and practical given the laboratory facilities and patient work load in your facility. patient work load in your facility.


intensive care unit infections. icu patients sickest patients (multiple diagnoses, multi-organ...

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