PREVENTION OF NOSOCOMIAL INFECTIONS

Dr. Sachin Verma MD, FICM, FCCS, ICFCFellowship in Intensive Care Medicine

Infection Control Fellows Course Consultant Internal Medicine and Critical Care

Ivy Hospital Sector 71 MohaliWeb:- http://www.medicinedoctorinchandigarh.com

Mob:- +91-7508677495

Principles of infection prevention

At least 35-50% of all healthcare-associated infections are associated with only 4 patient care practices:

Hand hygiene and standard precautions.Use and care of urinary cathetersUse and care of vascular access linesPrevention of health care associated pneumonia.

Alcohol-based handrub at point of

care

Access to safe, continuous water supply, soap and

towels

2. Training and Education

3. Observation and feedback

4. Reminders in the hospital

5. Hospital safety climate+

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• The 5 core components of the WHO Multimodal Hand Hygiene Improvement Strategy

1. System change

Why Don’t Staff Wash their

Hands?(Compliance estimated less than 50%)

Why Not?Skin irritationInaccessible hand washing facilitiesWearing glovesToo busyLack of appropriate staffBeing a physician

Why Not?

Working in high-risk areas

Lack of hand hygiene promotion

Lack of role model

Lack of institutional priority

Lack of sanction of non-compliers

Decontaminate hands

before having direct contact with patients or before inserting cvls

or other invasive devices that do not require surgical procedure

after having direct contact with a patient’s skin

after having contact with body fluids, wounds or broken skin if

not visibly soiled

after touching equipment or furniture near the patient

when moving from a contaminated body site to a clean-body site

during patient care

after removing gloves

Successful Promotion Education

Routine observation & feedback

Engineering controls

Location of hand basins

Possible, easy & convenient

Alcohol-based hand rubs available

Patient education

Successful Promotion

Reminders in the workplace

Promote and facilitate skin care

Avoid understaffing and excessive workload

Hand Hygiene Techniques

1. Alcohol hand rub

2. Routine hand wash 10-15 seconds

3. Aseptic procedures 1 minute

4. Surgical wash 3-5 minutes

Areas Most Frequently Missed

Routine Hand Wash

Alcohol Hand RubsRequire less time

Can be strategically placed

Readily accessible

Multiple sites

All patient care areas

Alcohol Hand RubsActs faster

Excellent bactericidal activity

Less irritating (??)

Sustained improvement

Visible soiling

Hands that are visibly soiled or potentially

grossly contaminated with dirt or organic

material MUST be washed with liquid soap

and water

Prevention of Catheter-Associated Urinary Tract Infection (CA-UTI)

Two main principles1 Avoid unnecessary catheterization2 Limit the duration of catheterization

Catheter insertion and maintenance

Practice hand hygienebefore insertion of the catheterbefore and after any manipulation of the catheter site

Catheter insertion and maintenance

Insert catheters by use of aseptic technique and sterile equipment

Cleanse the meatal area with antiseptic solutions is unnecessary Routine hygiene is appropriate

Properly secure indwelling catheters after insertion to prevent movement and urethral traction

Maintain a sterile, continuously closed drainage system

Do not disconnect the catheter and drainage tube unless the catheter must be irrigated

What you should not do to prevent catheter associated UTI

Do not use (avoid) catheter irrigation

Do not use systemic antimicrobials routinely as prophylaxis

Do not change catheters routinely

CATHETOR ASSOCIATED BLOOD STREAM INFECTIONS

Multimodal intervention strategies to reduce catheter-associated bloodstream infections:

- Hand hygiene- Maximal sterile barrier precaution at insertion- Skin antisepsis with alcohol-based chlorhexidine-

containing products- Subclavian access as the preferred insertion site- Daily review of line necessity- Standardized catheter care using a non-touch technique- Respecting the recommendations for dressing change

Education-based, multimodalprevention strategy of catheter related

infections

HEALTH CARE ASSOCIATED PNEUMONIA

1. Hand hygiene before and after patient contact, preferably by using alcohol based handrubbing

2. Avoid endotracheal intubation if possible 3. Use of oral, rather than nasal, endotracheal tubes

4. Minimize the duration of mechanical ventilation

5. Promote tracheostomy when ventilation is needed for a longer term

6. Glove and gown use for endotracheal tube manip

Prevention of Ventilator Associated Pneumonia

7. Avoid non-essential tracheal suction

8. Oral hygiene with chlorhexidine

9. Backrest elevation 30-45o

10. Maintain tracheal tube cuff pressures (>20) to prevent regurgitation from the stomach

11. Avoid gastric overdistension

12. Promote enteral feeding

13. Careful blood sugar control in patients with diabetes

14. Selective decontamination of digestive tract (SDD )in selected cases

Prevention of Ventilator Associated Pneumonia

Continuous Removal of Subglottic Secretions

Use an ET tube with

continuous suction

through a dorsal lumen

above the cuff to

prevent drainage

accumulation

HOB Elevation

HOB at 30-45o

Intubation and ventilation

• Avoid intubation and reintubation • Prefer non-invasive ventilation • Prefer orotracheal intubation & orogastric tubes • Continous subglottic aspiration • Cuff pressure > 20 cm H2O • Avoid entering of contaminate consendate into

tube/nebulizer • Use sedation and weaning protocols to reduce duration • Use daily interruption of sedation and avoid paralytic

agents

Systemic and enteral antibiotics

• Selective decontamination of the digestive tract (SDD) reduces the incidence of VAP.

• But SDD not recommended for routine use

• Prior systemic antibiotics helps to reduce VAP in selected patient groups but increases MDR

Stress bleeding, transfusion, hyperglycemia

• Trend towards less VAP with sucralfate (vs H2 blockers) but increased gastric bleeding

• Prudent transfusion, leukocyte-depleted red blood cell transfusion

• Intensive insulin therapy to keep glucose 80 - 110 mg/dl

Aspiration, body position

• Semirecumbent position (30 - 45°) especially when receiving enteral feeding

• Enteral nutrition is preferred over parenteral because of translocation risk

CLINICAL PULMONARY INFECTION SCORE

Criterion ScoreFever (°C) 38.5 but 38.9 1 >39 or < 36 2Leukocytosis <4000 or >11,000/L 1 Bands > 50% 1 (additional)Oxygenation (mmHg) PaO2/FIO2 <250 and no ARDS

2

Chest radiograph Localized infiltrate 2 Patchy or diffuse infiltrate 1 Progression of infiltrate (no ARDS or CHF) 2Tracheal aspirate Moderate or heavy growth 1 Same morphology on Gram's stain 1 (additional) Maximal scorea

12

"Bundled Interventions" to Prevent Common Health Care–Associated Infections and Other Adverse Events

Prevention of Central Venous Catheter Infections

Educate personnel about catheter insertion and care.

Use chlorhexidine to prepare the insertion site.

Use maximum barrier precautions during catheter insertion.

Ask daily: Is the catheter needed?

Prevention of Ventilator-Associated Pneumonia and Complications

Elevate head of bed to 30–45 degrees.

Give "sedation vacation" and assess readiness to extubate daily.

Use peptic ulcer disease prophylaxis.

Use deep-vein thrombosis prophylaxis (unless contraindicated).

Prevention of Surgical-Site Infections

Administer prophylactic antibiotics within 1 h before surgery; discontinue within 24 h.

Limit any hair removal to the time of surgery; use clippers or do not remove hair at all.

Maintain normal perioperative glucose levels (cardiac surgery patients).a

Maintain perioperative normothermia (colorectal surgery patients).a

Prevention of Urinary Tract Infections

Place bladder catheters only when absolutely needed (e.g., to relieve obstruction), not solely for the provider's convenience.

Use aseptic technique for catheter insertion and urinary tract instrumentation.

Minimize manipulation or opening of drainage systems.

Remove bladder catheters as soon as is feasible.

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