Infection Control in ICU

Dr Samir Sahu

Sr Intensivist & Director ICU

Kalinga Hospital

Introduction

• ICU patients are Immuno-compromised –as a non-specific response to critical illness or as a side effect of treatment

• Therefore they are at greater risk of nosocomial infection

• Multiple vascular catheters & tubes penetrate mucosal surfaces & increase risk of invasive infections

Nosocomial Infections

• Central line related infection

• Ventilator associated infection

• Urinary catheter related UTI

• Post-op wound infection

• Device related infection

Epidemiology

• Infected cases 7/100 admissions in Med ICU

• Nosocomial Infections – 30%(/100 adm)

• ESBLs > 50%, increased Death

• Infection rate - 1.3%

• Febrile Episodes – 5%

• Klebsiella, Staph, E.coli – from patients

Identify Reservoirs

• Colonized & Infected patients

• Environmental contaminations

• Common sources

Before Entering the ICU

• Leave your jacket or white coat outside (can carry flora from one patient to next)

• Neck ties dangle at all sorts of places – tuck them out of the way

• If you are going to stay in the ICU all day it is a good idea to wear OT dress to prevent contamination of clothes

Before Approaching a Patient

• Wash your hands thoroughly. If hands are socially clean you can use an alcohol disinfectant rub which is equally effective

Moving between Patients

• Wash hands or use alcohol disinfectant rub before leaving the bed

• Do not share equipments between patients – separate BP instrument & stethoscopes for each bed

• Do not use your own stethoscope which may be a vehicle for cross-infection

Universal (Standard) Precautions

• Wash hands before & after all patient & specimen contact

• Handle blood of all patients as potentially infectious

• Wear gloves for potential contact with blood or body fluids

• Place used syringes immediately in nearby impermeable containers. DO NOT recap or manipulate syringes in any way

Universal (Standard) Precautions

• Wear protective eyewear & mask if splatter with blood or body fluids is possible

• Wear gowns when splash with blood or body fluids is anticipated

• Handle all linen soiled with blood &/or body secretions as potentially infectious

• Process all laboratory specimens as potentially infectious

Halt Transmission

• Improve Hand Washing• Improve Asepsis• Barrier Precautions – gloves gown for colonized

patients• Eliminate any common source – disinfect

environment• Separate susceptible patients• Close unit to new admission if necessary• Adequate nurse to patient ratio

Hand Hygiene-Normal Flora

• Transient Flora - from contact with patient & contaminated environmental surfaces in close proximity of the patient - most commonly responsible for HCW associated infection - removed by routine hand washing

• Resident Flora – coagulase –ve Staph, (sometimes Staph, Gm-ve, yeast etc)

Hand Hygiene - Transmission

• Skin colonizers – Staph. aureas, Proteus Klebsiella, Acinetobacter

• Can contaminate patient gown, bed linen, bed side furniture & other objects in proximity of the patient

• Staph & enterococci are resistant to dessication & therefore more common contaminate

Hand Hygiene Practices

• Wet hands transmit more bacteria

• Adherence – 40%

• 20 opportunities/hr

Other Policies

• Finger nails – subungual region

• Gloves – reduces contamination, prevents infection & transmission

• Rings – more colonization

Hand Washing

• Single most important activity for reducing the transmission of infectious agents by contact & feco-oral routes

• Compliance is poor (48%)

• Noncompliance higher with physicians & attendants

Hand Washing

Reasons for poor compliance

• Shortage of staff

• Higher patient workloads

• Availability, adequacy & distance of sinks

• Compliance may improve with alcohol based hand rub(20sec/120sec)

Indications of Hand Hygiene• Soap & water (hygienic hand wash)

- when soiled with blood or body fluids - after going to toilet, eating

• Decontaminate (hygienic hand rub) - before contact with patient (more important)

- after patient contact (BP, lifting patient) - after contact with equipments - before giving IV lines

(to prevent transmission)

Technique of Hand Hygiene

• Soap & water (Hygienic Hand wash) - apply soap, rub vigorously for 15sec, dry (not to use multiple use towel)

• Surgical antisepsis - remove rings, watch, bracelets - scrub underneath of nails & wash - scrub hands & forearm with antimicrobial soap for 2-6min

Technique of Hygienic Hand Rub

• Pour hand rub into palm (coin size)

• First disinfect the tips of your finger & then rest of your hand

• Contact time 30 sec

• Rub until dry

• Hygienic hand rub better than hygienic hand wash

Improvement of Hand Hygiene Practices

• Education of staff

• Improve adherence – introduction of hand rub

• Monitor adherence

• Encourage family members to remind

• Administrative – education, motivation, system change (availability of sinks, soap, role model, introduction of hand rub)

My five moments for hand hygiene

WHO Guidelines on Hand Hygiene in Health care. WHO 2009. WHO Library Cataloguing-in-Publication Data.

Barrier Nursing• For serious infections or those colonized with

antibiotic-resistant organism• Do not enter unnecessarily• Wear an apron• Wash your hands & put on gloves• Mask & Gowns depends on nature of the problem• Instructions for entering the room is displayed• Remove protective aprons etc. before leaving the

room• Wash hands before leaving the room & use hand

rub once outside the room

Reverse Barrier Nursing

• For immuno-compromised patients

• Side room

• Barrier nursed to help protect them

Chemical Disinfection of Equipments

• Glutaryldehyde

• Completely immersed

Central line

• Chlorhexidine 2% - reduces inherant resident flora

Surface disinfection

• Around patient most important

• Clean & disinfect

• Up to down

• Procedure of disinfection is more important than the disinfectant

Infection Control Practices

• Each room with own sink & trolley with equipment for patient care

• Caps, masks, shoe covers, & gloves are required at all times in patient rooms & bathroom

• Sterile gloves for wound care procedures• Standard Precautions• Hand hygiene procedures• Cleaning once daily with tap water of the sink &

environment surfaces using glutaraldehyde & sodium hypochlorite solutions

Good Disinfection Practices

Prevention

• UTI – sterile technique during insertion - proper fixation to avoid soiling with

stool• Central line

– sterile technique during insertion-- daily inspection of insertion site

• VAP – proper position - sterile technique during suction

• Minimise Invasive devices

Prevention of CAUTI

• Insertion using aseptic technique & Sterile equipment

Procedure of Catheterization

Maintenance of Catheter

Urinary Catheter

• Checklist

The Ventilator Bundle

• The key elements of the Ventilator Bundle are:– Elevation of the Head of the Bed– Daily “Sedation Vacations” and Assessment of

Readiness to Extubate– Peptic Ulcer Disease Prophylaxis– Deep Venous Thrombosis Prophylaxis– Other potential additions

• Oral Care Protocol• Mobility Protocol

VAP

• Ventilator circuits

• Suctioning

• Humidifiers

Central Line Bundle 5 key “Best Practices”

• Hand Hygiene

• Use of Maximal Barrier Precautions

• Chlorhexidine for Skin Antisepsis

• Optimal Insertion Site

• Daily Review of Line Necessity & remove if not necessary

What are Maximal Barrier Precautions?

• For Provider:– Hand Hygiene– Non-sterile cap and mask

• All hair should be under cap• Mask should cover nose and mouth tightly

– Sterile gown and gloves

• For the Patient– Cover patient’s head and body with a large

sterile drape

Maximal Barrier Precautions

Chlorhexidine skin specialist

• Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions.

• Standard technique for Chlorhexidine is – – Prepare skin with antiseptic/detergent chlorhexidine 2 percent in

70 percent isopropyl alcohol.– Pinch wings on the Chlorhexidine applicator to break open the

ampoule. Hold the applicator down to allow the solution to saturate the pad.

– Press sponge against the 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).

Optimal Catheter Site Selection

• Percutaneously inserted catheters are the most commonly used central catheters.

• Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular & femoral site.

CR-BSI Checklist

• Before the procedure, did they:– Wash hands– Sterilize procedure site– Drape entire patient in a sterile fashion

• During the procedure, did they:– Use sterile gloves, mask and sterile gown– Maintain a sterile field

• Did all personnel assisting with procedure follow the above precautions

Central line Maintenance

• Catheter site Dressing

• Anticoagulant flush

• Replacement of set, tubings, fluids

• Replcement

Daily Review of Line

• This will prevent unnecessary delays in removing lines that are no longer clearly necessary in the care of patient.

• Necessary step to prevent infection includes,– Daily review of line necessity as part of

multidisciplinary round is must.– Include assessment for removal of central lines as

part of daily goal sheet.– Record time and date of line placement for record

keeping purpose and evaluation by staff to aid in decision making of removal.

Halt Progression from Colonization to Infection

• Extubate as early as possible

• Remove central lines when not necessary

• Remove Indwelling catheter

• Change of IV lines, 3-ways, ventilator circuits, HME filters as per protocol

• Prevention of VAP – suctioning, position,

Blood Cultures• Minimum 2 sets(from two sites)• Disinfect puncture site with clorhexidine in 70%

alcohol.• Minimum volume 20ml in each set (use 20 ml

syringe),(10 ml/bottle-2 bottles)• 2nd set can be drawn immediately after 1st set.• I bottle(10ml) aerobic, I bottle(10ml) anaerobic + 5ml

fungal(if suspected)• If suspecting CRBSI 1 set through central line & one

from peripheral line. Femoral draw can be contaminated with Gm –ve organisms.

Evidence for Blood Cultures

• 10ml yield 40%, 20ml - 70%, 60ml – 90%• 33% yield in Sepsis (KHL 7%, Apollo 8%)• Anaerobic infections 5% but anaerobic

bottle supports growth of many facultative anaerobes like Strepto, Staph, E coli, Pseudo

• Aerobic+Anaerobic better than 2 aerobics (JCM

2011)

Colonization Surveillance

• Oropharyngeal

• Rectal

• Once a week/3 times per week

• Positive predictive value

Detection

• Fever after 48hrs of intervention

• Increased TLC count

• Urine – pus cells

• Wound – pus

• VAP – purulent sputum

- new radiological shadow

• Evidence of Sepsis

Modify Host Risk

• Treat underlying disease & complications

• Control Antibiotic Use

Visitors in ICU - KHL

• Visitors will not be allowed during the rounds between 9am-11am & during handover between 7am-8am, 1pm-2pm, 7pm-8pm & during emergency procedures

• One attendant at a time

• No talking with sisters

• Not to sit near the patient

• Not to touch the patient

Three steps to Wisdom

• Learning

• Discipline

• Prudence

Global HAI Rates.Percentage of HAIs by Discharge.

Kalinga Hospital , Mixed ICU

Percentage of HAIs by Discharge. Kalinga Hospital, Mixed ICU

2%8% 11%

0% 0%7%

0% 2% 0% 0% 0% 0% 0% 0%6% 7%5% 5% 7%

0%

10%20%

30%40%

50%

60%70%

80%90%

100%

month

pe

rce

nta

ge

Global HAI Rates.Number of HAIs by 1000 Bed Days.

Kalinga Hospital , Mixed ICU

Number of HAIs by 1000 Bed Days. Kalinga Hospital, Mixed ICU

2,5

17,223,7

0,0 0,05,1

0,0 3,2 0,0 0,0 0,0 0,0 0,0 0,0

14,913,78,0 8,7

0,00,0

10,020,0

30,0

40,050,0

60,0

70,0

80,090,0

100,0

month

rate

per

100

0 be

d da

ys

Device Associated Infections in INICC. Benchmarking

9 per 1,000 CVC-days

20 per 1,000 MV days

6 per 1,000 UC days

0

5

10

15

20

25

IVD-BSI VAP CAUTI

NI p

er 1

000

devi

ce-d

ays

Victor D. Rosenthal,a Dennis G. Maki, Ajita Mehta, et al. International Nosocomial Infection Control Consortium (INICC) Report, Data Summary for 2002- 2007, Am J Infect Control ;36:627-37 - 2008IVD-BSI: intravascular devices associated blood stream infection, VAP: ventilator associated pneumonia. CA-UTI: catheter associated urinary tract infection

Central Line Associated Blood Stream Infection per 1000 Device Days. Kalinga Hospital, Mixed ICU

0,0 0,0 0,0 0,03,8

0,06,5 7,2

0,0 0,0 0,0 0,04,5

0,0 0,0 0,0 0,0 0,0 0,00,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

Month/Year

INICC: 9,0NHSN: 2,0

Device Associated Infection Rates.Central Line Associated Blood Stream Infection per 1000 Device Days.

Kalinga Hospital , Mixed ICU

 January 2007-August 2007 / October 2008-Agust 2009

CL Days 3548

Number of CLAB 4

Pooled CLAB Rate x 1000 CL Days 1,1

Catheter Associated Urinary Tract Infection per 1000 Device Days. Kalinga Hospital, Mixed ICU

3,17,0 7,2 3,4 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,00,0

5,70,0

5,1

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

month

Rat

e pe

r 10

00 F

olle

y C

athe

ter

Day

s

INICC: 6,0NHSN: 3,0

Device Associated Infection Rates.Catheter Associated Urinary Tract Infection per 1000 Device Days.

Kalinga Hospital , Mixed ICU

 January 2007-August 2007 / October 2008-Agust 2009

UC Days 6223

Number of CAUTI 11

Pooled CAUTI Rate x 1000 UC Days 1,77

Ventilator Associated Pneumonia per 1000 Device Days. Kalinga Hospital, Mixed ICU

17,5 14,86,5

22,0

32,5

0,0 0,06,9

0,0 0,0 0,0 0,0 0,0 0,0 0,0 0,00,0

18,4

0,00,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

month

Rat

e pe

r 10

00 V

entil

ator

Day

s

INICC: 20,0

NHSN 3,0

Device Associated Infection Rates.Ventilator Associated Pneumonia per 1000 Device Days.

Kalinga Hospital , Mixed ICU

 January 2007-August 2007 / October 2008-Agust 2009

Ventilator Days 2491

Number of VAP 21

Pooled VAP Rate x 1000 MV Days 8,43