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NOSOCOMIAL
INFECTION IN CRITICAL
CARE
Presented by,
Ruma sen
MN. Final

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LEARNING OBJECTIVES
1. PUBLIC HEALTH IMPACT OF HOSPITAL
ACQUIRED INFECTIONS.
2. EPIDEMIOLOGY
3. INDIAN SITUATION OF THE PROBLEM
4. Estimate the extent and nature of
nosocomial infections in hospital
5. Identify the changes in the incidence of
nosocomial infections and the pathogens
that cause them.

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Ignaz Semmelweis
Decreased Mortality with Improved Hand
Hygiene
Ignaz Semmelweis
(1818-65)
Chlorinated lime hand antisepsis

Page 4
Current Climate ……..
• Public Concern
• Quality Issues
– Clinical Governance
– Clinical Standards
– Accountability Reviews
– Performance Assessment
Framework

INTRODUCTION
• Nosocomial infection comes
from Greek words “nosus”
meaning disease and “
komeion” meaning to take
care of
• Also called as HOSPITAL
ACQUIRED INFECTION

DEFINITION
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.
6

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.
BACKGROUND OF
HOSPITAL INFECTIONS
7

Why one may be in icu
Ventilator support – respiratory failure –
pneumonia
Hemodynamic support – shock
Renal replacement therapy – renal failure,
severe acidosis
Monitoring, Neurological dysfunction,
Hematologic

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
9

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
10

TYPES BY ORIGIN
1.Endogenous:
Caused by the organisms that are
present as part of normal flora of
the patient
2. Exogenous:
caused by organisms acquiring by
exposure to hospital personnel,
medical devices or hospital
environment

TYPES OF NCI BY SITE
1. Urinary tract infections (UTI)
2. Surgical Site infections (SSI)
3. Lower respiratory infections (LRI)
4. Blood stream infections (BSI)
5. Catheter related blood stream
infections(CRBSI)
6. Meningitis

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EPIDEMIOLOGICAL INTERACTION
Intrinsic host susceptibility Age, Poor
nutritional status, Co morbidity, severity
of underlying disease
Agent factors
varieties of
organisms
Institutional and human
Reservoirs & their
virulence
Environmental factors hospital
location, diagnostic
procedures, immunosuppressive,
chemotherapy, antibiotics, med &
surgical devices, exposure to
infected patients or health
workers, asymptomatic carriers

DISEASE BURDEN
• 5-10% in developed countries
• 10-30% IN DEVELOPING COUNTRIES
• Rates vary between countries, within
the country, within the districts and
sometimes even within the hospital
itself, due to
1) Complex mix of the patients
2) Aggressive treatment
3) Local practices

• In the United States, the Centers for Disease Control and
Prevention estimated roughly 1.7 million hospital-associated
infections, from all types of microorganisms, including
bacteria and fungi combined, cause or contribute to 99,000
deaths each year.
• In Europe, where hospital surveys have been conducted,
the category of gram-negative infections are estimated to
account for two-thirds of the 25,000 deaths each year.
• United Kingdom ,In 2012 the Health Protection Agency
reported the prevalence rate of HAIs in England was 6.4%
in 2011,

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INDIAN SCENARIO

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INCIDENCE
• Average Incidence - 5% to 10%, but
maybe up to 28% in ICU
• Urinary Tract Infection - usually catheter
related -28%
• Surgical Site Infection or wound
infection -19%
• Pneumonia -17%
• Blood Stream infection - 7% to 16%

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INCIDENCE
• Depends upon
1. Average level of patient risk
depends upon intrinsic host factors
and extrinsic environment factors
2. Sensitivity &specificity of
surveillance programmes

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CONSEQUENCES OF
NOSOCOMIAL INFECTIONS
1. Prolongation of hospital stay:
Varies by site, greatest with
pneumonias and wound infections
2. Additional morbidity
3. Mortality increases - in order - LRI, BSI,
UTI
4. Long-term physical &neurological
consequences
5. Direct patient costs increased-
Escalation of the cost of care

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ECONOMICS OF NCIS
• Extra cost of NCI consequences
• Bed,
• Intensive care unit stay,
• Hematological, biochemical,
microbiological and radiological tests,
• Antibiotics & other drugs,
• Extra surgical procedures
• Working hours

• Crowded hospital
conditions
• New microorganism
• Increasing number of
people with
compromised immune
system
• Increasing Bacterial
resistance
Rise in nosocomial infection as a result of
four factor

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
22

MODES OF TRANSMISSION
There are five main modes of transmission
• Contact
• Droplet
• Vector borne
• Air borne
• Common vehicle

CONTACT TRANSMISSION
Most important and frequent mode of
transmission of nosocomial infections, is
divided into two subgroups:
• Direct-contact transmission
• Indirect-contact transmission.
Direct-contact transmission
Involves a direct body surface-to-body
surface contact and physical transfer of
microorganisms between a susceptible
host and an infected or colonized
person, such as occurs when a person
turns a patient, gives a patient a bath

• Indirect-contact transmission
Involves contact of a
susceptible host with a
contaminated intermediate
object, usually inanimate, such
as contaminated instruments,
needles, or dressings, or
contaminated gloves that are
not changed between patients

DROPLET TRANSMISSION
Droplet generated by sneezing
Coughing or respiratory tract procedures
like Broncoscopy or suction
VECTOR TRANSMISSION
Transmitted through insects and
Other invertebrates animals
such as mosquitoes and fleas.

AIR BORNE TRANSMISSION
Tiny droplet nuclei that remain (<5)
suspended in air.
COMMON VEHICLE TRANSMISSION
Transmitted indirectly by materials
contaminated with the infections.

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AGENTS OF NOSOCOMIAL INFECTIONS
VIRUS
BACTERIA
FUNGI

COMMON NOSOCOMIAL ORGANISMS

The inanimate environment is a
reservoir of pathogens
~ 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.
X represents a positive Enterococcus culture
The pathogens are ubiquitous

MRSA- Methicillin-resistant S.
aureus (MRSA
• 60% of nocosomial infection in ICU
• MRSA bacteria are also able to survive for
extensive periods on surfaces and objects
including door handles, floors, sinks, taps,
cleaning equipment and fabric
• Cotton: 4-21 days
• Terry: 2-14 days
• Polyester blend: 1-3 days
• Polyester: 1-40 days
• Polypropylene: 40-greater than 51.

• A break in the skin barrier, such as a surgical wound, burn,
catheter or intravenous line that allows bacteria to enter the
body
• Older age, comorbidities or multiple complex health issues,
and weakened immune systems Those with a weakened
immune system can include:
• Patients in hospital for a long period of time
• Patients on kidney dialysis (hemodialysis)
• Patients receiving cancer treatment or specific medications
that affect immune function
• Those who inject illegal drugs
• Individuals who have had surgery within a year of being back
in hospital.
• Estimates suggest that 49-65% of health care-
associated S. aureus infections are caused by methicillin-
resistant strains.

The 5 Cs can be used to remember
what factors make it easier for
MRSA to be transmitted:
•Crowding
•Contact (skin-to-skin)
•Compromised skin (open wounds)
•Contaminated (items and surfaces)
•Cleanliness (lack of)

Coagulase negative
staphylococci (CoNS)
• Part of the normal flora of human skin .
• Relatively low virulence but are increasingly recognized
as agents of clinically significant infection of the
bloodstream and other sites.
• Risk factors for CoNS
• Presence of foreign devices (such as intravascular
catheters)
• Immune compromise.

Vancomycin-resistant enterococci
• VRE can live in the human intestines and female genital
tract without causing disease (often called
colonization). However, sometimes it can cause
infections of the urinary tract, the bloodstream, or of
wounds associated with catheters or surgical
procedures

Pseudomonas aeruginosa
• Number 1 cause of intensive care unit (ICU)–related
pneumonia
• Number 2-ranked gram-negative organism, responsible for
9% of all nosocomial bacterial and fungal isolates
• Number 2 cause of nosocomial pneumonia
• Number 3-ranked isolate in hospital-acquired UTIs
• Number 4 cause of surgical site infections and of hospital-
acquired gram-negative rod bacteremia
• Number 5 hospital pathogen
• Number 8-ranked bloodstream isolate
• Causes 10% of nosocomial infections

• Clinical presentation is often identical to other gram-
negative organisms.
• Fever is usually present, except in very young or premature
infants. Fever is often accompanied by tachycardia and
tachypnea.
• Patients appear toxic and may present with apprehension,
disorientation, or obtundation.
• Signs of shock, including hypotension, azotemia, or acute
renal failure, may be observed.
• Respiratory failure occurs in the presence of bacteremic
pseudomonal pneumonia or in conjunction with airway
restrictive disease syndrome.

Acinetobacter baumanii
• Prolonged length of hospital stay
• Exposure to an intensive care unit (ICU)
• Receipt of mechanical ventilation, colonization pressure
• Exposure to antimicrobial agents, recent surgery,
invasive procedures, and underlying severity of illness .
outbreaks of infection have been traced to respiratory care
equipment, wound care procedures, humidifiers, and
patient care items.
Acinetobacter infection, with environmental contamination
found on curtains, laryngoscope blades, patient lifting
equipment, door handles, mops, and keyboards.

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FUNGI
• Due to increased antibiotic use &host
susceptibility
• Candida species– most common, causing
BSI (38% mortality)
• Changing bacterial & fungal spectrum in
the hospital reflects the increased use,
particularly of the newer antibiotics
• Development of resistance (MRSA, VRE,
MDRTB)
• Overcrowding & understaffing of nursing
units increased the rates of infections

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Clostridium difficile
• Causes antibiotic-associated diarrhoea and
pseudo membranous colitis life threatening
illnesses
• Normally affects only the elderly, especially
those on long-term broad-spectrum
antibiotics
• Produces two powerful toxins and is a
spore-former difficult to eradicate, resistant
to alcohol
• Reasons for recent increases still not known

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Risk factors
• Antibiotics
• Healthcare environment
• Acid suppression medication

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Pathophysiology
pseudomembrane

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• Contamination rates after contact with CDAD
patients
• Physicians medical Students -75 of the time
• Dialysis Technicians 66 of the time
• Nurses -56 of the time
• Physiotherapists 50 of the time
• Underside of fingernails 43
• Fingertips and Palms 37
• Underside of Rings 20
• C difficile spores remain in environment in

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Related to underlying
health status
Related to acute
disease process
Related to invasive
procedures Related to
treatment
Advanced age Surgery Endotracheal or
nasal
intubation *
Blood
transfusion
Malnutrition Trauma *
Central venous
catheterisation
*
Recent
antimicrobial
therapy
Alcoholism Burns Extracorporeal renal
support
Immunosuppressiv
e
treatments
Heavy
smoking
Surgical
drains
Stress-ulcer
prophylaxis
*
Chronic lung
disease
Nasogastric
tube
Recumbent
position
Diabetes Tracheostomy
Parenteral
nutrition
Urinary
catheter *
Length of
stay
Factors that predispose to nosocomial infection

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Patient Environment Organism
 Severity of illness
 Underlying disease
 Nutritional state
 Immunosuppression
 open wounds
 Invasive devices
 Multiple procedures
 Prolonged stay
 ventilation
 Multiple or
prolonged
antibiotics
 Changes in procedures or
protocols
 Multiple changes in staff
 Poor aseptic practice
 Patient to patient (busy,
crowded unit, staff shortages)
 Lack of isolation facilities
 No separation of clean and
dirty AREAS
 Lack of Hand washing
facilities Inadequate
decontamination of items &
equipment's
 Resistance
 Resilience
 Formation of slime
 Ability to adhere
 Pathogenicity
 Prevalence
RISK FACTORS

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Bloodstream infections (BSI)
Central line-associated BSI (CLABSI): A
laboratory-confirmed bloodstream
infection (LCBI) where central line (CL) or
umbilical catheter (UC) was in place for >2
calendar days on the date of event, with
day of device placement being Day 1,
AND the line was also in place on the date
of event or the day before.

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IV Catheter Biofilm 24 hours after
Insertion

Coagulase Negative Staphylococci
Slime-producing, Catheter Surface

Semi permanent Tunneled Catheters
(Groshong, Hickman, Mediport)
• long term i.v. therapy
• much lower rate of infection
• dacron cuff incites inflammatory response,
fibrosis at insertion site
• prevents bacteria from migrating along external
catheter surface
• locations of infection: exit site, tunnel, tip
• tunnel infection always requires catheter removal
• septic thrombophlebitis/pulmonary emboli

Groshong
catheter

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
54

EXAMPLE
• Patient has a central line inserted on June 1. On June 3,
the central line is still in place, and the patient’s blood is
collected for culture. The culture is positive for S. aureus.
• This is a CLABSI because the central line was in place for
>2 calendar days (June 1, 2, and 3), and still in place, on
the date of event (June 3).

Patient has a central line inserted on June 1. On
June 3, the central line is removed and on June
4 the patient’s blood is collected for culture. The
culture is positive for S. aureus.
•This is a CLABSI because the central line was in place
for >2 calendar days (June 1, 2, and 3), and was in
place the day before the date of event (June 4).

• Patient has a central line inserted on June 1. On June 3, the
central line is removed. On June 5 patient spikes a fever of
38.3°C and the patient’s blood is collected for culture. The
culture is positive for S. aureus.
• This meets LCBI Criterion 1 but it is not a CLABSI because the
Date of Event (June 5) did not occur on the day the central line
was discontinued (June 3) nor the next day (June 4).

The CLABSI rate per 1000 central line days is
calculated by dividing the number of CLABSIs by the
number of central line days and multiplying the result
by 1000. The Central Line Utilization Ratio is
calculated by dividing the number of central line days
by the number of patient days.

SURGICAL SITE INFECTIONS

Epidemiology of SSI
•SSI infection generally occurs within 30 days following surgery
•Some procedures monitored up to 90 days for SSI
•2% -5% surgical patients acquire SSI (300-500K per year)
•3% die (77% of deaths directly attributable to the SSI)
•Many result in long term disability
•SSI increases hospital length of stay 7-10 days
•Cost estimates vary, ~$30,000 per SSI
•Most estimates do not account for re-hospitalization, outpatient
treatment, post-discharge expenses, quality of life for the
patient, or any long term disability costs

Source SSI Microorganisms Surgery
Incidence (n/N) Gram+ve Gram-ve Type (%SSI)
Bhatia 2003 18.7% (116/615) S. Epidermis (42.24%)
MMSE (26.72%), MRSE
(15.5%)
S.aureus (15.55%)
MRSA (12.06%), MSSA
(3.2%)
Total (12.06%)
E. coli, P.aeruginosa
CABG (ns)
Agarwal 2003 1.6% (40/2558) S. aureus (57.5%) MRSA
35%,
MSSA 22.5%
P. aeruginosa (10%) Neurosurgeries (1.6%)
Pawar 2005 5.1% (7/136) Staphylococcus sp. (10%) - Cardiac surgery with
intraaortic balloon
pulsation (5.1%)
Lilani 2005 8.95% (17/190) S. aureus (35.3%) MRSA
(33%)
P. aeruginosa (4/17) E.coli
(2/17)
Thoracotomy (44.44%)
Gastrointestinal surgeries
Sharma 2009 2.5% (786/31927) Staphylococcus sp. Neurosurgeries (2.5%)
Joyce 2009 12% (135/1125) S.aureus (33.3%)
MRSA (14.0%)
E faecalis (33.3%)
VRE (1.4%)
P. Aeruginosa (24.4%),
E.coli
(7.4%), Klebsiella
spp(1.4%)
Gastrectomy (36.4%),
Cholecystectomy (15.4%),
Prostatectomy (15.2%),
Hysterectomy (10.4%),
Appendicectomy (3.4%)
Profile of Surgical site infections (SSIs) in India

Patel 2011 12.72% (7/55) S. aureus (42.86%) Klebsiella sp. (ESBL)
(57.14%)
Colon surgery (29.41%),
Amputation (50%)
Sarma 2011 21% (14/66) MRSA 67%, S. aureus
MSSA 33% E.faecalis
E coli
ESBL (43%),
ESBL+ Amp-C
hyperproducers
(29%) Amp-C
hyperproducers
(14%)
NDM-1 producer (14%)
Post-operative patients
Patel S 2012 16% (32/200) CoNS (14.3%)
S. aureus (7.1%)
E. coli (35.7%)
Klebsiella sp. (21.4%)
P. aeruginosa (14.3%)
Proteus mirabilis (7.1%)
Appendicetomy (0-40%)
Laparotomy (19.2-
31.6%)
Amputation (10-60%)
Cholecystectomy (7.1-
28.6%)
Nephrectomy (13.3-40%)

Pathogenesis of SSI
•Endogenous
• Patient Flora
•Skin
•GI tract
•Mucous membranes
•Seeding from pre-
existing sites of
infection
• Exogenous
• Surgical personnel flora
• Breaks in aseptic
techniques
• Inadequate hand hygiene
• Contaminated garments
• Equipment, surgical tools,
materials within operative
field
• OR environment, including
ventilation

SSI Pathogens
 Staphylococcus aureus - 30.0%
 Coagulase-negative staphylococci - 13.7%
 Enterococcus spp - 11.2%
 Escherichia coli - 9.6%
 Pseudomonas aeruginosa - 5.6%
 Enterobacter spp - 4.2%
 Klebsiella pneumonia - 3.0%
 Candida spp - 2.0%
 Klebsiella oxytoca - 0.7%
 Acinetobacter baumannii - 0.6%

SSI Surveillance Definition
Categorized
based on depth
infection

Superficial Incisional SSI Surveillance
Definition
Infection occurs within 30 days after surgical procedure AND
Involves only skin and subcutaneous tissue of the incision AND
Patient has at least 1 of the following:
• Purulent drainage from the superficial incision
• Organism isolated from an aseptically-obtained culture of fluid
or tissue
• Superficial incision that is deliberately opened by a surgeon
and is culture positive or not cultured and Patient has at least
one of the following signs or symptoms: pain or
tenderness, localized swelling, redness, heat
• Diagnosis of superficial SSI by surgeon or attending physician

Deep Incisional SSI
Definition
Infection occurs within 30 (or 90 days) after the operative
procedure AND Involves deep soft tissues of the incision,
e.g., fascial & muscle layers AND Patient has at least 1 of
the following:
• Purulent drainage from deep incision
• Deep incision spontaneously dehisces or opened by
surgeon and is culture positive or not cultured and fever >38
C, localized pain or tenderness (Note: a culture negative
finding does not meet this criterion)
• Abscess or other evidence of infection found on direct
exam, during invasive procedure, by histopathologic exam
or imaging test
• Diagnosis of deep SSI by surgeon or attending physician

Organ Space SSI
Definition
Infection occurs within 30 or 90 days after the operative
procedure AND
Infection involves any part of the body, excluding the skin
incision, fascia, or muscle layers that is opened or
manipulated during the operative procedure AND Patient has
at least 1 of the following:
• Purulent drainage from drain placed into the organ/space
• Organism isolated from an aseptically-obtained culture of
fluid or tissue in the organ/space
• Abscess or other evidence of infection found on direct exam,
during invasive procedure, or by histopathologic or exam or
imaging test

Interpreting SSI Data
• To make comparisons of SSI, use a
number called the SIR (standardized
infection ratio)
Observed SSI
• SIR = --------------------
• Predicted SSI
•

•Consider implementing
in addition to Core when
infections persist or rates
are high
Should become
standard practice

SSI Prevention Strategies: Core
• Administer antimicrobial prophylaxis in accordance with
evidence based standards and guidelines
• Administer within 1-hour prior to incision (2hr for vancomycin
and fluoroquinolones)
• Select appropriate agents on basis of:
Surgical procedure
Most common SSI pathogens for the procedure
Published recommendations
Discontinue antibiotics within 24hrs after surgery (48 hrs for
cardiac)

• Identify and treat remote infections – when possible
Before elective operation
• Postpone operation until infection resolved
Hair removal
• Do not remove hair at the operative site unless it will
interfere with the operation
• Do not use razors
If necessary, remove by clipping or by use of a
depilatory agent .

• Skin Prep
• Use appropriate antiseptic agent and technique for skin
preparation
Operating Room (OR) Traffic
• Keep OR doors closed during surgery except as needed
for passage of equipment, personnel, and the patient
Colorectal surgery patients
• Mechanically prepare the colon (Enemas, cathartic
agents)
• Administer non-absorbable oral antimicrobial agents in
divided doses on the day before the operation

• Maintain immediate postoperative normothermia
Surgical Wound Dressing
• Protect primary closure incisions with sterile
dressing for 24-48 hours post-op
• Control blood glucose level during the immediate
post-operative period - cardiac
• Measure blood glucose level at 6 am on post-op
day 1 and 2 (procedure day = day 0)
• Maintain post-op blood glucose level at
<200mg/dL

SSI Prevention Strategies: Supplemental
• Nasal screen for Staphylococcus aureus on patients
undergoing elective cardiac surgery, orthopedic,
neurosurgery procedures with implants.
• decolonize carriers with mupirocin prior to surgery
• Screen preoperative blood glucose levels and maintain
tight glucose control post-op day 1 and 2 in patients
undergoing select elective procedures. i.e., arthroplasties,
spinal fusions, etc.

Redose antibiotic at 3 hr intervals in
procedures with duration >3 hours .
Adjust antimicrobial prophylaxis dose for
patients who are obese (body mass index
>30)
•Use at least 50% fraction of inspired oxygen
intraoperatively and immediately
postoperatively in select procedure(s)
•Perform surveillance for SSI
•Feedback surgeon-specific infection rates

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Catheter-associated Urinary Tract
Infections (CAUTI)

• Major predisposing factor
• indwelling urinary catheter
• average of 26% of hospitalised patients are
catheterised
• risk of CAUTI is 1-2% per procedure
• Risk ↑ for each additional day of catheterisation
• Common in long-term catheterised patients
Background to CAUTI
surveillance
Risk Factors

Associated Risk Factors
• A history of previous catheter use
• Duration the catheter is in situ
• Length of stay in hospital prior to
catheter insertion
• Location of catheter insertion

CAUTI Data Definitions
A healthcare associated UTI considered to be
catheter associated if:
• An indwelling catheter is in situ at time of onset of
UTI (Criterion 1)
OR
• An indwelling catheter was removed within 3 days
prior to the onset of UTI (Criterion 2)

AND
The first positive urine specimen
is taken or the physician makes
a diagnosis more than 48 hours
after the catheter was inserted

For patient’s with an indwelling catheter in situ
AND
≥104
micro-organisms per ml from a catheter specimen
of urine
AND
CAUTI
Criterion 1 Definition
CAUTI Data DefinitionsCAUTI Data Definitions

CAUTI Criterion 1 cntd….
ONE or more of the following with no other
recognised cause:
• Loin Pain
• Loin or suprapubic tenderness
• Fever (≥38o
C skin temp)
• Pyuria (≥104
WBC per ml)
CAUTI Data DefinitionsCAUTI Data Definitions

CAUTI
Criterion 2 Definition
For patient’s who had catheter removal within 3
days before the onset of CAUTI
AND
≥ 105
micro-organisms from a mid stream
specimen
AND
CAUTI Data DefinitionsCAUTI Data Definitions

CAUTI Criterion 2 cntd….
ONE or more of the following with no other
recognised cause:
• Urgency
• Frequency
• Dysuria
• Loin Pain
• Loin or suprapubic tenderness
• Fever (≥ 38o
C skin temp)
• Pyuria (≥ 104
WBC per ml)
CAUTI Data DefinitionsCAUTI Data Definitions

CAUTI Definitions
• CAUTI must meet one of the criteria 1 or 2 as
described
• Patients with asymptomatic bacteriuria/bacteria in
their urine are NOT considered to have a CAUTI

CASE STUDY
• A 52 year male is admitted with a severe
headache and is found to have a
subarachnoid hemorrhage from a ruptured
aneurysm. The neurosurgeons evacuate the
hematoma and clip his aneurysm. Post-op
he remains on a ventilator.
• On hospital day 5 he spikes a fever to 102º F
and is noted to have copious secretions from
his endotracheal tube. Increasing amounts
of inspired O2 are required. Blood and
sputum cultures grow highly resistant
Enterobacter cloacae.

Epidemiology ofEpidemiology of
Ventilator AssociatedVentilator Associated
Pneumonia (VAP)Pneumonia (VAP)
90

NOSOCOMIAL PNEUMONIA
• The most important are patients
on ventilators in ICU.
• Recent and progressive
radiological opacities of the
pulmonary parenchyma,
purulent sputum and recent
onsite fever.
Most commonly caused by
acinetobacter.

92
Nosocomial Pneumonias
Account for 15% of all hospital
associated infections
Account for 27% of all MICU acquired
infections
Primary risk factor is mechanical
ventilation (risk 6 to 21 times the rate for
nonventilated patients)

93
Susceptibility to
Nosocomial Pneumonias
IntubatioIntubatio
nn
AlteredAltered
HostHost
DefensesDefenses
TrachealTracheal
ColonizationColonization
IncreasedIncreased
NosocomialNosocomial
PneumoniaPneumonia
ss

94
Primary Route of Bacterial Entry into
Lower Respiratory Tract
 Micro or macro aspiration of
oro pharyngeal pathogens
 Leakage of secretions
containing bacteria around
the ET cuff

95
VAP Etiology
 Most are bacterial pathogens, with Gram
negative bacilli common
 Pseudomonas aeruginosa
 Proteus spp
 Acinetobacter spp
 Staphlococcus aureus
 Early VAP associated with non-multi-
antibioticresistant organisms
 Late VAP associated with antibiotic-
resistant organism

• Hospital-acquired
fevers occur in
one-third of all
medical inpatients
• Nosocomial fevers
even more
common in the
ICU
Nosocomial Fevers
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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

98
Causes of Fever in the ICU
• Surgical site
infections
• Intravenous-line
infections
• Nosocomial
pneumonia
• Nosocomial
sinusitis
• Intraabdominal
infections
• Urinary catheter-
associated
bacteriuria
• Drug fever
• Post-operative
fever
• Neurosurgical
causes

How To Diagnose??
• A positive result of semi quantitative Culture ( 15
CFU per catheter segment) 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)
99

Biomarkers
• Procalcitonin (PCT)-: The peptide procalcitonin is
synthesized by monocytes that are in the process of
adhesion. PCT levels rise when there is local or systemic
bacterial infection but not in the presence of a virus or
autoimmune disease. Thus, PCT is more specific than
CRP for detecting bacterial infection.
• C-reactive protein (CRP)-This acute phase protein is
released by the liver in response to inflammation or tissue
insult and is widely used as a highly nonspecific marker
of sepsis.

Diagnosis of ventilator-associated
pneumonia
• Gram staining, quantifying microorganisms in
polymorphonuclear cells in bronchoalveolar lavage
samples.
PCR assays
• Nuclear material extracted from BAL
• qPCR amplified up 16s DNA –i.e. quantifies bacterial load
• Quantitative assay, therefore the time to crossing the
‘threshold’ is inversely proportional to the amount of 16s DNA
present.
• Shorter time to crossing threshold (Ct) indicates higher burden
of bacteria
• Compared to conventional culture as the ‘gold standard’

Surviving Sepsis Campaign

• Step 1: Screening and Management of
Infection
• Step 2: Screening for Organ Dysfunction and
Management of Sepsis (formerly called
Severe Sepsis)

Sepsis Core Measure (SEP-1) Highlights
SIRS Criteria
• Temp >101
• Temp < 96.8
• HR > 90
• RR > 20
• WBC > 12,000
• WBC < 4000
• > 10% Bandemia
Organ Dysfunction
Variables
• SBP < 90
• MAP < 70
• SBP decrease > 40 from
known baseline
• Cr > 2.0
• UOP < 0.5 ml/kg/hr for > 2
hours
• Bilirubin > 2.0
• Platelets < 100,000
• INR > 1.5 or PTT > 60 secs
• Altered Mental Status
• Lactate > 2

Septic shock
• severe sepsis with hypoperfusion despite adequate
fluid resuscitation or a lactate > 4.
• Within 3 hours of presentation:
Measure serum lactate
Obtain blood cultures prior to antibiotics
Administer antibiotics
Within 6 hours of presentation:
Repeat serum lactate if initial lactate is >2
For septic shock:
• Within 3 hours of presentation:
Measure serum lactate
Obtain blood cultures prior to antibiotics
Administer antibiotics
Resuscitation with 30mL/kg crystalloid fluids
Within 6 hours of presentation:
Repeat volume status and tissue perfusion assessment
Vasopressor administration (If hypotension persists after fluid)

Recommendations: Initial Resuscitation
and Infection Issues sepsis-2
• Initial Resuscitation
• Screening for Sepsis and Performance Improvement.
• Diagnosis
• Antimicrobial therapy.
• Source control
• Infection Prevention

BUNDLES
• WITHIN 3 HOURS:
1) Measure lactate level
2) Obtain blood cultures
prior to administration
of antibiotics
3) Administer broad
spectrum antibiotics
4) Administer 30 ml/kg
crystalloid for
hypotension or lactate
≥4mmol/L
• With in 6 hours
• Vasopressors - to maintain a
mean arterial pressure
(MAP) ≥65 mm Hg
• Re-assess volume status
and tissue perfusion and
document findings.
• Re-measure lactate if initial
lactate elevated.

Conclusion
Nosocomial infections are associated
with a great deal of morbidity, mortality
and increased financial burden.
Intensive care is a risk factor for the
emergence of antibiotic resistant
bacteria. Gram-positive bacteria have
overtaken Gram-negative organisms
as the predominant cause of
nocosomial infections.

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