ICU INFECTIONS

BASIS, DIAGNOSIS, AND PREVENTION

Dr.T.V.Rao MD

DR.T.V.RAO MD 1
 DEFINITIONS
NOSOCOMIAL INFECTION :
An infection acquired in a patient in a
hospital or other healthcare facility in
whom it was not present or incubating
at the time of admission or the residual
of an infection acquired during a
previous admission.

DR.T.V.RAO MD 2
 BACKGROUND OF
HOSPITAL INFECTIONS
Nosocomial infections
have been recognized
for over a century as a
critical problem
affecting the quality of
health care and a
principal source of
adverse healthcare
outcomes.

DR.T.V.RAO MD 3
 RISK OF INFECTIONS IN ICU
Patients hospitalized in ICUs are 5 to 10 times
more likely to acquire nosocomial infections
than other hospital patients. The frequency of
infections at different anatomic sites and the risk of
infection vary by the type of ICU, and the frequency
of specific pathogens varies by infection site.
Contributing to the seriousness of nosocomial
infections, especially in ICUs, is the increasing
incidence of infections caused by antibiotic-
resistant pathogens
DR.T.V.RAO MD 4
 WHY ONE MAY BE IN ICU
WITH
5

And why do they come to the ICU

Ventilator support respiratory failure pneumonia

Hemodynamic support shock

Renal replacement therapy renal failure, severe acidosis

Monitoring, Neurological dysfunction, Hematologic

DR.T.V.RAO MD
 ICU : FACTORS THAT INCREASE CROSS-
INFECTIONS
Lack of Hand washing facilities
Patient 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

DR.T.V.RAO MD 6
 NOSOCOMIAL FEVERS
Hospital-acquired
fevers occur in
one-third of all
medical inpatients
Nosocomial fevers
even more
common in the
ICU
DR.T.V.RAO MD 7
 INFECTIOUS CAUSES OF
FEVER WHILST IN ICU
Ventilator associated
pneumonia
Catheter related blood
stream infections
Urosepsis
Intra-abdominal infections
Sinus infections
Diarrhoea

DR.T.V.RAO MD 8
 FEVER IN THE ICU
ICU patients have several underlying
medical/surgical conditions
ICU patients undergo many invasive diagnostic and
therapeutic procedures
Therefore, fever in ICU patients must be thoroughly
and promptly evaluated to discriminate infectious
from non-infectious etiologies

DR.T.V.RAO MD
9
 CAUSES OF FEVER IN THE ICU
Surgical site infections Urinary catheter-
Intravenous-line associated
infections bacteriuria
Nosocomial pneumonia
Drug fever
Nosocomial sinusitis
Intraabdominal
Post-operative fever
infections Neurosurgical
causes
DR.T.V.RAO MD
10
 THE OBVIOUS FOCUS
Community acquired pneumonia
Acute CNS infection
Urinary tract infection
Abdominal focus of infection
Wound infection / Pus collections
Trauma with infection

DR.T.V.RAO MD 11
 DEVICE RELATED NOSOCOMIAL INFECTION

A device-associated infection is an infection in a

patient with a device (i.e., central line, ventilator, or
indwelling urinary catheter) that was in use within
the 48-hour period before onset of infection. If the
interval since discontinuation of the device is
longer than 48 hours, there must be compelling
evidence that infection was associated with device
use.
DR.T.V.RAO MD 12
 ICU PATIENTS DIFFERS FROM MANY PATIENTS
PAY MORE ATTENTION

Sickest patients (multiple diagnoses, multi-

organ failure, immunocompromised, septic
and trauma)
Move less
Malnourished
More obtunded (Glasgow coma scale)
Diabetics and Heart failure
DR.T.V.RAO MD 13
 INFECTIOUS CAUSES OF
FEVER WHILST IN ICU
Ventilator associated
pneumonia
Catheter related blood
stream infections
Urosepsis
Intra-abdominal
infections
Sinus infections
Diarrhoea

DR.T.V.RAO MD 14
 PATIENT PRESENTING TO ICU
WITH FEVER

Patient with an Acute un-differentiated

obvious focus of
infection fever

Where is the focus? What is causing this

fever?

DR.T.V.RAO MD 15
 RISK FACTORS
operative surgery
intravascular and urinary catheterization
mechanical ventilation of the respiratory tract
Other risk factors include traumatic injuries,
burns, age (elderly or neonates), immuno-
suppression and existing disease

DR.T.V.RAO MD 16
 ICU CARE IS MORE INVASIVE
More invasive life lines
and procedures
including surgeries
Longer length of stay
More IV and parenteral
drugs
More tube feeding and
Parenteral nutrition
More ventilation
DR.T.V.RAO MD 17
 FACTORS INFLUENCING INCREASED
INFECTIONS IN ICU
Hand washing facilities
Patient 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 & equipments
Inadequate cleaning of environment

DR.T.V.RAO MD 18
 THE INANIMATE ENVIRONMENT IS A
RESERVOIR OF PATHOGENS

X represents a positive Enterococcus culture

The pathogens are ubiquitous

~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient
Environment. Hayden M, ICAAC, 2001, Chicago, IL.
 SOME HEALTH-CARE ASSOCIATED
INFECTIONS
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
DR.T.V.RAO MD 20
 MANAGING FEVER IN ICU PATIENTS
Fever in the ICU can have many infectious and
noninfectious etiologies
Crucial to identify the precise cause as some of the
conditions in each groups are life-threatening, while others
require no treatment
Routine fever work-up not cost-effective
If initial evaluation shows no infection, antibiotics should
be withheld
Empiric antibiotics may be started in the unstable patient,
but stopped if infection is not evident later
DR.T.V.RAO MD
21
 DEVICE RELATED NOSOCOMIAL INFECTION
A device-associated infection is an infection in a
patient with a device (i.e., central line, ventilator, or
indwelling urinary catheter) that was in use within
the 48-hour period before onset of infection. If the
interval since discontinuation of the device is
longer than 48 hours, there must be compelling
evidence that infection was associated with device
use.

DR.T.V.RAO MD 22
 Sources of Infection
Intrinsic contamination of
infusion fluid

Port for
additives Connection with administration set
Insertion site
Injection ports
Administration set connection
with IV catheter

DR.T.V.RAO MD 23
 1. Extra luminal Spread
Patients own skin micro flora Sources of
Infection
Microorganism transferred by the
hands of Health Care Worker
Contaminated entry port, catheter tip 2. IntraluminalSpread
Intralumunal Spread
prior or during insertion Contaminated
Contaminatedinfusate
infusate
Contaminated disinfectant solutions (fluid,
(fluid,medication)
medication)
Invading wound

Skin attachment

Skin
Fibrin Vein

3. Haematogenous Spread
Infection from distant focus
DR.T.V.RAO MD 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

DR.T.V.RAO MD 25
 FUNGI TOO INFECTIVE IN
ICU PATIENTS

DR.T.V.RAO MD 26
 RISK FACTORS FOR
ASPERGILLOSIS

Neutropenia
steroids
Environmental
exposure
Building work
Compost heaps
Marijuana smoking
DR.T.V.RAO MD 27
 INVASIVE ASPERGILLOSIS
incidence increasing
commonest cause of
infectious death in
many transplant
units
commonest cause of
death in childhood
leukaemia

DR.T.V.RAO MD 28
 PROTECTED ENVIRONMENT
HEPA (for allogeneic HSCT patients only)
99.97% of all particles >3u diam)
>/=12 ACH
Pressure differential >2 Pa
Directed air flow
Sealed rooms
Respiratory protection (N95 respirator) if leaving room only during periods of
building construction
Standard hygiene barrier precautions
No flowers, potted plants, carpets
Vacuums to have HEPA filters
HICPAC guidelines CDC 2004

DR.T.V.RAO MD 29
 BASIC POLICIES IN MICROBIOLOGICAL
DIAGNOSIS OF ICU INFECTIONS

DR.T.V.RAO MD 30
 CRITERIA FOR DIAGNOSIS
fever.
cough.
development of purulent sputum, in conjunction
with radiologic evidence of a new or progressive
pulmonary infiltrate.
a suggestive Gram stain, and positive cultures
of sputum, tracheal aspirate, pleural fluid, or
blood.
DR.T.V.RAO MD 31
DR.T.V.RAO MD 32
 HOW TO DIAGNOSE?
A positive result of semi quantitative Culture ( 15 CFU per
catheter segment) Maki D, et al NEJM 1977;296:1305 or
quantitative ( 102 CFU per catheter segment) catheter culture, whereby
the same organism isolated from a catheter segment and a peripheral
blood sample
Simultaneous quantitative cultures of blood samples with a
ratio of 5 : 1 (CVC vs. peripheral)
Differential time to positivity :positive result of culture from a
CVC is obtained at least 2 hr earlier than is a positive result of
culture from peripheral blood)

DR.T.V.RAO MD 33
 REMEMBER.
If You put a central line in a
patient with documented
Bacteremia, then later next
day somebody may obtain a
blood culture from both the
central lien and from
periphery, >>>>>>> a
positive blood culture from
both sites, does not mean
that the central lien is the
source.

DR.T.V.RAO MD 34
 DEALING WITH STAPHYLOCOCCUS AUREUS
REMOVE the central line .
Systemic antibiotics for minimal 14 days.
Failure to clear bacteremia within 72 hours Or
patient with high risk for endovascular infection
or having prosthesis may be indicative for longer
3-6 weeks of treatment.
TTE or TEE are strongly advised.
Blood Culture should be repeated during
therapy and1-2 weeks after completion of
therapy, looking for relapses.
 COAGULASE NEGATIVE STAPHYLOCOCCI

CVC can be retained, if necessary, in patients with

uncomplicated, catheter-related, bloodstream
infection.
If the CVC is retained, patients should be treated
with systemic antibiotic therapy for 7 days.
Treatment failure is a clear indication for removal of
the catheter .
 A RANDOMIZED AND PROSPECTIVE STUDY OF 3 PROCEDURES FOR THE
DIAGNOSIS OF CATHETER-RELATED BLOODSTREAM INFECTION WITHOUT
CATHETER WITHDRAWAL CID MARCH 2007

Conclusions. CR-BSI can be assessed

without catheter withdrawal in patients without
neutropenia or blood disorders who have catheters
inserted for a short time and are hospitalized in the
intensive care unit. Because of ease of
performance, low cost, and wide availability, we
recommend combining semi quantitative
superficial cultures and peripheral vein blood
cultures to screen for CR-BSI, leaving differential
quantitative blood cultures as a confirmatory and
more specific technique.

DR.T.V.RAO MD 37
 DO NOT TREAT COLONIZED CENTRAL LINES
GET GUIDED BY MICROBIOLOGY REPORTS
A central line is
removed and it is
growing less than 15
CFU.
Patient is not septic and
blood Culture is
negative.
>>> No indication to
treat the infected or
colonized central line.
DR.T.V.RAO MD 38
 PROBLEMS WITH AIR SAMPLING
HAS LIMITATIONS ???
Incubation period of IPA
unknown
Estimates vary from 48
hours -3 months
Geographical and seasonal
variation in spore counts
and predominant species
Variable efficiency of
different air samplers
May not take account of
surface contamination
Settle plates, contact plates,
honey jars
 NEW FRONTIERS ON INCREASING
ICU INFECTIONS
Emphasis on patient safety
Move from inpatient to outpatient environment
Increase in population age
Persons >65yo numbered 36 million in 2004
and by 2030 there will be 72 million
Increase in antimicrobial resistance (e.g.,
MRSA)

DR.T.V.RAO MD 40
 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

DR.T.V.RAO MD 41
 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

DR.T.V.RAO MD 42
 INFECTION CONTROL MEASURES

1 Identify reservoir Colonized and infected

patients Environnemental contamination;
Common sources
2. Halt transmission among patient Improve
hand washing and asepsis Barrier precautions
(gloves, gown) for colonized and infected
Patients Eliminate any common source;
disinfect environment Separate susceptible
patients Close unit to new admissions if
necessary
DR.T.V.RAO MD 43
 INFECTION CONTROL MEASURES

3. Halt progression from colonization to infection

Discontinue compromising factors when possible
(eg, extubate, remove nasogastric tube,
discontinue bladder catheters, as clinically
indicated; rotate IV catheter sites; proper
ventilator and pulmonary care)
4. Modify host factors Treat underlying disease
and complications Control antibiotic use (rotate,
restrict, or cease)
DR.T.V.RAO MD 44
 TRADITIONAL ICP ACTIVITIES

Surveillance
Outbreak investigations
Policy development and implementation
Environmental/infection control rounds
Education (infection control, blood borne
pathogen, TB)
Regulatory compliance
Committee participation
DR.T.V.RAO MD 45
 NEW ICP RESPONSIBILITIES
Increased regulations (OSHA, FDA)
Emerging pathogens (avian influenza)
IHI campaign
Increase training/education requirements
Post-exposure prophylaxis (HIV, HBV)
Epidemiologic typing of outbreak pathogens
Interpreting screening cultures (MRSA, VRE)
Risk adjusted surveillance (SSI, CR-BSI, VAP)
Sentinel event analysis
DR.T.V.RAO MD 46
 CONCLUSIONS :
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

DR.T.V.RAO MD 47
 GROWING CONCERNS WITH INFECTIONS IN
ICU

Nosocomial infections, especially those caused by

antibiotic-resistant pathogens, represent an important
source of morbidity and mortality for the patient
hospitalized in an ICU. Important antibiotic-resistant
nosocomial pathogens include MRSA, VRE, Gram-
negative bacilli (especially, Klebsiella and Enterobacter)
producing extended-spectrum b-lactamases, multiple
drug-resistant M tuberculosis, and fluconazole-resistant
Candida sp.

DR.T.V.RAO MD 48
 CAN WE CONTROL ICU INFECTIONS
The key to control of antibiotic-resistant pathogens in
the ICU is rigorous adherence to infection control
guidelines and prevention of antibiotic misuse.
Antibiotic restriction policies clearly result in reduced
drug costs. Evidence suggests that reducing use of
certain antibiotics may lead to a decreased prevalence
of antibiotic-resistant pathogens: vancomycin, VRE;
gentamicin, gentamicin-resistant Gram-negative bacilli;
and, ceftazidime, Gram-negative

DR.T.V.RAO MD 49
 WISH WIN THE PROBLEM
FACE THE CHALLENGES

Increase infection control resources are a win-win-win

investment
Reduced patient morbidity and mortality
Net cost savings to institution, society and patient
Improve patient satisfaction
From the standpoint of the hospital and society, the benefits
exceed the costs
Hospitals should support a ratio of ICP per beds of 1:150

DR.T.V.RAO MD 50
 MICROBES ON SKIN PLAY A MAJOR ROLE
SKIN DISINFECTION A MAJOR PREVENTIVE
MEASURE
The major cause of
infection during the
first weeks of
indwelling time is from
skin microorganisms.
Rannem, et. al., 1990
Maki, et. al., 1991
Maki (review), 1994
Widmer (review),
1997
 USING CHLORHEXIDINE 0.5% FOR
SKIN DISINFECTION
A meta-analysis
determined that
chlorhexidine gluconate
significantly reduces the
incidence of bacteremia
in patients with central
venous catheters
compared to povidone-
iodine for insertion-site
skin disinfection.
Chaiyakunapruk et al. Chlorhexidine compared with
povidone-iodine solution for vascular catheter-site
care: A meta-analysis. Ann Intern Med. 2002;136:792 .
 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 before puncturing
the site (~ 2 minutes).
ALCOHOL BASED HAND SANITIZERS
Recommended by CDC
based
on strong experimental,
clinical, epidemiologic and
microbiologic data
Antimicrobial superiority
Greater microbicidal
effect
Prolonged residual
effect
Ease of use and application
AN INTERVENTION TO DECREASE CATHETER-RELATED BLOODSTREAM INFECTIONS IN
THE ICU.

N ENGL J MED PRONOVOST P, ET AL: 355(26):2725-2732, 2006

(1) hand washing,

(2) use of full-barrier precautions during placement
of catheters,
(3) cleansing of the skin with chlorhexidine,
(4) use of sites other than the femoral vein when
possible,
(5) removal of catheters that were no longer needed.
The analysis included almost 2000 ICU-months and
>375,750 catheter-days of data.
 WARNING
Nosocomial Infections in ICU are Waiting

DR.T.V.RAO MD 56
 BE KIND TO YOUR PATIENTS
REMEMBER ONE THING

PLEASE WASH YOUR

HANDS
 Programme created by Dr.T.V.Rao MD for
Health care Workers in the Developing world
Email
doctortvrao@gmail.com

DR.T.V.RAO MD 58