1. 1
VISHAL 1-12-2012

2. Modes of transmission of
nosocomial infections
Common ICU infections
 Evidence based prevention
strategies
2

3. 3
Pittet et al 2006
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4. 4

5.  Skin and oral cavity of patients colonized in hours to days
Staph. aureus, Proteus mirabilis, Klebsiella spp.
Acinetobacter, Enterococci present @102
-106
CFU /cm2
skin
 Perineal/inguinal > axilla > trunk > upper limbs and hands
 Patients on hemodialysis , diabetes, dermatitis, broad
spectrum antibiotics are at increased risk
 10 skin squames containing viable microorganisms are shed⁶
daily, objects in the immediate environment of the patient
become contaminated with patient flora acting as fomites
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6. 6

7. 7
Panhotra Am J Infect Control 2005

8. 8
Pittet et al 2006
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9. 9

10.  “Clean Activities” like clinical examination,
lifting or bed making
Up to 102
-104
CFU from HCWs hands
Phillips, BMJ 1977
 HCWs intercepted after handling MRSA
colonized patient but before hand wash
17% of worker’s gloves positive
McBride, J Hosp Inf
2004
10

11.  Surveillance cultures of HCWs hands in ICU
21% of MDs; 5% of nurses positive
Daschner, J Hosp Inf 1988
 Serial Cultures of SICU HCWs hands
100% positive for GNB and 64% positive for Staph aureus at
least once
Maki, Ann Int Med 1978
 Rings, artificial or long nails, dermatitis increase
frequency of hand contamination of HCWs
Trick, Clin Inf Dis 2003 11

12. 12
Zachary, Inf Control Hosp Epidem. 2001
Site Percentage positive for
organism
Gloves / Hands 63
Gowns 37
Stethoscopes 31
Stethoscope after wipe 2

13. 13Pittet, Arch Int Med 1999

14. 14
Pittet et al 2006
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15. 15
Microbe Mean survival time (min)
Klebsiella spp 2
E. coli 6
Rotavirus 20
Pseudomonas spp 30
Acinetobacter spp 60
VRE 60

16. 16
Pittet et al 2006
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17. 17
- Pittet D et al. Ann Intern Med 1999
HCW Compliance OR
Nurse 52% 1
Respiratory therapist
nursing attendants
47% 1.28
Others 38% 2.15
Physicians 30% 2.80
48 % - Witterick, Crit Care Med 2008

18. 18
Pittet et al 2006
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19. 19

20.  Respiratory Tract Infections (RTI)
 Blood Stream Infections (BSI)
 Intraabdominal & Urosepsis (UTI)
 Skin & Soft Tissue Infections (SSTI)
20

21.  Advanced age
 Associated co-morbidities
 Increased severity of disease (APACHE score)
 Prolonged ICU stay
 Interinstitutional transfer
 Use of invasive medical/ surgical devices
 Irrational use , use of broad spectrum Abx
 Poor nutrition < 6 cal/kg / day
21

22.  Nosocomial Pneumonias – HCAP, HAP, VAP
 Nosocomial Maxillary Sinusitis
Nosocomial Pneumonia
 HCAP – Health care associated Pneumonia
 Hospitalised > 2 days within 90 days of RTI , or
 Received parenteral therapy within 30 days, or
 Received treatment in long term care facility
22

23.  HAP - Hospital acquired pneumonia
had Pneumonia > 48 hrs after hospitalisation and not
incubating
 VAP – Ventilator Acquired/ Ventilation
Associated Pneumonia
Pneumonia post 48 hrs of endotracheal intubation
Early- < 4 days
Late - > 4 days
23

24.  1 out of four who get intubated develop VAP
 Mortality ranges from 30- 70 %
 Causes –
a) Normal oropharyngeal flora changes due to loss
of fibronectin due to airway
( Bacteroides -> endogenous GNB)
b) Spread from contigous sites
c) Blood stream infection
Higher mortality seen with late VAP + Oropharyngeal
secretions
Valles , Int Care Med - 2007 24

25.  New or worsening CXR infiltrates +
 One or more of following-
a) Change in secretions character
b) Positive growth from specimen culture
 Protected brush culture > 103
CFU/ ml
 BAL > 104
CFU/ ml
 ETA > 105
CFU/ ml
c) Rise in antibody titres (IgM or IgG fourfold)
d) Histological evidence
Specific Objective Scoring scale - CPIS score >6
Procalcitonin > 0.5 ng/ml (PPV – 69-79% in VAP)
25

26. 26
2003
Category IA. - Strongly recommended , supported by well
designed experimental, clinical, or epidemiologic studies.
Category IB. - Strongly recommended , supported by some
clinical or epidemiologic studies and by strong
theoretical rationale.
Category IC. - Required for implementation, as mandated by
federal or state regulation or standard.
Category II. - Suggested for implementation , supported by
suggestive clinical or epidemiologic studies or by
strong theoretical rationale.

27.  Several revisions have been done following these 2003
guidelines.
 CDC – MMWR (Morbidity & Mortality Weekly Report)
- 2004
 Coffin SE, strategies to prevent VAP in ICU
- Infec Control Hosp Epidem -2008
 Majority of recommendations of 2003 are still valid.
27

28.  Staff Education and involvement - I A
 Infection and Microbiologic Surveillance
 at risk critically ill patients - IB
 all ICU patients not recommended - II
 Sterilization of Equipment and Devices
 Cleaning before sterilisation - IA
 Autoclaving - IA
 Use sterile water for rinsing post chemical
sterilisation, if not then filter tap water f/b drying - IB
28

29. Tubings and accessories
 Do not routinely sterilize or disinfect the internal
machinery of mechanical ventilators - IA
 Periodically drain out condensate fluid in tubings,
donning gloves - IB
 Dont routinely change tubings unless visibly soiled - IA
 Filter at expiratory phase of tubing - Unresolved
 Humidifiers fluid – only distilled water - IA
29

30.  HME usage vs Heated humidifier - Unresolved
HME have higher incidence of VAP than heated
humidifiers (39.6% vs 15.7%)
- Lorente, Critical care Forum 2006
 Nebulisation
 Single use aerosol / MDI - IB
 With solution in nebuliser chamber - IC
 Can reuse bains circuit, AMBU, Traheal or face mask,
Venturimeters or reservoir bags, Tpiece - IB
 after autoclaving
30

31.  Hand hygiene before & after handling patient-IA
 Hand wash with soap and water if dirty or
 Alcohol rub if clean
Wear gloves and gown - IB
Suctioning of ET/ TT secretions
 Multiuse closed-system suction catheter or the
single-use open system suction catheter
- Unresolved
No difference found in either usage
- Magiorre, Intensive Care Med- 2006
- Jongerden , Crit Care Med - 2007
31

32.  Using sterile or clean gloves for suction
– Unresolved
 Single use catheter for open system - II
 Sterile fluid for irrigation - II
 Use of isotonic saline instillation before tracheal
suctioning (ISIBTS - 8ml) in closed suctioning
system is better than plain suctioning
- Caruso, Crit Care Med -2009
10.8% vs 23.5% VAP rates
Thins out & increase secretion, increase cough
Reduces ET Biofilm 32

33.  Prevention of aspiration
 Use NIV if possible to avoid intubation - II
 Extubate to NIV - II
 Avoid repeated intubations - II
 Oral preferred to nasotracheal - IB
 Subglottic aspiration of secretions - II
Continous better than intermittent
- Bouza, Chest – 2008
Reduced VAP rates- (26.7 % vs 47.5%)
Reduced Mortality - ( 44.4% Vs 52.5%)
33

34.  Supraglottic suction before extubation,reintubation – II
 Type of ET tube
 HVLP with ultrathin (7 µm) polyurethrane cuff
membrane better
 Antimicrobial coated ET tubes preferred
NASCENT trial – North American Silver Coated ET study
– Berra , Intensive Care Med -2008
35.9% Relative risk reduction to develop VAP
Reduced mortality in patients with VAP –14 % vs 36%
34

35.  Prevention of aspiration associated with feeding
 30-45 degree head end elevation - II
(5 % vs 23 % in supine) – Drakulovik, Lancet 1999
 Continous vs intermittent NG feeds - unresolved
 NG vs NJ feeds - unresolved
But latter a/w reduced incidence of late pneumonia in
TBI patients - Acosta , Intensive Care Med- 2010
 Routine verification of placement Radiologically +
35

36.  Selective Oral Decontamination (SOD) – II
Method for SOD(topical Abx, Chlorhex) - Unresolved
 Selective Digestive tract Decontamination (SDD)
- Unresolved
SDD though reduced the incidence of MODS in
critically ill ventilated pts,it did not reduce overall mortality.
(systematic review of RCTs) - Silvestri,Int care Med
2010
 DOC for prevention of SRMB – Unresolved
36

37.  Physiotherapy & mobilisation
 Early ambulation, incentive spirometry - IB
 Chest physiotherapy routinely - Unresolved
Contradictory evidences
 Increased mortality in patients on ventilator for > 48 hrs
- Templeton, Int Care Med , 2007
 Reduced mortality (49 vs 24% )and CPIS score
- Pattanshetty, Ind J Crit Care Med, 2010
 Kinetic therapy or continous lateral rotation 37

38. Continous lateral rotation was found to have
reduced incidence of VAP - Staudinger, CCM 2010
 Antibiotic prophylaxis, Empirical treatment of VAP
- Unresolved
 Pneumococcal vaccination for high risk groups – IB
Nasomaxillary sinusitis
Avoid nasotracheal intubation
Semirecumbent position
Xylometazoline + budesonide appplication
Hand hygiene
38

39.  Primary – no identifiable focus
 Secondary – related to infection at other site
 CRBSI / CLABSI - Catheter Related or Central
Line Associated BSI
 Infective endocarditis related BSI
CRBSI diagnostic criteria
 High clinical suspicion
 Positive bloood cultures- 2 peripheral or
1 peripheral + 1 central
 Colony count 3- 10 times in central than peripheral with
central culture positivity > 2 hrs before peripheral
Defervescence after removel of CVC line
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40. 40
2011
Educate healthcare personnel regarding - IA
1) Indications for intravascular catheter use,
2) Proper procedures for the insertion and
maintenance of intravascular catheters,
3)Infection control measures to prevent CRBSI
Only trained personell to do insertion - IA
Maintain 1:1 or 1:2 ratio of nurses to patient - IB

41. Peripheral catheters
 PICC line if duration of iv treatment is anticipated to
be > 6 days - II
 Upper limb access better than lower - II
 Daily examination for signs of phlebitis - IB
 Removal the moment early features seen or
malfunction noticed or catheter not needed - IB
41

42. Central line / Cental venous catheter
 Evaluate infective complication more over
mechanical one before selecting site - IA
 Avoid femoral in adults - IB
 Subclavian preferred over jugular in non tunneled
catheres except in CKD where otherwise - IB
 Subclavian or jugular in tunneled one -Unresolved
 Ultrasound guided - IB
42

43.  Minimum number of ports possible – IA
 Use of a designated lumen for TPN - Unresolved
 When adherence to stict asepsis during insertion
doubtful,(e.g casualty, emergency) remove within 48
hrs - IB
 Remove CVC when not required - IA
43

44. Hand hygiene and aseptic technique
 Hand wash (soap/ABHR – Alcohol Based Hand Rub)
before and after inserting lines - IB
 clean gloves for peripheral catheters - IC
 Sterile gloves for arterial and cental lines -IA
 New sterile gloves before handling the new catheter
when guidewire exchanges are performed. - II
 Clean or sterile while changing dressing - IC
 44

45.  Cap , face mask, sterile gown and gloves,
sterile ultrasound probe cover during
 insertion,
 adjustment or
 guidewire exchange of PICC and CVC - IB
 Skin preparation
 Peripheral line – any antiseptic - IB
 Central line - > 0.5 chlorhex in alcohol base - IA
 Chlorhexidine vs betadine - Unresolved
45

46. Catheter site dressing regimen
 Sterile gauze or sterile , transparent , semipermeable
dressing at insertion site - IA
 Active oozing, sweating – use gauze - II
 Replace if wet, soiled or loose -IB
 No topical antibiotic ointments except for dialysis
catheters - IB
Avoid contact with water during sponging - IB
46

47.  Gauze dressing change after 2 days - II
 Transparent one after 7 days - IB
 Regularly examine the insertion site - IB
 Through dressing
 While changing dressing
 Permit removal of dressing for evaluation of site if
high index of suspicion of CRBSI - IB
47

48.  2% chlorhex daily body wash - II
 Antimicrobial (minocycline / rifampicin) or
antiseptic (chlorhex/ silver sulfadiazine ) impregnated
CVC can be used in pts needing CVC > 5 days if
only combined with so called
“COMPREHENSIVE STRATEGY”
 Educating HCW handling lines
 Strict aseptic measures as mentioned before
 > 0.5 % chlorhex with alcohol for skin preparation
- IA
48

49.  No systemic prophylactic antibiotics - IB
 Povidone , polymixin, bacitracin ointment at the free
tip of dialysis cath after dialysis - IB
 Antibiotic lock or antibiotic flush - II
 Replacement of catheters
Peripheral - only when indicated - IB
CVC / PICC - only when indicated - IB
- only on basis of new onset fever, rule out
non infectious or non CRBSI cause of
49

50. Guidewire exchanges
 Preferably to be avoided. Do not use for prevention
of CRBSI . Better use new site - IB
 Can use for malfunctoning catheter replacement if
previous one has no evidence of infection - IB
Arterial lines –
Most of the guidelines are same.
Replace whole assembly after 96 hrs - IB
No dextrose containing solutions in pressure bag - IA
50

51. Tubings replacement
 Tubings for IV fluids, drug infusions to be replaced
ideally every 96 hrs, max 7 days - IA
 Tubings used for blood, blood products, TPN -
ideally within 24 hours of their initiation for infusion
- IB
 Propofol infusion tubings within 12 hrs - IA
51

52.  Most of them are Catheter Associated UTI (CAUTI)

2009
 Use urinary catheter only if indicated
 Avoid use in high risk, terminate use ASAP
 Surgical patient no routine use, remove within 24 hrs if
not required
 Avoid use for urinary incontinence
- IB
52

53.  Appropriate indication-
 Acute urinary retention or bladder outlet obstruction
 Need for accurate measurements of output in critically ill
 Perioperative use :
 Urologic surgery or other surgery on contiguous structures of
the genitourinary tract
 Anticipated prolonged duration of surgery
 Patients anticipated to receive large-volume infusions or
diuretics during surgery
 Need for intraoperative monitoring of urinary output
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54.  Assist in healing of open sacral or perineal wounds
in incontinent patients
 Patient requires prolonged immobilization
(e.g., potentially unstable thoracic or lumbar spine,
multiple traumatic injuries such as pelvic fractures)
 To improve comfort for end of life care if needed
Inappropriate
 As a substitute for nursing care
 To obtain samples for labs, cultures
54

55.  Alternatives –
 External catheter use - II
 Self Intermittent Bladder Catheterisation - II
 Supra Pubic Catheterisation - Unresolved
 Insertion -
 Trained personell - IB
 Strict asepsis during insertion , manipulation - IB
55

56.  Properly secure over lower abd wall - IB
 Choose smallest bore possible to avoid trauma - IB
 Maintain a closed drainage, replace if damaged - IB
 Urobag always below level of bladder but not touching
the floor -IB
 Clean emptying practices - IB
56

57.  Do not routinely change catheter or urosac at fixed
intervals - IB
 Indication driven change acceptable - IB
 Suspected infection
 Obstuction
 Breached closed drainage system
 Do not use prophylactic antibiotics for CAUTI - IB
 Unless obstruction highly suspected, do not flush
catheter - II
57

58.  Bladder irrigation or collecting bag instillation with
antibiotics, antiseptics not recommended - II
 Cleaning of periurethral area with antiseptics to
prevent CAUTI not recommended - IB
 Cleaning of glans and meatal surface while daily
bath with chlorhex recommended - IB
 Antibiotic, antiseptic coated catheter use - IB
if associated with the “ comprehensive strategy”
 Silicone catheters, one way valve use - II
58

59.  In case of suspected obstruction better change
catheter than flushing - IB
 Use of ultrasound to decide on obstruction for cause
of oliguria - unresolved
 Samle collection for labs aseptically - IB
 Periodic surviellance, HCW education - IB
59

60. 1999
 Most of the recommendations are same for asepsis
 OR like asepsis, restricted personell entry in SICU - IB
 15 air exchanges / hr- min 3 fresh air , filter all air - IB
 >0.5 % chlorhex in alcohol for skin prep, dressing - IB
 Avoid antibiotic prophylaxix for SSTI - IB
60

61. Guidelines already quoted and those for -
 Hand washing – 2003
 Isolation of patients – 2007
 Disinfection, sterilisation and housekeeping - 2008
Can be acessed and downloaded from the following
link –
http://www.cdc.gov/hicpac/pubs.html
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62. 62
IGNAZ SEMMELWEIS (1818 – 1865)
DEFENDER OF MOTHERHOOD

63. 63