Download Current Challenges in the ICU Prof C Williams

Current Challenges in
the ICU
Prof Craig Williams
Institute of Healthcare Associated
Infection UWS
Is HAI a problem in ICU
Type of ward
Prevalence HAI %
General
4.8
ICU
14.2
p<0.0001
Scottish prevalence study 2011
Does it matter?
• Analysis of an American hospital database:
• In-hospital mortality in ICU patients was 4 times higher in patients with
HAI (18.5% vs 4.5%).
• Length of stay in the ICU doubled in patients with HAI, from a mean of
8.1 days to 15.8 days.
• Central catheter use OR, 3.4 or mechanical ventilation [OR, 2.8], trebled
the risk of developing an HAI
Joly 22nd European Congress of Clinical Microbiology and Infectious Diseases 2012
How do infections occur
ICU Infection may be complex
• Bugs need to get onto the patient
• Hands
• Environment
• Patients own flora
• Devices then breach the patients
defences
• Infection occurs
Intubation Associated Pneumonia rate
Bacteria causing ICU pneumonia S&W
BSI Scotland only
Things are improving
Current Challenges
•We know the bugs
•We understand the route of infection
•We’ve got the bundles
•Why are we still getting HAI
Unit as a
whole
Hospital
Environment
Patient Factors
Unit as a whole: Effect of Surveillance
• 2,771 patients, 19,848 intubation-days
• A quasi-experimental study 2004-2010 in two ICUs
• Surveillance was interrupted during the year 2007 in unit A and
continuous in unit B
• The VAP rate increased in unit A from 7.8% to 17.1% 2 (P <0.001);
• in unit B, it was 7.2% and 11.2% (P = 0.17).
• All-cause mortality and length of stay increased in unit A (P = 0.028
and P = 0.038), In unit B, no change in mortality was observed (P =
0.22),
• VAP incidence, length of stay and all-cause mortality rose after HAI
surveillance disruption in ICU.
Benet Critical Care 2012, 16:R161
Patient factors:Oral Hygiene and VAP
• Does dental treatment enhance oral antisepsis, thus preventing (LRTIs)
• Observer-blind randomized clinical trial 254 adult patients in ICU
• The experimental group (n = 127) had access to dental care provided by a dental
surgeon, 4-5 times a week. Besides routine oral hygiene, care also included teeth
brushing, tongue scraping, removal of calculus, atraumatic restorative treatment
of caries, and tooth extraction.
• The control group (n = 127) had access to routine oral hygiene only, which
included the use of chlorhexidine as a mouth rinse, which was performed by the
ICU nurse staff.
• Ventilator-associated pneumonia rates per 1,000 ventilator-days were 16.5 (95%
CI, 9.8-29.5) in the control group and 7.6 (95% CI, 3.3-15.0) in the experimental
group (P < .05).
Bellissimo-Rodrigues, ICHE 2014 Nov;35(11):1342-8.
Patient Factors:Decolonisation Strategies
all adult ICUs in a given hospital
assigned to the same strategy.
Group 1 implemented MRSA screening
and isolation;
group 2, targeted decolonization (i.e.,
screening, isolation, and
decolonization of MRSA carriers);
group 3, universal decolonization
Huang N Engl J Med 2013; 368:2255-2265
Hospital environment: Copper
ICU patients assigned to:
traditional patient room
copper room where bed
rails, tables, IV poles, and
nurse’s call buttons were
made solely from copperbased metals.
Hospital environment: Copper
The proportion of patients who
developed HAI and/or
colonization with MRSA or VRE:
copper surfaces (7.1%)
traditional rooms (12.3%).
The proportion of patients
developing HAI with MRSA or
VRE
copper rooms (3.4%)
traditional rooms (8.1%).
How long does
cleaning last?
• What is an acceptable level of
microbial flora on high-touch
surfaces? ≤100 CFU/100
cm2 potential pathogens
• ≤250 CFU/100 cm2 total microbial
colony counts.
Attaway AJIC 2012 Dec;40(10):907-12
Environment, single v multibed rooms
Rates of acquisition of infectious organisms in an ICU before and after a change
from multibed to single rooms.
•
•
•
•
The methicillin-resistant S aureus acquisition rate fell by 47% (95% CI,1%-71%)
C difficile acquisition rate fell by 43% (95% CI, 7%-65%), and the
yeast acquisition rate fell by 51% (95% CI, 34%-64%).
No effect was observed on the acquisition rate of coagulase-negative Staphylococcus species,
the most common endogenous organism, for which no change would be expected.
Conversion to single rooms can substantially reduce the rate
at which patients acquire infectious organisms while in
the ICU.
Teltsch Arch Intern Med. 2011,10;171(1):32-8.
Summary
• HAI in ICU is multifactorial
• Many improvements have been made and the number of infections is
decreasing
• Additional further improvements may be made by focusing on
• methods of reducing bacterial load/colonisation
• The hospital environment
• audit
Thanks
PJ Pseudomonas in the Paediatric Intensive care 1.pptx