Download Cumulative risk of developing VAP with the duration of mechanical

Need for a Global Approach

Global burden: HAIs lead to excess morbidity,
mortality, and healthcare costs worldwide

Proliferation of invasive healthcare internationally
without commensurate infection prevention
infrastructure

Antimicrobial resistance: everyone’s problem
Global Burden

Healthcare-associated infection (HAI) in the United
States (2002)
 1/20 patients
 1.7 million HAIs
 99,000 deaths

Developing countries
 Limited data from low income countries
 Estimated prevalence: at least three times greater than United
States
Klevens et al Public Health Reports 2007.
Allegranzi et al Lancet 2011.
Why might there be more HAIs in
middle- and low-income countries?

Less infection prevention and control infrastructure

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Training lacking in general infection control
Improper use of equipment (e.g., reuse of single-use equipment)
Insufficient reprocessing
Less surveillance, awareness, and targeted prevention efforts
Proliferation of invasive medical care across the
globe
 Large dialysis organizations expanding across boarders
 Increase in medical tourism
Antimicrobial Resistance

Studies suggest that approximately ½ of
antimicrobial use in US healthcare settings is
inappropriate

Rising resistance leads to decreasing treatment
options and increasing cost

Inappropriate prescribing contributor to C. difficile
epidemic
Klebsiella Pneumoniae
Carbapenemase
KPC confers resistance to all b-lactams including
extended-spectrum cephalosporins and carbapenems
Is the predominant mechanisms of carbapenem
resistance in Enterobacteriaceae (CRE) in the
US.
Mortality-associated with Resistance
OR 3.71 (1.97-7.01)
OR 4.5 (2.16-9.35)
Patel et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
Multidrug Resistant Organism (MRO)
• Multidrug resistant organisms of concern at
PSMH are Methicillin Resistant Staphylococcus
Aureus (MRSA), Vancomycin Resistant
Entercoccus (VRE) and Clostridium Difficile (C.
Dif)
• MRO’s are bacteria that have become
resistant to many of the antibiotics used to
treat infections caused by them.
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Clostridium Difficile
 Patients admitted with diarrhea or develop diarrhea
after admission are placed in Contact Isolation until
C. dif is ruled out and Infection Control Department
discontinues isolation.
 Positive C.dif patients are to be in Contact Isolation
until discharge
 Never use Alcohol foam or gel for hand hygiene
(Alcohol foam and gels do not kill C. diff spores)
 Always wash hands with soap and water (use friction
when washing hands with soap and water to rinse
spores down the drain).
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Toxic Colon from C Difficile
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Cost of NCI
England
• Average cost per NCI: 3.000 pounds
• Extra days:
Urinary tract infections:
Pneumonia:
Surgical site infections:
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Why surveillance?
• NCI cause of morbidity and mortality
• One third may be preventable
• Surveillance = key factor
– an infection control measure
– overview of the burden and distribution of NCI
– allocate preventive resources
• Surveillance is cost-efficient!!
Infection Control Unit
Global Disease Detection & Response Program
US Naval Medical Research Unit No.3
 Head
 IC specialists
 IC training





coordinator
Epidemiologists
M &E specialists
Pharmacist
Health
communication
specialist
Anthropologist
What are Hospital Acquired Infections (HAI’s)
•
•
•
•
•
Blood Stream Infections
Ventilator Associated Pneumonia (VAP)
Surgical Site Infections (SSI)
Urinary Catheter Associated Infection (CAUTI)
Multi-drug Resistant Organism (MRO)
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Healthcare-Associated Infection (HAI)
Types
HAI
Pneumonia
Deviceassociated
infections
(subtypes)
Ventilatorassociated
(VAP)
Urinary tract
infection
Catheterassociated
(CAUTI)
Bloodstream
infection
Central lineassociated
(CLABSI)
Target of many prevention efforts
Picture courtesy S Schrag
http://www.lightstalkers.org/images/show/305512
http://www.featurepics.com/FI/Thumb300/20090428/Foley-Bag-1166380.jpg
Surgical
Site
Infection
Others
Cumulative risk of developing VAP with the duration of
mechanical ventilation.
• Although length of time with an endotracheal tube in
place increases the risk of nosocomial pneumonia,
the greatest risk is during the first 2 weeks of
intubation.
• Nearly all intubated children will have colonization of
their endotracheal tube with hospital-acquired
organisms by a mean of 5 days.
The most common organisms isolated in the
developing countries
• Enterobacteriaceae spp. (26%)
• Pseudomonas aeruginosa (26%), with
60% resistant to fluoroquinolones
• S. aureus (22%), with 84% methicillin
resistant
• Acinetobacter spp. (20%)
• The bacterial organisms identified most often are
gram-negative bacilli, with P. aeruginosa being the
most common species identified in PICUs.
• The second most common bacterial etiology of
pediatric nosocomial pneumonia is the gram-positive
organisms. The frequently isolated bacteria are S.
aureus and coagulase-negative staphylococci.
• S. epidermidis nosocomial pneumonia is a common
cause in the NICU population and is typically the
result of hematogenous spread.
• Anaerobic nosocomial pneumonia is rare in the
pediatric population but accounts for 23% of
nosocomial pneumonias in adults.
Ventilator associated
pneumonia
 Ventilator-associated pneumonia
remain important causes of
morbidity and mortality despite
 advances in antibiotics therapy,
 better supportive care modalities,
 and use of a wide-range of preventive
measures
Ventilator associated
pneumonia
 The exact incidence of VAP is 6 to 20 fold greater
than in Non-Ventilated patients.
 VAP is associated with a higher crude mortality
than other hospital-acquired infections (Level II).
How does the lung get infected ?
 Sources of pathogens for VAP include
 The environment (air, water, equipment,), and
 Transfer of microorganisms between the patient and
staff or other patients (Level II)
 A number of host- and treatment-related factors,
 Severity of the patient’s underlying disease,
 Prior surgery,
 Exposure to antibiotics
 Exposure to invasive respiratory devices and equipment.
(Level II).
How does the lung get infected ?
 Aspiration of
 oropharyngeal pathogens, or
 leakage of secretions around the
endotracheal tube
are the primary routes of bacterial entry into
the lower respiratory tract (Level II)
How does the lung get infected ?
 Hematogenous spread from infected intravenous
Catheters.
 Bacterial translocation from the gastrointestinal
tract lumen are uncommon pathogenic mechanisms
(Level II)
How does the lung get infected ?
 Infected bio-film in the endotracheal
tube, with subsequent embolization to distal
airways, may be important in the pathogenesis
of VAP (Level III)
 The sinuses may be potential reservoirs of
nosocomial pathogens but their contribution is
controversial, (Level II)
Things that DO NOT prevent VAP
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Chest physiotherapy
Early tracheostomy.
Change of ventilatory circuits
Change of HME filters
In line suctioning
Prophylactic antibiotics
Risk factors for Ventilator-Associated
Pneumonia (VAP)
Patient
•
Age
•
Burns
•
Coma
•
Lung disease
•
Immunosuppression
•
Malnutrition
•
Blunt trauma
Devices
• Invasive ventilation
• Duration of invasive
ventilation
• Reintubation
• Medication
• Prior antiobiotic
treatment
• Sedation
VAP Prevention
1. Hand hygiene before and after patient contact,
preferably 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
VAP Prevention (con’t)
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
Is there a role for oral antiseptics ?
•
Oral chlorhexidine application reduces
VAP in one study but not for general
use – I
ATS Guidelines 2005
Catheter Associated Urinary Tract
Infections (CAUTI)
• Urinary Catheter Associated Infections are
defined as an infection occurring 48 hours
after insertion of a urinary catheter, signs and
symptoms of infection (fever, pain, frequency,
urgency, increased white count, etc.) and a
positive urine culture of 100,000CFU/ml with
no more than 2 species of bacteria.
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Prevention of Catheter-Associated
Urinary Tract Infection (CA-UTI)
Two main principles
Avoid unnecessary catheterization
Limit the duration of catheterization
Indications for the use of indwelling urethral
catheters
• Indications
–
–
–
–
–
Perioperative use for selected surgical procedures
Urine output monitoring in critically ill patients
Management of acute urinary retention and urinary obstruction
Assistance in pressure ulcer healing for incontinent residents
As an exception, at patient request to improve comfort
• Urinary incontinence is not an accepted indication for
urinary catheterization
– 21 to 50 percent of urinary catheters not indicated
Lo et al. (2008) Infect Control Hosp Epidemiol Suppl 1:S41-50
What you should not do to prevent CAUTI
• Do not use (avoid) catheter irrigation (A-I)
• Do not use systemic antimicrobials routinely as prophylaxis (A-II)
• Do not change catheters routinely (A-III)
Lo et al. (2008) Infect Control Hosp Epidemiol Suppl 1:S41-50
Sources of the catheter-associated
bloodstream infection
Intraluminal from
tubes and hubs
Hematogenous
from distant sites
Skin
Vein
Extraluminal from
skin
Multimodal intervention strategies to reduce
catheter-associated bloodstream infections:
- Hand hygiene
- Maximal sterile barrier precaution at insertion
- Skin antisepsis with alcohol-based chlorhexidinecontaining 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
Eggimann P. Lancet 2000; 35: 290
Pronovost P. N Engl J Med 2006; 355: 26
Zingg W. Crit Care Med 2009; 37: 2167
GENERAL PRINCIPLES
Good general ward hygiene:
- No overcrowding
- Good ventilation
- Regular removal of dust
- Wound dressing early in day
- Disposable equipment
 HAND WASHING
most important Before and after patient contact
before invasive procedures
Many Personnel Don’t Realize
When
They Have Germs on Their Hands
• Healthcare workers can get 100s to 1000s of bacteria on their
hands by doing simple tasks like:
–
–
–
–
–
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pulling patients up in bed
taking a blood pressure or pulse
touching a patient’s hand
rolling patients over in bed
touching the patient’s gown or bed sheets
touching equipment like bedside rails, overbed tables, IV pumps
Casewell MW et al. Br Med J 1977;2:1315
Ojajarvi J J Hyg 1980;85:193
Why
Don’t Staff Wash
their Hands
(Compliance estimated at less than 50%)
Why Not?
•
•
•
•
•
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Skin irritation
Inaccessible hand washing facilities
Wearing gloves
Too busy
Lack of appropriate staff
Being a physician
(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection
Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)
Why Not?
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•
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•
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Working in high-risk areas
Lack of hand hygiene promotion
Lack of role model
Lack of institutional priority
Lack of sanction of non-compliers
Successful Promotion 
• Education
• Routine observation & feedback
• Engineering controls
– Location of hand basins
– Possible, easy & convenient
– Alcohol-based hand rubs available
• Patient education
(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page
381)
Hand hygiene is the
simplest, most effective
measure for preventing
hospital-acquired
infections.
Any Questions???
• Thank you for not asking!!!