Download Infections in the intensive care unit

Infections in the
intensive care unit
Wanida Paoin
Thammasat University
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 vancomycinresistant enterococci (VRE) are being isolated with
increasing frequency in ICUs
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:
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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)
CATHETER-ASSOCIATED UTI
 UTI is the most common nosocomial infection (> 40%
of all nosocomial infections)
 CAUTIs are the second most common cause of
nosocomial bloodstream infection, which have an
attributable mortality
 Risk factors
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The major risk factor is an indwelling urinary catheter
The risk increases directly with the duration of
catheterization.
The daily incidence of catheter-associated bacteriuria is
approximately 5%
After catheters have been in place for 1 week, bacteriuria
or candiduria develop in 25%; after 30 days, the great
majority of patients will have bacteriuria.
CATHETER-ASSOCIATED UTI
 Other important risk factors for CAUTI
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Patients with other sites of active infection
Long hospital stay
Malnutrition
Female sex
Abnormal serum creatinine
Improper catheter care (particularly placement
of the drainage tube above the level of the
bladder)
Prevention
 The most effective method to prevent CAUTI is to avoid
unnecessary placement of indwelling urinary catheters
and to limit the duration of catheterization once a
catheter is in place.
 Use of indwelling catheters should be limited to
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patients with anatomic or physiologic urinary
obstruction;
patients undergoing surgery of the genitourinary tract;
patients requiring accurate monitoring of urine output
(ie, critically ill or postoperative patients);
debilitated, comatose, or paralyzed patients.
 Once a catheter is in place, it should be removed as
quickly as possible, when it is no longer needed.
Prevention
 The condom catheter is a good alternative to the
indwelling catheter for men and is associated with lower
rates of bacteriuria
 Intermittent bladder catheterization has been shown to
reduce the incidence of UTI in long-term spinal cord
injury patients compared to an indwelling catheter, this
approach has not been studied in patients with shorterterm indwelling bladder catheters.
 Suprapubic catheters might be more comfortable for
patients and have been shown to lower the incidence of
bacteriuria
Catheter insertion and maintenance
 Aseptic technique: handwashing, sterile gloves,
a sterile drape, antiseptic solution
 Once in place,
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Maintaining a closed drainage system
The only part of the drainage system that
should be opened is the bag drainage tube
The number of manipulations and accesses of
the drainage system should be minimized.
The collecting tubing and bag should always be
placed below the patient and the tubing should
be maintained at a level above the drainage bag
Antimicrobial therapy
 Topical antimicrobials
Place between the catheter and urethral mucosa
 Soaking catheters in, continuous irrigation of the bladder with
an anti-infective solution,
 Placement of anti-infective solutions into the collection bag
 Not been shown to effectively prevent CAUTI
 Systemic antimicrobial prophylaxis
 Can reduce the risk for CAUTI in short-term catheterization;
 Increased long term risk for infections caused by multidrug
resistant organisms
 Treatment of asymptomatic bacteriuria does not decrease the
incidence of febrile episodes but does increase the recovery of
antibiotic-resistant bacteria
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Different catheter composition
 Catheters impregnated with antimicrobial agents
(minocycline and rifampin) and the antiseptic agent
nitrofurazone have been demonstrated to reduce
CAUTI rates in small studies
 The potential for selection of multidrug-resistant
pathogens
 The silver-hydrogel catheter prevents adherence of
bacterial and yeast pathogens to the catheter surface.
 Catheters coated with antiseptic silver compounds have
shown promise by some investigators but have been
ineffective in other large, well-controlled trials.
Strategies for Prevention of CAUTI
Avoid unnecessary placement of indwelling urinary +++
catheters
Remove catheters as quickly as possible
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Alternative condom catheter, intermittent bladder
catheterization
Aseptic technique in catheter insertion
Appropriate catheter maintenance
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Antimicrobial therapy
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Different catheter composition
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