INFECTION CONTROL IN THE ICU

JOÃO MELO ALVES, MDLISBOA, PORTUGAL

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GENERAL ICUDIRECTOR: PROF. CHARLES SPRUNG, MD

DEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CAREHEAD OF DEP.: PROF. CHARLES WEISSMAN, MD

HADASSAH EIN KEREM UNIVERSITARY HOSPITAL JERUSALEM

Ignaz Semmelweis (1818 – 1865)

21% PSSA0.4% MRSA

Prospective observational study in Canterbury NZ8 years (1998-2006); n=779

Huggan PJ et al. Intern Med J 2010 (40:2)

Sir Alexander Flemming (1881 – 1955)Nobel Prize 1945

ICUsFrikdin SK et al. Infect Dis Clin North Am 1997 (11:2)

<10% HOSPITAL BEDS

>20% NOSOCOMIAL INFECTIONS

EPIC ICRBSI – OR 1.73

Pneumonia – OR 1.91

Sepsis – 3.75

Vincent JL et al. JAMA 1995 (274:8)

EPIC I >1000 ICUs

>10000 patients

17 european countries

EPIC II

60% patients infected

Infection vs mortality OR 1.51

Leading cause of mortality in ICU

40% of all ICU expenditures

Indwelling catheters

Vincent JL et al. JAMA 2009 (302:21)

EPIC II >1000 ICUs

>14000 patients

Worldwide study – 75 countries

Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)

Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)

“IA: periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters”

CDC 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections

Antibiotics control

Hand hygiene

Contact precautions

DecolonizationBathing

SOD/SDD

Nasal carriage

Device specific strategies

Antibiotics control

Hand hygiene

Contact precautions

DecolonizationBathing

SOD/SDD

Nasal carriage

Device specific strategies

A-LINES (vs. CVC)

BLOOD CULTURES & CRBSI

UTI IN THE UCI

ET & SPUTUM CULTURES

A-LINES (vs. CVC)

A-LINES (vs. CVC)

BLOOD CULTURES & CRBSI

UTI IN THE ICU

ET & SPUTUM CULTURES

A-Lines as source of BSI

49 studies - only one study MSBP vs sterile gloves

O’Horo JC et al. Crit Care Med 2014 (42:6)

IB: aseptic technique for insertion and care of intravascular catheters

IC: clean gloves, rather than sterile, for PVC, after skin antisepsis

IA: sterile gloves for arterial and CVC catheters

IB: maximal sterile barrier precautions (incl cap, mask, sterile gown, sterile gloves, sterile full body drape) for insertion of CVC, PiCC or guidewire exchange

CDC Prevention Intravascular Catheter Related infections 2011

A-Lines as source of BSI

49 studies, 222 BSI, >30000 catheters

1.26 /1000 cath-days

O’Horo JC et al. Crit Care Med 2014 (42:6)

Arterial CRBSI

Prospective cohortn=2500, 2949 catheters

Femoral vs Radial /1000 cath-days:Local: 3.02 vs 0.75BSI: 1.92 vs 0.25

Increased durationPoor aseptic technique on insertion

Lorente L et al. Crit Care 2006 (10)

Rates of CRBSI/1000 cath-days

AL 1.7 vs. CVC 2.7

PVC 0.5

PiCC 1.1 (inpatients = CVC)

PAC 3.7

Maki DG et al. Mayo Clin Proc 2006 (81:9)

106 ICU, >300000 cath-days

18 months – The Provonost checklist

Handwashing

MSBP

Clorhexidine-ethanol

Avoidance of femoral

Removal ASAP

7.7 1.4

Pronovost P at al. NEJM 2006 (355)

n=3154, 2y cohort of catheter care

incidence rate/1000 pt-days

Exit-site infection 9.23.3 (RR 0.36)

CRBSI 11.33.8 (RR 0.33)

VAP/VAT/CAUTI no change

Global NI 52.434.0

Eggimann P et al. Lancet 2000 (355)

Routine replacement has no role

More mechanical complications

No advantage in reducing CRBSI

Cobb DK et al. NEJM 1992 (327)Eyer S et al. Crit Care Med 1990 (18)

Direct vs guidewire techniques

Less likelihood of success

Longer to perform

Used more catheters

Required more punctures

Guidewire 82% vs direct 65% success

Beards SC et al. Anaesthesia 1994 (49)Mangar D et al. Anesth Analg 1993 (76)

AL are NOT peripheral IVs

PVC are replaced routinely at 72-96h

(CDC-IB) – AL routine replacement

has no role

Risk of CRBSI increases with duration

Dedicated AL kits (e.g. Seldinger

techniques) have higher success

rates and lower complications

Infection rates are similar to CVC

1.26 – 1.92 /1000 cath-days

Maki DG et al. Mayo Clin Proc 2006 (81:9)

Transducers, tubing, flushing

device and solutions routinely

replaced every 96h

Recommendation based on CVC and

PAC studies!

Recommendations do not adress arterial lines

Insertion

Maintenance

Infection

… MSBP?

BLOOD CULTURES AND CRBSI

A-LINES (vs. CVC)

BLOOD CULTURES & CRBSI

UTI IN THE ICU

ET & SPUTUM CULTURES

1 BC = 20mL = 2 bottles

∆mL= ∆3% yield Mermel LA, Maki DG. Ann Intern Med. 1993 (119:4)

Aseptic cleaning – 70% alcohol, >0.5% clorhexidine

Should NOT be taken from IV cath at insertion9.1 vs 2.8% false positives (catheter vs. dedicated venipuncture)

Norberg A et al. JAMA 2003 (289) – >4100 BC!

Bacteremia is usually intermittent and of low quantities

One BC is rarely usefulLeads to under/overtreatment

Minimum 2 sets (4 bottles) from separate venipuncturesLow/moderate pretest – two simultaneous, one 6h later

High pretest, suspected continuous bacteremia – two setsHigh pretest, suspected pathogen a likely contaminant – four sets

Timing is neither sensitive nor specificTechnique, number, volume are more important for detection

Riedel S et al. J Clin Microbiol 2008 (46) – n=1436

CDC: CLABSI vs. CRBSI

Suspected when BSI occurs with CVC and no other apparent source

Fever: greater sensitivity, poor specificity.

Inflammation/pus at site: greater specificity, poor sensitivity

Safdar N, Maki Dg. Crit Care Med 2002 (30)

CRBSI

Paired CVC + peripheral blood cultures (labeled bottles)

Quantitative: CFU >3x CVC vs periph – most labs don’t perform

Differential time to positivity: CVC ≥2h before peripheral – sens 85%, spec 95%

Safdar et al. Ann Intern Med 2005 (142:6)Bouza E et al. Clin Infect Dis 2007 (44:6)

Diagnosis

(Same organism on tip + 2 periph culture)

Same organism on peripheral + CVC cultures

Safdar et al. Ann Intern Med 2005 (142:6)Raad I et al. Ann Intern Med 2004 (140:1)

Blot F et al. J Clin Microbiol 1998 (36:1)Blot F et al. Lancet 1999 (9184)

Criteria

Positive CVC (CNS), negative periperal

Colonization likelyIncreased risk for CRBSI

Follow closely vs. removal

Culturing Tips

Not routinely – only if CRBSI suspected

<7-10d: intradermal segment >7-10d: tip (most likely catheter colonization) Neg peripheral cultures: no antibiotherapy

O’Grady NP et al . CDC 2002 guidelines for the prev of intravascular catheter-related infections

“Risk of infection increases with duration of placement, but routine replacement does not decrease that risk”

Webster J et al. Cochrane Database Syst Ver 2013 (4)

RCT n=160, 4 replacement strategiesCRBSI/1000 cath-days

Q3d, new place – 3 Q3d, guidewire – 6 Clinical indication, new place – 2 Clinical Indication, guidewire – 3 New sites increased mechanical complications

Cobb DK et al. NEJM 1992 (327:15)

CDC guidelines IB: do not routinely replace CVCs, PiCCs, HD caths,

PACs to prevent CR-infections (new place or guidewire)

II: do not remove CVC/PiCCs on the basis of fever alone. Use clinical judgment.

IB: use guidewire exchange to replace malfunctioning catheter if no evidence of infection is present

IB: do not use guidewire exchanges to replace suspected infected catheterCDC Prevention Intravascular Catheter Related infections 2011

REMOVAL Severe sepsis/shock Endocarditis or metastatic infection Suppurative thromboplebitis >72h persistent bacteremia under atb Specific pathogens (SA, enteococci, GNR, fungi,

mycobacterium)

SALVAGE – no role in ICU Uncomplicated CRBSI with long-term catheters Salvage therapy (e.g. antibiotic lock) Except specific pathogens (…)

MONITOR, DO NOT TREAT Positive tip, no clinical signs Positive CVC BC, negative peripheral

Staphylococcus aureus 25-32% BSI develop INFECTIVE ENDOCARDITIS TEE 5-7d after +BC >72h is an ominous sign

Abraham J et al. Am Heart J 2004 (147:3)Fowler VG Jr et al. J Am Coll Cardiol 1997 (30:4)

Sullenberger AL et al. J Heart Valve Dis 2005 (14:1)

URINARY TRACT INFECTIONS IN THE ICU

A-LINES (vs. CVC)

BLOOD CULTURES & CRBSI

UTI IN THE ICU

ET & SPUTUM CULTURES

When to treat?

<5% of bacteriuric cases bacteremia

Leading cause of nosocomial BSI 17% of all HA-BSI (lower proportion in ICU)

CA-urosepsis 10% mortality

Gould CV et al. Infect Control Hosp Epidemiol 2010 (31)

Diagnosis: cultures and symptoms

Asymptomatic CA-bacteriuria: ≥105 CFU/mL of uropathogenic bacteria Pyuria >10 WBC/uL has low sensitivity but >90% specificity – doesn’t make the diagnosis Cloudy appearance and foul smell are NOT correlated with bacteriuria

Bacteriuria: 3-10%/day of catheterization

Hooton TM et al. Clin Infect Dis 2010 (50:5)Nicolle LE. Infect Dis Clin North Am 2012 (26:1)

“II: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as

INFECTION, obstruction, or when the closed system is compromised”

CDC Guideline for prevention of catheter-associated urinary tract infections 2009

Trautner BW, Darouiche RO. Am J Infect Control 2004 (32:3)Raz R et al. J Urol 2000 (164:4)

Start antibiotics and replace catheter

Fewer and later relapses

Shorter time to afebrile status

Improved clinical status at 72h p<0.001

Less rate of complications (bacteremia, pyelonephritis) p=0.015

UTIUROSEPSIS

Bacteriuria ≥105 CFU/mLFever, sepsis or bacteremia

No alternate sources

ENDOTRACHEAL TUBES & SPUTUM CULTURES

A-LINES (vs. CVC)

BLOOD CULTURES & CRBSI

UTI IN THE ICU

ET & SPUTUM CULTURES

Ventilator associated tracheobronchitis

Horan TC et al. CDC/NHSN surveillance definition. Am J Infect Control 2008 (36:5)

Fever>38ºC

No other recognizable source of infection

New/increased sputum production

Positive culture of tracheal aspirates

No radiographic infiltrate or evidence of pneumonia

Lower respiratory tract colonization ↔ VAPPseudomonas, Acinetobacter, Staph aureus

Prospective cohort VAT vs VAP (n=28 / 83)

Length of hospital stay

Duration of hospital stay

Survival rate to discharge

Need for tracheostomy

Need for antibiotics

Dallas J et al. Chest 2011 (139:3)

RCT n=58, antibiotics vs placebo (8 days)

Treatment improves outcomes

Reduced ICU mortality: 18 vs 47% – trial stopped early!

Fewer episodes of VAP: 13 vs 47%

More ventilator free days

Management of VAT=VAP

Nseir S el at, VAT Study Group. Crit Care 2008 (12:3)

Clinical importance seems to be similar to VAP

Infection control is a MAJOR issue

AL should probably be handled like CVCInsertion technique and MSBP

Never take ONE blood cultureAlways TWO OR MORE separated, dedicated venipunctures

Culture the CVC

Diagnose and treat UTIRemove the catheter – colonization is not a limitation

Don’t wait for VAP – treat the VAT

1. Antimicrobial resistance: global report on surveillance. World Health Organization 2014

2. Naomi P.O’Grady et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. HICPAC,

CDC.

3. Carolyn V Gould et al. Guideline for prevention of catheter-associated urinary tract infections 2009. HICPAC, CDC.

4. Philippe Eggimann, Didier Pittet. Infection control in the ICU. Chest 2001, 120 (6)

5. Australian guidelines for the prevention and control of infection in healthcare. 2010, Australian Government.

6. Healthcare Society Infection guidelines. http.//www.his..org.uk/resources-guidelines/

7. ASPIC Asia Pacific Society of Infection Control Guidelines. July 2012. http:// apsic.info/guidelines.php

8. SHEA Society for Healthcare Epidemiology of Americas. Compendium of Strategies to prevent healthcare-

associated infections in acute care hospitals (SHEA, IDSA, AHA, APIC, JC) 2014 update – several statements

published on Infection Control and Healthcare Epidemiology Journal since 2008

Executive summary 2014 updates: Infection control 2014 (35:8)

João Melo Alves – joaomeloalves@gmail.com

http://www.slideshare.net/joaomeloalves

REFERENCE BIBLIOGRAPHY