HOSPITAL AQUIRED INFECTIONS PREVENTIVE MEASURESAsja Jakli University Medical Centre Ljubljana Department of Infectious diseases and Febrile Ilnesses Intensive care unit SLOVENIJA

INTRODUCTION

After admission to a hospital patient expects to get better However this is not always the case, sometimes they get even worse.

The most common hospitalisation complication is Hospital aquired infection

Hospital Aquired Infections 50% of hospital treatment complications relate to HAI

DEFINITION(1) DEFINITION(1) Hospital

acquired infections (HAI), are (HAI), infections associated with diagnostics, treatment, medical care and rehalbilitation in a hospital or other health institution. HAI may be present in healthcare centres, Spa, centres, Elderly homes, Disability and Psychiatry institutions. Patients and medical staff can acquire HAI

DEFINITION DEFINITION (2)Infections occurring in a healthcare establishment e.g. hospital, nursing home, in patient asymptomatic on admission and presenting with an infection 48 hours after admission or examination in healthcare institutions. institutions.

Can be indicated also after patients discharge, even up to 12 months post surgery in implants.

RISK FACTORS

Age ( neonates, elderly) Central Venous Catheters Temporary or permanent implants Surgical and other invasive procedures Burn patients Antibiotic treated patients Mechanically Ventilated patients Malignants Diabetes Immuno compromised patients Malformations Chronic diseases Hospitalisation time ICU treated patients

HAI INCIDENCE45% 40% 35% 30% 25% 20% 15% 10% 5% 0% UTI I PNEUM NIA BACTE EMIA AND EP I THE

WAYS OF TRANS ISSION Contact

direct; most frequently - hand to hand direct; contamination from medical staff - Indirect; through medical equipment Airborne (droplets or aerogen) Bloodborne at transfusion or needlestick injuries Common carrier: food, water, drugs

HAI REVENTION HAND

HYGIENE (DISINFECTION, hand washing, using gloves) Isolation following strict protocols Sterilization and disinfection Infection control epidemiologists Medical staff education sta

UTI REVENTION AND URINARY CATHETERS UTI

include sympthomatic UTI, sympthomatic asympthomatic bacteriurias and others are the most common HAI (up to 40%) especially when a long term catheter is inserted. More then 80% of UTI relate to urinary catheter

UTI

INFECTION ENTERS URETHRA VIA

periurethral mucous sheath internal catheter lumen junction of collection bag cath / drain tube connection Infection from: anus vagina meatus prepuce hands of care giver cross infection hands of patient

CRITICAL SITES IN A DRAINAGE SYSTEM2. Catheter / drain tube connection 1. Catheter insertion1 3 2

3. Drain tube / bag connection

4. Drain spout

CRITRICAL SITES IN A DRAINAGE SYSTE Catheter

insertion Catheter and bag connection Sampling port Drain spout Urine reflux

CATHETERISATION ETHODS AND UTI RISKS

Single catheterisation bacteriuria incidence in 1-5 % after a procedure Intermitent catheterisation less risk for infection compared to inserted catheters Short term catheterisation up to 72 hrs, incidence of bacteriuria at 10 20 % of patients Long term catheterisation over 72 hrs, risk for bacteriuria is 5-10 % per catheterisation day 5-

MEASURES FOR UTI REVENTION

General measures ( medical staff skills, education, use of protocols, hand hygiene) Catheters insertion only when indicated Material choice depends on indication and estimated lenght of catheterisation Postopki dela ( insertion and catheter replacement, urine bag drainage and replacement, closed drainage system use, unobstructed urine flow, sampling, urine catheter flushing, documentation)

URINARY CATHETERS material choice PVC

intermitent catheterisation Short term catheterisation siliconised latex or latex Long term catheterisation (over 1month) 100% silicone or teflon Hydrogel Catheter for longer period 2-3 2months Silver or antibiotic coated catheters??

Centre for Disease Control RecommendationsCATHETER CHOICE 1. Best type of catheterizationintermittent as associated with lower risk of infection and keeps bladder working 2. Indwelling catheters Preferably SPC 0-5 days - coated latex - encrustation/irritation 0-5 days or more - 100% silicone - inert material - better patient compliance Size 10-12Fr No larger than 18Fr

URINARY DRAINAGE AG Closed

system Dry irreversable chamber or antireflux valve Urine sampling port ( needleless) Drain spout at the bottom Bag replacement according to hospital/institutional standard Urinary bag drainage when 2/3 full

MINIMAL REQUIREMENTS FOR UTI PREVENTION

Catheter insertion only if necessary Education about insertion and catheter care Sterile urinary catheter and sterile urinary drainage bag Hand hygiene disinfection Aseptic technique Urinary bag placed below the bladder level Closed drainage system Catheter fixation Unobstructed urine flow

Ventilator Associated Pneumonia (VAP) and Preventive Measures

Ventilator Associated Pneumonia (VAP) is infection of lower airways, initiated after 48 hours of intubation Is the most frequent complications in patients, admitted to ICU Incidence is between 8 to 46,3 episodes per 1000 days of mechanical ventilation Mortality is very high 20 50 %, with some source pathogens up to 70 % VAP prolongs mechanical ventilation, length of stay in ICU and associated costs

PathogenesisGram negative bacteria: Escherichia coli, Enterobacter negative bacteria: spp.,Klebsiella spp.,Stenotrophomonas maltophillia, Acinetobacter spp. Gram positive bacteria: Enterococcus spp. and Staphylococcus aureus Viruses less frequent: influenza virus, herpes simplex Viruses frequent: virus, and citomegalovirus at immunocompromised patients Fungi / yeast

Risk Factors ( )Present

EFORE admission to ICU: ICU:

Male gender Age COPD Urgent surgery Admission after trauma

VAP - Risk Factors for developing VAP

Aspiration of oral and/or gastric secretions is the primary route of bacterial entry into the lungs and is believed to be a primary factor in the development of VAP

Mouth / oropharynx Colonisation/Contamination of equipment & accessories Gastric bacterial overgrowth Aspiration of oral and/or gastric contents Impaired mucociliary clearance Colonisation of tracheal tube biofilm Enteral tube Transmission by staff Previous pulmonary disease

Risk Factors ( )Present AFTER admission to ICU:

Diseases severity score APACHE II (Acute Physiologic and Chronic Health Evaluation) High sum LOD on Day 2 (LOD - Logistic Organ Disfunction) Consciousness disorder Glasgow comma scale 6 13 Haemodyalisys Hipoalbuminemia, uremia Mechanical ventilation (MV), length of MV, unplanned extubation and reintubation Mouth / oropharynx Colonization and/or Gastric bacterial overgrowth Bronchoscopy and tracheotomy Nasogastric tube and parenteral feeding Previous treatments with antibiotics, steroids, immunosupressives, H2 blockers Continuous sedation Transfusion

VAP Preventive MeasuresEducation of staff Tracing VAP Prevention of cross-contamination of microbes crossAffecting Risk factors for VAP Preventing legionella disease Preventing transfer of aspergilus Preventing Preventing virus transfer accordingly to transport manners Affecting patients response Diagnosing and controlling epidemics

NonNon-Invasive Mechanical Ventilation (NIV)

Indication: Indication: patients with acute respiratory failure, COPD with acute exacerbation and cardiac insufficiency, weaning from MV and less frequent for long-term NIV longContra-Indication: Contra-Indication: patients with facial trauma, patients with no spontaneous breathing, patients with increased sputum or saliva excretion, patients with upper digestive tract bleeding, haemodynamically instable patients, patients with upper airway physical obstruction, nonnoncooperative patients and patients with compromised safety reflexes

NIV

Benefits: less invasive for patient with less complications, especially respiratory infection Complications: mask leak, skin iritation/breakaga (nose or face decubitus), eye decubitus) irritation, mucosa humidity loss, uncomfortable, gastric insuflation feeling

Handling and Changing Equipment

Breathing circuits (7 days, at contamination) days, contamination) Condensation in circuits Active / Passive Humidification Use of highly efficient bacterial/viral filters Inhalation system

ET and Tracheostomy Tubes

Change if needed Intubation and replacement done aseptically Suctioning of secretion above the cuff (subglottic suctioning) Silver coated ET tubes Sealing of the cuff

Solution: EVAC tube with subglottic suctioning

Solution: EVAC tube with subglottic suctioning

New ET tubes: cuff, designTracheal Wall Cuff Creases

Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: a pilot study. Van de Velde, Gent, Belgium

The Journal of Thoracic and Cardiovascular Surgery: April 2008

n = 164

New study on SealGuard tracheal tube published on The Journal of Thoracic and Cardiovascular Surgery: April 2008 This is the extension of the former published abstract from van de Velde but in-cludes about 3 times more patients (164). The results show a 46% risk reduction for early onset pneumonia in cardio-surgery patients. Beside the Lorente study (64% risk reduction in early and late onset in combination with EVAC) this study shows the effect only whilst using a PU cuff SealGuard tubeConclusion:

Polyurethane cuffed endotracheal tubes can reduce the frequency of early postoperative pneumonia in cardiac surgical patients. 46% risk reduction

INFLUENCE OF AN ENDOTRACHEAL TUBE WITH POLYURETHANE CUFF AND SUBGLOTTIC SECRETION DRAINAGE ON PNEUMONIALeonardo Lorente, MD, PhD; et al.

Am J Respir Crit Care Med.

7 Oct 8

n = 280

Methods: Clinical randomized trial in a 24-bed medical-surgical intensive care unit. Patients expected to require mechanical ventilation for more than 24 hours were randomly assigned to one of two groups: one was ventilated with ETT-PUC-SSD and the other with ETT-C. Main Results: VAP was found in of 40 ( . %) patients in the ETT-C group and 11 of 140 (7.9%) in the ETT-PUC-SSD group (p=0.001). Cox regression analysis showed: - ETT-C as risk factor for global VAP (Hazard Ratio=3.3; 95% confidence interval = 1.66-6.67; p=0.001), - early-onset VAP (Hazard Ratio=3.3; 95% confidence interval = 1.19-9.09; p=0.02) - late-onset VAP (Hazard Ratio=3.5; 95% confidence interval = 1.34-9.01; p=0.01). Conclusion: The use of an endotracheal tube with polyurethane cuff and subglottic secretion drainage helps prevent early and late-onset VAP.

64% risk reduction

Airway Suctioning

Open Vs. Closed system Open suction: suction: Each suctioning new suction catheter, Each patient needs own connecting tube and collecting chamber Replace connecting tube and Y-piece every 24 hours Y 3 x day change decontaminant (1% chlorid based solution) solution)

Complications and risks of disconnectionsThe interruption of ventilation and the maneuver itself can lead to severe effects Pulmonary, Haemodynamic and Neurologic Complications Loss of PEEP and FiO2 Entrainment of room air into the lungs Aspiration of gas from the respiratory tract Atelectasis Reduction of Pulmonary Compliance Oxygen Desaturation and Hypoxaemia Hypotension, Hypertension Bradycardia, Tachycardia Arrhythmia, Asystole Increased Intracranial Pressure

Airway Suctioning

Open Vs. Closed system Closed Suction: Single patient use Does not interrupt ventilation no pressure falls in the airway or oxygentation changes Almost diminishes risks of cross-contamination to crossmedical staff Minimizes contamination of patients environment

Spreading of micro-organisms microwith open suctioningR. Distler / Prof. Dr. B. Wille

Results on nursing staff

7 CFUs = ca. 2 %

9 CFUs = ca. 2 % 22 CFUs =6%

9 CFUs = ca. 2 %

30 CFUs = 8 %

154 CFUs = 38 %

159 CFUs = 42 %

(right)

(left)

Spreading of micro-organisms microwith open suctioningResults on patients1 CFU =5% 1 CFU =6% 1 CFU =5%

R. Distler / Prof. Dr. B. Wille Institute for Hospital Hygiene and Infection Control, Gieen (Germany)

16 CFUs = 84 %

(right)

(left)

Blank test: 1-2 CFUs*/25 l air With open suctioning: Average 126 CFUs /25 l air

Patient PositioningBed elevation, Head lifted: 30 - 45 45 VAP clinically diagnosed with 34 % of patients with no bed elevation and 8 % of patients with head elevation; after considering microbiologic results VAP diagnosed with 23% (no elevation) and 5% of patients (with elevation) (Draculovich et al.) al.)

Enteral FeedingMeasuring residual volumes, which should not exceed 150 ml Feeding in half-sited halfposition Oro-gastric tube Ororecommended

Early Tracheotomy

Early tracheotomy (less than 7 days from intubation) intubation) does not decrease VAP incidence and has no affect on length of mechanical ventilation, treatment in ICU or mortality

Oral HygieneRegular oral hygiene with antiseptic solutions (chlorhexidine) is very efficient and inexpensive method of preventing lower airway infection (Houston S, Hogland P, Anderson JJ, et all: Am J Crit Care 2002; 11:567- 70) 11:567 Oral hygiene with chlorhexidine and chlorhexedine/colistine has efficiently decreased risk of VAP. Collonization of oropharynx with Gram negative bacteria has been reduced by 17 % using chlorhexidine, and by 46% when using combination chlorhexedine/colistine. Collonization with Grma positive bacteria has been reduced by 30% or 27% respectively. (Barclay L, Vega C, Am J Respir Crit Care Med. 2006; 173: 1297-1298, 1348-1355) 12971348

Use of Drugs for prevention of stress ulcer

Usage of H2 receptor blockers Link between H2 receptor blockers, anti-thrombosis antidrugs, and VAP incidence has not been fully explained, however opinion exists that in combination with other preventive measures they could influence the reduction of VAP

Sedation

Daily sedation discontinuations reduce risk of VAP In a randomized controlled study, Kress et al. has decreased length of MV from 7,3 days to 4,9 days (N=128), which has reduced risk of VAP and eased weaning/extubation.

Antibiotic TreatmentFollow protocols Too late or incorrect antibiotic treatment increases mortality Use of wide-spectrum antibiotic and after 48-72 hours wide48evaluate antibiotic effect Implementation of microbiologic cultures results

Medical Staff

OverOver-crowded departments of ICU Insufficient number of medical staff Over-laboured medical staff Over Under educated medical staff

Are all important risk factors for Nosocomial infections and transfer of micro-organisms within hospitals. micro-

VASCULAR CATHETERS RELATED INFECTIONS AND MEANS OF PREVENTION

Bacteremia and sepsis represent 10 % of HAI High mortality 25 50% Main risk factors are CVC and implants Most common in ICUs

PATHOGENESIS Most

common causers: S.aureus, MRSA and coagulase negative staphilococks Enteroccoci and fungi (Candida spp.)

RISK FACTORS Primary

disease and disease severity CVC insertion site Catheter type and material Catheterisation lenght Catheter manipulation risks Number of catheter manipulations Number of people manipulating the catheter

TYPES OF VESSEL CATHETERS Short

peripheral venous catheters Peripheral arterial catheters Central vessel catheters: Peripherally inserted central catheters Untunneled venous catheters( femoral, jugular, subclavian) Tunneled venous catheters Implanted central venous catheters

GENERAL RULES OF CVC RELATED INFECTION PREVENTION

Doctor determines the usage according to indication; removal when catheter no longer necessary Correct hygiene procedure education Control over the infection prevention procedures that apply to central vessel catheters Instructions and strict procedures for vessel catheter manipulation Documentation Monitoring of infection related to vessel catheters

PREVENTIONAL APPROACH MEDICAL CARE

Hand hygiene Use of protective wear (gloves, gowns, masks..) Use of antiseptics - chlorhexidine Protocol insertion of CVC, monitoring of insertion site, insertion site care (dressings) removal of CVC, documentation Assesment of system necessity - handling with infusion systems Education of personnel

CONCLUSION

HAI present an important epidemiological, diagnostic, therapeutical and economical issue. HAI treatment is long term and expensive, since microorganisms that cause infections are often resistent to antimicrobial drugs HAI can not be completely prevented, however can be significantly decreased with correct apporach

Thank you for your attention!