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Infection Control in the Intensive Care Unit
Infection Control in the IntensiveCare Unit
H. K. F. van Saene • L. SilvestriM. A. de la Cal • A. GulloEditors
Infection Controlin the IntensiveCare Unit
Third Edition
Foreword by Julian Bion
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H. K. F. van SaeneInstitute of Aging and Chronic DiseasesUniversity of LiverpoolLiverpoolUK
L. SilvestriDepartment of Emergency and Unit of
Anesthesia and Intensive CarePresidio Ospedaliero di GoriziaGoriziaItaly
M. A. de la CalDepartment of Intensive Care MedicineHospital Universitario de GetafeGetafe, MadridSpain
A. GulloDepartment of Anesthesia
and Intensive CareSchool of MedicineUniversity Hospital CataniaCataniaItaly
ISBN 978-88-470-1600-2 e-ISBN 978-88-470-1601-9DOI 10.1007/978-88-470-1601-9Springer Milan Heidelberg Dordrecht London New York
Library of Congress Control Number: 2011929635
� Springer-Verlag Italia 1998, 2005, 2012This work is subject to copyright. All rights are reserved, whether the whole or part of the material isconcerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcast-ing, reproduction on microfilm or in any other way, and storage in data banks. Duplication of thispublication or parts thereof is permitted only under the provisions of the Italian Copyright Law in itscurrent version, and permission for use must always be obtained from Springer. Violations are liable toprosecution under the Italian Copyright Law.The use of general descriptive names, registered names, trademarks, etc. in this publication does notimply, even in the absence of a specific statement, that such names are exempt from the relevantprotective laws and regulations and therefore free for general use.Product liability: The publishers cannot guarantee the accuracy of any information about dosage andapplication contained in this book. In every individual case the user must check such information byconsulting the relevant literature.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
The essential of intensive care is theprevention of complications
C. P. Stoutenbeek 1947–1998
Foreword
In 1847, Ignatius Semmelweis’s friend and colleague Jakob Kolletschka died ofsepsis after his finger had been cut during a post-mortem examination at theAllgemeine Krankenhaus in Vienna. Semmelweis made the connection betweenthe process which caused the death of his friend, and that which caused the post-partum deaths of so many of the mothers in his obstetric clinic at the hospital. Hisstudy of the prevention of puerperal sepsis through effective hand hygiene, and hissubsequent career, are classical examples of how inspired insight may fail to betranslated into effective action because of defective communication, professionalresistance to change, cultural incomprehension that beneficent individuals couldalso be agents of harm, and lack of an underpinning scientific mechanism.
No such criticisms can be made of the editors and contributors for this valuableand successful book, now in its third edition, which brings together internationalexperts in infection and infection control to review the most recent scientificevidence in preventing critically ill patients from suffering additional harm throughthe acquisition of autogenous and exogenous infections during their hospital stay.Wider attitudes to one of the components discussed, selective digestive decon-tamination, do bear some comparison with the Semmelweis story in terms of thegap between the scientific evidence and implementation in practice. Future edi-tions of this book will no doubt contain additional reflections from the behaviouralsciences. In the meantime, intensive care and infection control practitioners willfind both fact and wisdom in this compendium to guide their practice and improvepatient care.
November 2011 Julian BionProfessor of Intensive Care Medicine
University Department of Anaesthesia and ICMQueen Elizabeth Hospital
Edgbaston, Birmingham, UK
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Preface
A week-long postgraduate course was organised in Trieste, Italy, in 1994. Thiscourse was extremely popular Europe wide. Participants were so impressed thatthey asked for copies of the lectures, and as a result of the many requests, lecturerswere asked to provide a manuscript of their lecture(s). These manuscripts resultedin the first edition of this book, published in 1998.
This first edition contained five sections, each based on a day of the course,which comprised six lectures. The five sections Essentials in Clinical Microbiology,Antimicrobials, Infection Control, Infections on ICU, and Special Topics. Theformat remains the same today.
There are two previous editions to this 2011 edition: 1998 and 2005. Thedifferences between the first edition and this latest one are in the first and lastsections. Two chapters from the first edition are merged in the first section:Carriage, and Colonisation and Infection. This occurred because 85% of allinfections are endogenous and characterised by these three stages. The otherdifference is a chapter on microcirculation and infection in Section 5. Perhapsthe most important difference between the previous editions and this most recentedition is pictured on the front cover: 15% of all infections are exogenous, andresearch over the 6 years since the last edition has shown that topically appliedantimicrobials are able to control exogenous infections. However, topicallyapplied antimicrobials should only be part of the prophylactic protocol whenexogenous infections are endemic.
This third edition is current, with references to publications from 2011. Weregard it as important that all statements are justified by the best available evi-dence. All authors have made efforts to avoid unsubstantiated expert opinion.Although prevention is not entirely separate from therapy, prevention rather thancure is pivotal in this publication.
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We are grateful to Donatella Rizza, Catherine Mazars and Hilde Haala for thetheir superb assistance. We hope that this third edition is instructive, and helpful inyour daily practice and that you enjoy it.
November 2011 H. K. F. van SaeneL. Silvestri
M. A. de la CalA. Gullo
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Contents
Part I Essentials in Clinical Microbiology
1 Glossary of Terms and Definitions . . . . . . . . . . . . . . . . . . . . . . . 3R. E. Sarginson, N. Taylor, M. A. de la Caland H. K. F. van Saene
2 Carriage, Colonization and Infection . . . . . . . . . . . . . . . . . . . . . . 17L. Silvestri, H. K. F. van Saene and J. J. M. van Saene
3 Classification of Microorganisms Accordingto Their Pathogenicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29M. A. de la Cal, E. Cerdà, A. Abella and P. Garcia-Hierro
4 Classification of ICU Infections . . . . . . . . . . . . . . . . . . . . . . . . . . 41L. Silvestri, H. K. F. van Saene and A. J. Petros
5 Gut Microbiology: Surveillance Samples for Detectingthe Abnormal Carrier State in Overgrowth. . . . . . . . . . . . . . . . . 53H. K. F. van Saene, G. Riepi, P. Garcia-Hierro,B. Ramos and A. Budimir
Part II Antimicrobials
6 Systemic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67A. R. De Gaudio, S. Rinaldi and C. Adembri
7 Systemic Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99C. J. Collins and Th. R. Rogers
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8 Enteral Antimicrobials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123M. Sánchez García, M. Nieto Cabrera, M. A. González Gallegoand F. Martínez Sagasti
Part III Infection Control
9 Evidence-Based Infection Control in the Intensive Care Unit . . . . 145J. Hughes and R. P. Cooke
10 Device Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159A. R. De Gaudio, A. Casini and A. Di Filippo
11 Antibiotic Policies in the Intensive Care Unit . . . . . . . . . . . . . . . 173H. K. F. van Saene, N. J. Reilly, A. de Silvestre and F. Rios
12 Outbreaks of Infection in the ICU: What’s up at the Beginningof the Twenty-First Century? . . . . . . . . . . . . . . . . . . . . . . . . . . . 189V. Damjanovic, N. Taylor, T. Williets and H. K. F. van Saene
13 Preventing Infection Using Selective Decontaminationof the Digestive Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203L. Silvestri, H. K. F. van Saene and D. F. Zandstra
Part IV Infections on ICU
14 Lower Airway Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219J. Almirall, A. Liapikou, M. Ferrer and A. Torres
15 Bloodstream Infection in the ICU Patient . . . . . . . . . . . . . . . . . . 233J. Vallés and R. Ferrer
16 Infections of Peritoneum, Mediastinum, Pleura, Wounds,and Urinary Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251G. Sganga, G. Brisinda, V. Cozza and M. Castagneto
17 Infection in the NICU and PICU . . . . . . . . . . . . . . . . . . . . . . . . . 289A. J. Petros, V. Damjanovic, A. Pigna and J. Farias
18 Early Adequate Antibiotic Therapy. . . . . . . . . . . . . . . . . . . . . . . 305R. Reina and M. A. de la Cal
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19 ICU Patients Following Transplantation . . . . . . . . . . . . . . . . . . . 315A. Martinez-Pellus and I. Cortés Puch
20 Clinical Virology in NICU, PICU and AICU . . . . . . . . . . . . . . . . 333C. Y. W. Tong and S. Schelenz
21 AIDS Patients in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353F. E. Arancibia and M. A. Aguayo
22 Therapy of Infection in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . 373J. H. Rommes, N. Taylor and L. Silvestri
Part V Special Topics
23 The Gut in the Critically Ill: Central Organ in AbnormalMicrobiological Carriage, Infections, Systemic Inflammation,Microcirculatory Failure, and MODS . . . . . . . . . . . . . . . . . . . . . 391D. F. Zandstra, H. K. F. van Saene and R. E. Sarginson
24 Nonantibiotic Measures to ControlVentilator-Associated Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . 401A. Gullo, A. Paratore and C. M. Celestre
25 Impact of Nutritional Route on Infections: ParenteralVersus Enteral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411A. Gullo, C. M. Celestre and A. Paratore
26 Gut Mucosal Protection in the Critically Ill Patient:Toward an Integrated Clinical Strategy. . . . . . . . . . . . . . . . . . . . 423D. F. Zandstra, P. H. J. van der Voort, K. Thorburnand H. K. F. van Saene
27 Selective Decontamination of the Digestive Tract:Role of the Pharmacist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433N. J. Reilly, A. J. Nunn and K. Pollock
28 Antimicrobial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451N. Taylor, I. Cortés Puch, L. Silvestri, D. F. Zandstraand H. K. F. van Saene
Contents xiii
29 ICU-Acquired Infection: Mortality, Morbidity, and Costs . . . . . . 469J. C. Marshall and K. A. M. Marshall
30 Evidence-Based Medicine in ICU . . . . . . . . . . . . . . . . . . . . . . . . 485A. J. Petros, K. G. Lowry, H. K. F. van Saene and J. C. Marshall
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
xiv Contents
Contributors
A. Abella Department of Intensive Care Medicine, Hospital Universitario deGetafe, Madrid, Spain
C. Adembri Section of Anesthesiology and Intensive Care, Department of Med-ical and Surgical Critical Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
M. A. Aguayo Unidad de Cuidados Intensivos, Instituto Nacional Tórax, Santiago,Chile
J. Almirall PhD, MD Pneumology, Consorci Sanitari del Maresme, Barcelona,Spain
F. E. Arancibia Unidad de Cuidados Intensivos, Instituto Nacional Tórax,Santiago, Chile
G. Brisinda Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore,Rome, Italy
A. Budimir Department for Clinical and Molecular Microbiology, University ofZagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
A. Casini MD Careggi Teaching Hospital, Section of Anaesthesia, Department ofCritical Care, University of Florence, Florence, Italy
M. Castagneto Istituto di Clinica Chirurgica, Università Cattolica del SacroCuore, Rome, Italy
C. M. Celestre MD Department of Anesthesia and Intensive Care, School ofMedicine, University Hospital Catania, Catania, Italy
E. Cerdà Department of Intensive Care Medicine, Hospital Universitario de Parla,Madrid, Spain
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C. J. Collins Clinical Microbiology, Trinity College Dublin, Dublin, Leinster,Ireland
R. P. Cooke Department of Microbiology, University Hospital Aintree NHSFoundation Trust, Liverpool, Merseyside, UK
I. Cortés Puch Intensive Care Unit, Hospital Universitario de Getafe, Getafe,Madrid, Spain
V. Cozza Dipartimento di Chirurgia ‘‘F. Durante’’, ‘‘Sapienza’’ Università diRoma, Rome, Italy
V. Damjanovic School of Clinical Sciences, University of Liverpool, Liverpool,UK
A. R. De Gaudio MD Careggi Teaching Hospital, Section of Anaesthesia,Department of Critical Care, University of Florence, Florence, Italy
M. A. de la Cal Department of Intensive Care Medicine, Hospital Universitario deGetafe, Getafe, Spain
A. de Silvestre Department of Anesthesiology and Intensive care, UniversityHospital of S. Maria della Misericordia, Udine, Italy
A. Di Filippo MD Careggi Teaching Hospital, Section of Anaesthesia, Depart-ment of Critical Care, University of Florence, Florence, Italy
J. Farias Paediatric Intensive Care Unit, Children’s Hospital Ricardo Gutierrez,Buenos Aires, Argentina
M. Ferrer PhD, MD Servei de Pneumologia i Allèrgia Respiratòria, HospitalClínic, IDIBAPS, CibeRes (CB06/06/0028), Barcelona, Spain
R. Ferrer Critical Care Center, Hospital Sabadell, Sabadell, Barcelona, Spain
P. Garcia-Hierro Department of Medical Microbiology, Hospital Universitario deGetafe, Madrid, Spain
M. A. González Gallego Servicio de Medicina Intensiva, Hospital Clínico SanCarlos Universidad Complutense, Madrid, Spain
A. Gullo Department of Anesthesia and Intensive Care, School of Medicine,University Hospital Catania, Catania, Italy
J. Hughes Infection Prevention and Control, 5 Boroughs Partnership NHSFoundation Trust/University of Chester Warrington, Winwick, Warrington,Cheshire, UK
A. Liapikou MD 1st Department of Respiratory Medicine, SOTIRIA RegionalChest Disease Hospital of Athens, Athens, Greece
K. Lowry Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland,UK
xvi Contributors
J. C. Marshall Department of Surgery and Intensive Care, St Michael’s Hospital,Ontario, Canada
Department of Surgery and Interdepartmental Division of Critical Care, GeneralHospital and University of Toronto, Toronto, Canada
K. A. M. Marshall Department of Surgery and Interdepartmental Division ofCritical Care, General Hospital and University of Toronto, Toronto, Canada
A. Martinez-Pellus Intensive Care Unit, University Hospital ‘‘Virgen de la Ar-rixaca’’, Murcia, Spain
F. Martínez Sagasti Servicio de Medicina Intensiva, Hospital Clínico San CarlosUniversidad Complutense, Madrid, Spain
M. Nieto Cabrera Servicio de Medicina Intensiva, Hospital Clínico San CarlosUniversidad Complutense, Madrid, Spain
A. J. Nunn Pharmacy Department, Alder Hey Children’s NHS Foundation Trust,Liverpool, Merseyside, UK
A. Paratore MD Department of Anesthesia and Intensive Care, School of Med-icine, University Hospital Catania, Catania, Italy
A. J. Petros Pediatric Intensive Care Unit, Great Ormond Street Children’sHospital, London, UK
A. Pigna Neonatal Intensive Care Unit, San Orsola Ospedale, Bologna, Italy
K. Pollock Department of Pharmacy, Western Infirmary, K Pollock, SeniorPharmacist, Glasgow, UK
B. Ramos Department of Medical Microbiology, University Hospital Getafe,Madrid, Spain
N. J. Reilly Pharmacy Department, Royal Liverpool Children’s NHS Trust, AlderHey, Liverpool, UK
R. Reina Intensive Care Unit, Hospital Interzonal de Agudos ‘‘General SanMartín’’, La Plata, Buenos Aires, Argentina
G. Riepi Faculty of Medicine, University of Montevideo, Montevideo, Uruguay
S. Rinaldi Section of Anesthesiology, Villa Fiorita Hospital, Prato, Italy
F. Rios Pharmacy, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
Th. R. Rogers Clinical Microbiology, St. James’s Hospital and Trinity CollegeDublin, Dublin, Leinster, Ireland
J. H. Rommes PhD, MD Gelre Ziekenhuizen Apeldoorn, Intensive Care,Apeldoorn, The Netherlands
Contributors xvii
M. Sánchez Garcia PhD, MD Servicio de Medicina Intensiva, Hospital ClínicoSan Carlos Universidad Complutense, Madrid, Spain
R. E. Sarginson Paediatric Anaesthesia, Royal Liverpool Children’s NHS Trust,Liverpool, Merseyside, UK
S. Schelenz Institute of Biomedical and Clinical Sciences, School of Medicine,Health Policy and Practice Faculty of Health University of East Anglia, Norwich,UK
G. Sganga Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore,Rome, Italy
L. Silvestri Department of Emergency and Unit of Anesthesia and Intensive Care,Presidio Ospedaliero di Gorizia, Gorizia, Italy
N. Taylor School of Clinical Sciences, University of Liverpool, Liverpool,Merseyside, UK
K. Thorburn Paediatric Intensive Care Unit, Royal Liverpool Children’s NHSTrust Alder Hey, Liverpool, UK
C. Y. William Tong Infection, Guy’s and St Thomas’ NHS Foundation Trust andKing’s College London School of Medicine, London, UK
A. Torres MD Servei de Pneumologia i Al�lèrgia Respiratòria, Hospital Clínic,Barcelona, Spain
J. Vallés Critical Care Center, Hospital Sabadell, Sabadell, Barcelona, Spain
H. K. F. van Saene Institute of Ageing and Chronic Diseases, University ofLiverpool, Duncan Building, Liverpool, UK
School of Clinical Sciences, University of Liverpool, Liverpool, UK
J. J. M. van Saene School of Clinical Sciences, University of Liverpool,Liverpool, Merseyside, UK
P. H. J. van der Voort Department of Intensive Care Medicine, Onze LieveVrouwe Gasthuis, Amsterdam, The Netherlands
T. Williets School of Clinical Sciences, University of Liverpool, Liverpool, UK
D. F. Zandstra Department of Intensive Care Unit, Onze Lieve Vrouwe Gasthuis,Amsterdam, The Netherlands
xviii Contributors
