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10/16/2012
Dr.T.V.Rao MD
10/16/2012
Dr.T.V.Rao MD
EPIDEMIOLOGY
Contributing factors
Patients in ICUs have more chronic comorbid illnesses and more severe acute physiologic derangements. The high frequency of indwelling catheters among ICU patients The use and maintenance of these catheters necessitate frequent contact with health care workers, which predispose patients to colonization and infection with nosocomial pathogens. Multidrug-resistant pathogens such as methicillinresistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE) are being isolated with increasing frequency in ICUs
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Surgical-site infection
Nutrition-related and malnutrition
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Indications
IV fluids and drugs Blood and blood products Total Parenteral Nutrition (TPN) Hemodialysis Hemodynamic monitoring
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Incidence of CR-BSI
Type of catheter
Teflon or Polyurethane ( < infections) vs Polyvinyl chloride or Polyethylene
Site of insertion
Subclavian (< infections) vs Internal Jugular & Femoral (high risk of colonization & deep venous thrombosis)
Many CLs in patients on non-ICU hospital wards are placed outside those wards (Emergency room, ICU, Operating room, or Pre-operative areas) In one study, 49% of CLs were present on admission to the ward. Rates of BSI in this study were higher in CLs placed in Emergency Room Define where placement occurs and review technique in those areas
Trick et al. Am J Infect Control 2006;34:636-41.
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Sources of Infection
Intrinsic contamination of infusion fluid
Port for additives
Connection with administration set Insertion site Injection ports Administration set connection with IV catheter
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1. Extra luminal Spread Patients own skin micro flora Microorganism transferred by the hands of Health Care Worker Contaminated entry port, catheter tip prior or during insertion Contaminated disinfectant solutions Invading wound attachment Skin
Skin Fibrin
Sources of Infection
2. Intraluminal Spread Intralumunal Spread Contaminated infusate Contaminated (fluid, medication) infusate (fluid, medication)
Vein
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Prevention of CR-BSI
Written Protocol Sterile procedure
Must be performed by trained staff according to written guidelines Sterile gown, Sterile gloves, Sterile large drapes Don't shave the site
Hand disinfection
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Prevention of CR-BSI
Skin antisepsis 2% Chlorhexidine gluconate has shown to have lower BSI than 10% Povidone-iodine or 70 % Alcohol 2-min drying time before insertion
Maki DG et al. Lancet 1991;338:339-43
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Prevention of CR-BSI
Dressing
Gauze dressings every 2 days Transparent dressing every 7 days on short term catheter Replace dressing when catheter is replaced or dressing becomes damp or loose.
Grady NP et al, HICPAC draft guidelines: 2002
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Prevention of CR-BSI
Catheters removal
Dont replace it routinely Replace it if: Inserted in an Emergency Non functioning Evidence of local or systemic infection
General handling
Prevention of CR-BSI
Administration sets
Replacement at 72-h intervals No difference in phlebitis if left for 96 hours Lines for lipid emulsion: replacement at 24-h intervals Lines for blood product : remove immediately after use
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Prevention of CR-BSI
Topical antibiotic
Prophylactic use of topical Mupirocin (Bactroban) at insertion site or in nose is not recommended
Rapid development of Mupirocin resistant Mupirocin affect the integrity of Polyurethane catheter
Systemic antibiotic
Prophylactic use of antibiotic is not recommended at the time of catheter insertion
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Interventions
Michigan Keystone Project
Decrease in CLABSI in 103 ICUs in Michigan (66% reduction) Basic interventions:
Hand hygiene Full barrier precautions during CL insertion Skin cleansing with chlorhexidine Avoiding femoral site Removing unnecessary catheters Use of insertion checklist Promotion of safety culture
Urinary Catheterization
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+++
+++ +++
+++ ++ +
34
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45%
13%
29% 9%
2%
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4%
Haley, 1986 36
- Mechanical ventilation - Tracheostomy - Use of a Nasogastric Tube - Supine Position Factors that impede normal Pulmonary Toilet - Abdominal or thoracic surgery - Immobilisation
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Prevention in ICU
Turn patients to encourage postural drainage Encourage to take deep breaths and cough. Maintain an upright position (elevate patients head to 30- 45 degree angle) to reduce reflux and aspiration of gastric bacteria.
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Nasogastric Tube
May erode the mucosal surface Block the sinus ducts Regurgitation of gastric contents leading to aspiration. Verify placement of the feeding tube in the stomach or small intestine by X ray Elevate the head of the bed 30- 45 degrees
Ventilators
After every patient, clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturers instructions.
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Suction Bottle
Use single-use disposable, if possible Non-disposable bottles should be washed with detergent and allowed to dry. Heat disinfect in washing machine or send to Sterile Service Department.
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Nebulizers
Use sterile medications and fluids for nebulization Fill with sterile water only. Change and reprocess device between patients by using sterilization or a high level disinfection or use single-use disposable item. Small hand held nebulizers minimise unnecessary use between uses for the same patient disinfect, rinse with sterile water, or air dry and store in a clean, dry place Reprocess nebulizers daily
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Humidifiers
Clean and sterilize device between patients. Fill with sterile water which must be changed every 24 hours or sooner, if necessary. Single-use disposable humidifiers are available but they are expensive.
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Oxygen mask
Change oxygen mask and tubing between patients and more frequently if soiled
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Antibiotics use
Must avoid widespread use of broad spectrum antibiotics
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Fever >38 C OR urgency OR frequency OR dysuria OR suprapubic tenderness without other cause OR Urine culture with at least 105 organisms per ml or no more than two species of organisms
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Hand washing
Single most effective action to prevent HAI resident/transient bacteria Correct method - ensuring all surfaces are cleaned more important than agent used or length of time taken No recommended frequency - should be determined by intended/completed actions Research indicates: poor techniques - not all surfaces cleaned frequency diminishes with workload/distance poor compliance with guidelines/training
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Why we are not washing hands ??? Working in high-risk areas Lack of hand hygiene promotion Lack of role model Lack of institutional priority Lack of sanction of non-compliers
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EPIDEMIOLOGY
A multicenter, prospective cohort surveillance study of 46 hospitals in Central and South America, India, Morocco, and Turkey. Rates of device-associated infection were determined between 2002 and 2005; an overall rate of 14.7 percent or 22.5 infections per 1000 ICU days was found. Specific devices:
Ventilator associated pneumonia (VAP); 24.1 cases/1000 ventilator days (range 10.0-52.7) CVC-related bloodstream infections; 12.5/1000 catheter days (7.8-18.5) Catheter-associated urinary tract infections; 8.9/1000 catheter days (1.7-12.8)
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Do remember the Reasons for Infections are Many but solutions are few
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The Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World Email
doctortvrao@gmail.com
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