Prevention of nosocomial infections

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

1. PREVENTION OF NOSOCOMIAL INFECTIONS Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Ivy Hospital Sector 71 Mohali Web:- http://www.medicinedoctorinchandigarh.com Mob:- [phone]

2. 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 catheters Use and care of vascular access lines Prevention of health care associated pneumonia .

3. Alcohol-based handrub at point of care A ccess 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 + + + + The 5 core components of the WHO Multimodal Hand Hygiene Improvement Strategy 1. System change

4. Why Don’t Staff Wash their Hands? (Compliance estimated less than 50%)

5. Why Not? Skin irritation Inaccessible hand washing facilities Wearing gloves Too busy Lack of appropriate staff Being a physician

6. 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

7. 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

8. Successful Promotion Education Routine observation & feedback Engineering controls Location of hand basins Possible, easy & convenient Alcohol-based hand rubs available Patient education

9. Successful Promotion Reminders in the workplace Promote and facilitate skin care Avoid understaffing and excessive workload

10. Hand Hygiene Techniques Alcohol hand rub Routine hand wash 10-15 seconds Aseptic procedures 1 minute Surgical wash 3-5 minutes

11. Areas Most Frequently Missed

12. Routine Hand Wash

13. Alcohol Hand Rubs Require less time Can be strategically placed Readily accessible Multiple sites All patient care areas

14. Alcohol Hand Rubs Acts faster Excellent bactericidal activity Less irritating (??) Sustained improvement

15. Visible soiling Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material MUST be washed with liquid soap and water

16. Prevention of Catheter-Associated Urinary Tract Infection (CA-UTI) Two main principles 1 Avoid unnecessary catheterization 2 Limit the duration of catheterization

17. Catheter insertion and maintenance Practice hand hygiene before insertion of the catheter before and after any manipulation of the catheter site

18. 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

19. Maintain unobstructed urine flow Empty the collecting bag regularly, using a separate col- lecting container for each patient, and avoid allowing the draining spigot to touch the collecting container Keep the collecting bag below the level of the bladder at all times Do not routinely use silver-coated or other antibacterial catheters Do not screen for asymptomatic bacteruria in catheterized patients Do not treat asymptomatic bacteruria in catheterized patients except before invasive urologic procedures

20. 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

21. CATHETOR ASSOCIATED BLOOD STREAM INFECTIONS

22. 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

23. Education-based, multimodal prevention strategy of catheter related infections

24. HEALTH CARE ASSOCIATED PNEUMONIA

25. 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

26. 7. Avoid non-essential tracheal suction 8. Oral hygiene with chlorhexidine 9. Backrest elevation 30-45 o 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

27. Continuous Removal of Subglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation

28. HOB Elevation HOB at 30-45 o

29. 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

30. 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

31. 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

32. CLINICAL PULMONARY INFECTION SCORE Criterion Score Fever (°C)     38.5 but 38.9 1   >39 or < 36 2 Leukocytosis     <4000 or >11,000/L 1   Bands > 50% 1 (additional) Oxygenation (mmHg)     Pa O2 /FI O2 <250 and no ARDS   2 Chest radiograph     Localized infiltrate 2   Patchy or diffuse infiltrate 1   Progression of infiltrate (no ARDS or CHF) 2 Tracheal aspirate     Moderate or heavy growth 1   Same morphology on Gram's stain 1 (additional)   Maximal score a   12

33. "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).

34. 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.

35. « Talking walls »

36. Thank you