Prevention of nosocomial infections
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PREVENTION OF NOSOCOMIAL INFECTIONS
Dr. Sachin Verma MD, FICM, FCCS, ICFCFellowship in Intensive Care Medicine
Infection Control Fellows Course Consultant Internal Medicine and Critical Care
Ivy Hospital Sector 71 MohaliWeb:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495
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 cathetersUse and care of vascular access linesPrevention of health care associated pneumonia.
Alcohol-based handrub at point of
care
Access 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+
+
+
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• The 5 core components of the WHO Multimodal Hand Hygiene Improvement Strategy
1. System change
Why Don’t Staff Wash their
Hands?(Compliance estimated less than 50%)
Why Not?Skin irritationInaccessible hand washing facilitiesWearing glovesToo busyLack of appropriate staffBeing a physician
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
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
Successful Promotion Education
Routine observation & feedback
Engineering controls
Location of hand basins
Possible, easy & convenient
Alcohol-based hand rubs available
Patient education
Successful Promotion
Reminders in the workplace
Promote and facilitate skin care
Avoid understaffing and excessive workload
Hand Hygiene Techniques
1. Alcohol hand rub
2. Routine hand wash 10-15 seconds
3. Aseptic procedures 1 minute
4. Surgical wash 3-5 minutes
Areas Most Frequently Missed
Routine Hand Wash
Alcohol Hand RubsRequire less time
Can be strategically placed
Readily accessible
Multiple sites
All patient care areas
Alcohol Hand RubsActs faster
Excellent bactericidal activity
Less irritating (??)
Sustained improvement
Visible soiling
Hands that are visibly soiled or potentially
grossly contaminated with dirt or organic
material MUST be washed with liquid soap
and water
Prevention of Catheter-Associated Urinary Tract Infection (CA-UTI)
Two main principles1 Avoid unnecessary catheterization2 Limit the duration of catheterization
Catheter insertion and maintenance
Practice hand hygienebefore insertion of the catheterbefore and after any manipulation of the catheter site
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
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
CATHETOR ASSOCIATED BLOOD STREAM INFECTIONS
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
Education-based, multimodalprevention strategy of catheter related
infections
HEALTH CARE ASSOCIATED PNEUMONIA
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
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
14. Selective decontamination of digestive tract (SDD )in selected cases
Prevention of Ventilator Associated Pneumonia
Continuous Removal of Subglottic Secretions
Use an ET tube with
continuous suction
through a dorsal lumen
above the cuff to
prevent drainage
accumulation
HOB Elevation
HOB at 30-45o
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
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
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
CLINICAL PULMONARY INFECTION SCORE
Criterion ScoreFever (°C) 38.5 but 38.9 1 >39 or < 36 2Leukocytosis <4000 or >11,000/L 1 Bands > 50% 1 (additional)Oxygenation (mmHg) PaO2/FIO2 <250 and no ARDS
2
Chest radiograph Localized infiltrate 2 Patchy or diffuse infiltrate 1 Progression of infiltrate (no ARDS or CHF) 2Tracheal aspirate Moderate or heavy growth 1 Same morphology on Gram's stain 1 (additional) Maximal scorea
12
"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).
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.
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