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Intensive Care Unit
infections
ICU patients
Sickest patients (multiple diagnoses,
multi-organ failure,
immunocompromised, septic and
trauma)
Move less
Malnourished
More obtunded (Glasgow coma
scale)
Diabetics and Heart failure
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ICU Care is Invasive
More invasive lines and
procedures including
surgeries
Longer length of stay
More IV and parenteral
drugs
More tube feeding and
Parenteral nutrition
More
ventilation
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ICU : Factors that increase crossinfections
Hand washing facilities
Patient close together or sharing rooms
Understaffing
Preparation of IVs on the unit
Lack of isolation facilities
No separation of clean and dirty AREAS
Excessive antibiotic use
Inadequate decontamination of items & equipments
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dr yrkefallah-phd
of nursing-2015
Inadequate
cleaning
of environment
Some Health-Care Associated
Infections that May Occur
UTI associated with Foley catheters
Lower respiratory tract infection (post-op
and ventilator dependent)
Skin necrosis (skin breakdown)
Blood stream infection (and line associated)
Surgical-site infection
Nutrition-related and malnutrition
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Strategy for Prevention
Handwashing
Use gloves to prevent contamination of
the hands when handling respiratory
secretions
Wear gloves and gowns (contact
precautions) during all contact with
patients and fomites potentially
contaminated with respiratory
secretions
Use aseptic technique
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Strategy for Prevention
Clean and decontaminate all equipment after use
Sterilise or use high-level disinfection for all items
that come into direct or indirect contact with
mucous membranes
Rinse and dry items that have been chemically
disinfected
Package and store items to prevent contamination
before use
Keep environment clean, dry and dust free
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Conclusions : Strategy for Infection
Prevention
Strict attention to Hand hygiene
Prudent Antibiotic use
Aseptic technique
Disinfection/Sterilization of items and equipment
Education of staff infection control awareness
Keep Environment Clean, Dry and dust free
Surveillance of nosocomial infection to identify
problems areas & set priorities
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Intensive Care Unit
Prevention of Blood stream infections
Central Venous Catheters
Indications
IV fluids and drugs
Blood and blood products
Total Parenteral Nutrition (TPN)
Haemodialysis
Haemodynamic monitoring
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Serious Infective
Complications
Blood Stream Infections (BSI)
Septic pulmonary emboli
Metastasis infection
– Acute endocarditis
– Osteomyelitis
– Septic arthritis
Shock and organ failure
Poor outcome: Staph.aureus or Candida.
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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)
No. of Lumen
Single-lumen catheter (< infections) vs Multi-lumen
catheter
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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. Extraluminal Spread
Patient’s 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
Sources of Infection
2.
IntraluminalSpread
Spread
Intralumunal
Contaminated
Contaminatedinfusate
(fluid,
medication)
infusate
(fluid,
medication)
Skin attachment
Skin
Fibrin
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Vein
3. Haematogenous Spread
Infection from distant
focus
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Prevention of CR-BSI
Written Protocol
Must be performed by trained staff according to
written guidelines
Sterile procedure
Sterile gown, Sterile gloves, Sterile large drapes
Don't shave the site
Hand disinfection
With an antiseptic solution eg
gluconate
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Chlorhlexidine
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Prevention of CR-BSI
Skin antisepsis
2% Chlorhlexidine gluconate has shown
to
have lower BSI than 10% Povidone-iodine
or 70 % Alcohol
2-min drying time before insertion
Chlorhlexidine gluconate or 10% Povidoneiodine
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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.
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Prevention of CR-BSI
Catheters
removal
Don’t replace it routinely
Replace it if:
– Inserted in an Emergency
– Non functioning
– Evidence of local or systemic infection
General handling
Opening of hub: Use antiseptic-impregnated
pads eg Chlorhexidine gluconate or povidone
iodine
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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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Urinary Catheterization
External urethral meatus &
urethra
Pass catheter when bladder full for wash-out
effect.
Before catheterization prepare urinary meatus
with an antiseptic ( e.g. povidone iodine or 0.2%
chlorhexidine aqueous solution)
Inject single-use sterile lubricant gel (e.g. 1-2%)
lignocaine into urethra and hold there for 3
minutes before inserting catheter.
Use sterile catheter.
Use non-touch technique for insertion
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Junction between catheter &
drainage tube
Do not disconnect catheter unless
absolutely necessary.
For urine specimen collection disinfect
outside of catheter proximal to junction
with drainage tube by applying alcoholic
impregnated wipe and allow it to dry
completely then aspirate urine with a
sterile needle and syringe.
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Junction between drainage tube
& collection bag
Keep bag below level of bladder. If it is
necessary to raise collection bag above
bladder level for a short period, drainage
tube must be clamped temporarily.
Empty bag every 8 hours or earlier if full.
Do not hold bag upside down when
emptying
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Tap at bottom of collection
bag
Collection bag must never touch floor.
Always wash or disinfect hands (eg with
70% alcohol) before and after opening tap.
Use a separate disinfected jug to collect
urine from each bag.
Don't put disinfectant into urinary bag.
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Intensive Care Unit
Nosocomial Pneumonia
Risk factors for bacterial
pneumonia
Host Factors
Elderly
Severe Illness
Underlying Lung Disease
Depressed Mental Status
Immunocompromising
Conditions or Treatments
Viral Respiratory Tract
Infection
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Risk factors for bacterial
pneumonia
Colonisation
Intensive Care Setting
Use of Antimicrobial Agents
Contaminated hands
Contaminated Equipment
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Risk factors for bacterial
pneumonia
Factors that facilitate reflux
& aspiration into the lower RT
- Mechanical ventilation
- Tracheostomy
- Use of a Nasogastric Tube
- Supine Position
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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
patient’s head to 30º- 45º degree angle) to
reduce reflux and aspiration of gastric
bacteria.
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Gastric Ulcer Prophylaxis
Stomach of a healthy person : Acidic pH () &
normal peristalsis movement prevent bacterial
growth
Alkaline pH () and loss on normal peristalsis
lead to bacterial colonisation which increases
the risk of ventilator-associated pneumonia
Mechanical ventilation patients are at increased
risk for upper GI haemorrhage from stress
ulcers.
H2 blockers or antacids are used to prevent
stress ulcers dr yrkefallah-phd of nursing-2015
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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 30º- 45 º
degrees
Remove NG Tube if not necessary
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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
manufacturer’s instructions.
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Suctioning mechanically
ventilated patients
Handwashing before and after the
procedure.
Wear clean gloves to prevent crosscontamination
Use a sterile single-use catheter ; if it is not
possible then rinse catheter with sterile
water and store it in a dry, clean container
between uses and change the catheter
every 8 - 12 hours.
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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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Problem-Detection in
the ICU’s
Examples illustrating difficult to
detect infections:
Long Incubation period
• Hard to detect HIV, Hep B or Hep C due to
long incubation period
• Easier to detect Staph aureus food borne
illness, or toxic shock due to re-use of
medication vial.
• These infections occur 1 hr to days post
event.
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Examples of difficult to detect
infections:
Uncultivable organisms
Viruses are under appreciated as causes of
nosocomial infections. Except in cases of high
morbidity viral cultures are not done in resource
scarce settings. Impact food-borne, respiratory,
water borne illnesses.
We don’t know the spectrum of anti-microbial
activity of most preservatives and cleaners for
many viruses.
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Define the problem to tracked
Advantages:
– The occurrence then can be compared in
different facilities and in different time periods
– Definitions can be suspect, probable or
– confirmed depending upon the information
that is available
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Examples from the NNIS
Manual
Symptomatic Urinary Tract Infection:
– Patient must have one of the two criteria:
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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Definition of surgical site
infection (no implant)
Occurs within 30 days of surgery
AND has one of the following:
Purulent drainage from drain OR
Organism isolated from aseptically
obtained fluid in the organ space
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Example of lab-confirmed
blood stream infection
Patient has a recognized pathogen cultured from
one or more blood cultures
AND
Organism cultured is not related to another
infection at another site
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Prior to starting any
surveillance
Agree upon a written case definition that is
practical given the laboratory facilities and
patient work load in your facility.
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