Prevention of intensive care unit infections

Traditional approaches to definitions of nosocomial infections and their prophylaxis focus on time cut-offs and non-antibiotic manoeuvres. In general, the time cut-off of 48 h has been applied to distinguish community and hospital infection from ICU infection, and hand washing has been the cornerstone of conventional policies for the prevention of ICU infections occurring after 48 h. In contrast, the philosophy of antibiotic prophylaxis using selective decontamination of the digestive tract is based on the criterion of the carrier state of a limited range of potential pathogens that are involved in three different types of infection: endogenous infections, both primary and secondary, and exogenous infections. Most infections are of primary endogenous development due to micro-organisms carried in the admission flora and are controlled by parenteral cefotaxime administered immediately on admission. The aim of polymyxin E/tobramycin/amphotericin B applied topically in the throat and gut is to prevent secondary endogenous infections due to micro-organisms acquired on the unit, and generally occurring after 7 days. Exogenous infections caused by micro-organisms not previously carried can occur at any time during the stay on the unit and only high standards of hygiene are able to prevent them. The most extensive meta-analysis reports data on 5727 patients enrolled in 33 randomized trials and indicates a significant reduction of both infections (OR=0.35; 95% CI=0.29–0.41) and total mortality (OR=0.80; 95% CI=0.69–0.93). There are no randomized trials available which show that rigid implementation of hand washing reduces morbidity or mortality. The aim of this review is to help readers distinguish between what is evidence-based, and what is still largely opinion-based.     

Classification of adverse events occurring in a surgical intensive care unit

INTRODUCTION: We aimed to describe the preventability and provider specificity of surgical intensive care unit (SICU) deaths and complications compared with those in a cohort of trauma patients. METHODS: Data were collected on all trauma and SICU admissions from July 1, 2001, to June 30, 2004, from administrative (Trauma Base and Project Impact) and morbidity databases. Services were protocol driven and staffed by in-house attendings. Performance improvement assessments were made by consensus. Deaths and complications were classified as preventable, potentially preventable, or nonpreventable, and provider-specific or not. Statistical significance was established at the P < .05 level. RESULTS: One hundred sixty-eight deaths (5.6% rate), 464 procedure-related, and 694 non-procedure-related complications were noted in 2969 SICU patients compared with 166 deaths (3.6% rate), 178 procedure-related, and 261 non-procedure-related complications in 4,655 trauma patients. Thirty-one percent of SICU deaths were preventable/potentially preventable compared with 14% of trauma deaths, but only 1.9% was attributable to the SICU provider. SICU complications were less frequently preventable/potentially preventable than in trauma patients (52% versus 61%) and less often provider-specific (5% versus 19%). CONCLUSIONS: SICU complications are deemed preventable less often than in trauma patients and, if so, infrequently incriminate the SICU provider. Preventable and potentially preventable SICU deaths are rarely attributed to SICU care. These data suggest that SICU performance improvement should focus on systems solutions and pre-SICU care.     

Healthcare-associated infections in the intensive care unit

The advances made in healthcare in recent years have been remarkable. However, the full benefits of progress have been hampered by the increasing frequency of healthcare-associated infection (HCAI). This is particularly true of the invasive processes involved in providing critically ill patients with intensive care. The rise in multidrug-resistant pathogens has mirrored the increase in incidence of HCAIs. This increasing threat to patient safety is associated with significant morbidity and mortality along with substantial cost implications in the intensive care unit. Although it is unrealistic to believe that HCAIs can be eradicated, it is certainly true that, with due attention to the processes of intensive care, many cases could be prevented.     

Nosocomial infections in the intensive care unit

Nosocomial infection in the intensive care unit (ICU) is associated with increased mortality, morbidity and length of stay. It is defined as infection that begins 48 hours after admission to hospital. The commonest types are ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), urinary catheter-related infection and surgical site infection. The common pathogens include Staphylococcus aureus, Pseudomonas aeruginosa, Candida, Escherichia coli and Klebsiella species. Antimicrobial resistance is increasing and has emerged from selective pressure from antibiotic use and transmission via health workers. Prevention of infection is fundamental and can be achieved through good antimicrobial use and infection control, including hand hygiene. Grouped, easy-to-follow best practice activities called ‘care bundles’ have been developed to prevent VAP and CLABSI. Microbiological cultures are central to rapid and accurate diagnosis, which improves outcomes and reduces resistance. The principles of treatment include early antimicrobial therapy (after appropriate specimens are taken) targeted to the local microbes, then de-escalation according to culture and susceptibility results. This article summarizes the pathogenesis, risk factors, microbiology, diagnosis, prevention and treatment of VAP, CLABSI and nosocomial urinary tract infection in the adult ICU.     

Fungal infections in the intensive care unit

Invasive infections through to sepsis caused by fungi in intensive care units have increased markedly in the past few years. In the mean time almost every tenth case of sepsis in the intensive care unit is the result of an invasive fungal infection. Not only hemato-oncological or organ-transplanted patients are affected but increasingly also those patients who have been under intensive care for a considerable time and who exhibit particular risk factors. The lethality among the afflicted patients is high. The diagnosis of fungal infections is still difficult; unambiguous, highly sensitive and specific test procedures are still lacking. The decision for therapy must often be made empirically and as early as possible. In the past few years newly developed antimycotic agents have opened up new options for therapy.     

Epidemiology of catheter-related infections in intensive care unit

Catheter-related infections remain an important cause of nosocomial infection in the ICU. They include colonization of the device, exit-site infection and catheter-related bloodstream infection with or without bacteraemia. Data from clinical studies and surveillance networks should be compared cautiously due to important methodological differences and wide variations of device-utilization ratio between units or countries. In France, two regional networks (C-CLIN Paris-Nord and C-CLIN Sud-Est) produced comparable and reproducible results. Colonization represents five-six cases per 1000 catheter-days and bacteraemia represents one case per 1000 catheter-days. Incidence rates from North American studies are usually four to five times higher. Numerous risk factors have been identified. Some of them could be used to stratify patients according to risk of catheter-related infection and to allow more valid comparison between ICU's performances. Participation of French ICUs to the recent national surveillance networks (REA RAISIN and REACAT RAISIN) should be encouraged.     

�����֢�໤��������Ը�Ⱦ����5��ع˷�����

目的 了解外科重症监护病房（SICU）中医院获得性感染（nosocomial infection,NI)的流行病学规律。指导临床防治。方法 对SICU1996年1月至2000年12月间181例NI情况进行回顾性分析。结果 平均感染率9.81%,常见感染部位是呼吸道（36.96%)、胸腹腔（25.47%)和血行感染（9.32%),各部位主要病原菌种类具有统计学差异,呼吸道、胸腹腔和胆道以细菌为主,泌尿道和消化道以真菌为主,混合感染52.25%。常见病原菌是肠球菌、耐甲氧西林的葡萄球菌、铜绿假单胞菌、大肠埃希杆菌、白色念珠菌和热带念珠菌。结论 SICU内NI主要病原菌因感染部位而不同,菌种复杂,耐药菌株多,应建立相应的监控制度,掌握病原菌变化规律,现有效地预防和治疗ICU内获得性感染。     

非重症监护病房多重耐药菌感染来源及分布

目的:分析非重症监护病房(ICU)多重耐药菌(MDRO)感染来源及分布,为制定精准化MDRO防控措施提供依据。方法:选取南京医科大学第一附属医院2017年10月至2019年9月802例自非ICU科室MDRO感染者体内分离出的1116株MDRO菌株作为研究对象,依据来源将MDRO分为院外感染(外院转入、社区获得)和院内感染(本院转入、科室获得)两大类型共4个组别进行分析。结果:本院非ICU科室感染的MDRO以碳青霉烯类耐药肠杆菌科(CRE)(384/1116、34.41%)及耐甲氧西林金黄色葡萄球菌(MRSA)(331/1116、29.66%)为主;不同科室MDRO感染构成差异有统计学意义(χ^(2)=185.687、P<0.001),4种常见MDRO感染最多的科室为老年医学科(147/1116、13.17%)、神经外科(112/1116、10.04%)和康复医学科(95/1116、8.51%)。CRE、MRSA、碳青霉烯类耐药鲍曼不动杆菌(CRAB)和碳青霉烯类耐药铜绿假单胞菌(CRPA)检出率分别为10.69%(704/6584)、43.83%(554/1264)、33.72%(376/1115)和27.11%(475/1752),均显著低于全院科室CRE、MRSA、CRAB、CRPA的平均检出率[25.35%(3474/13704)、51.48%(1093/2123)、79.15%(4704/5943)和46.99%(2051/4365)],差异均有统计学意义(χ^(2)=584.309、15.583、960.632、203.726,P均<0.001);非ICU科室间以上4种MDRO检出率差异均有统计学意义(χ^(2)=190.766、97.642、75.078和69.515,P均<0.001)。MDRO感染部位主要为下呼吸道(540/1116、48.39%)、手术部位(132/1116、11.83%)和泌尿道(123/1116、11.02%)。院外感染者共641例(57.44%),包括外院转入(373/1116、33.42%)和社区获得(268/1116、24.01%);院内感染者475例(42.56%),包括本院转入(52/1116、4.66%)和科室获得(423/1116、37.90%)。结论:本院非ICU科室MDRO感染近2/3来源于院外输入和院内转入,需重视感染控制基本措施落实并通过信息系统早期识别,且各科室间MDRO感染来源及分布不同,应根据其特点制定针对性措施,实现精准化防控。     

A 10-year experience with major burns from a non-burn intensive care unit

Objective

The aim of this study was to review clinical data and outcomes of patients with burns in a Mexican non-burn intensive care unit (ICU).

Methods

We did a retrospective analysis of our single-centre database of burn patients admitted to the ICU in the Hospital Civil Fray Antonio Alcalde (University Hospital). The sample was divided for analysis into two groups according to the outcome ‘death’ or ‘discharge’ from ICU.

Results

Overall mortality was 58.2%, without a decreasing trend in mortality rates through the years. We identified the presence of third-degree burns (odds ratio (OR) 1.5, p = 0.003), and >49% total burned surface area (TBSA; OR 3.3, p ≤ 0.001) was associated with mortality. Mean age was higher in deceased patients (38.2 years vs. 31.3 years, p = 0.003) as was the TBSA (62.8% vs. 36.4%, p ≤ 0.001). At multivariate analysis, inhalation injury was not associated with increased mortality, but it was with more mechanical ventilation days. Early surgical debridement/cleansing was performed in most patients; however, the mean of the procedures was 1.7 per patient in both groups.

Conclusion

We identified significant factors associated with mortality. These variables and prognosis from non-burn ICUs differ broadly compared with burn intensive care units (BICUs); thus, more structured, multidisciplinary and specialised treatment strategies are still needed.     

A brief review of Panton-Valentine leukocidin producing staphylococcal infections in the intensive therapy unit

Panton-Valentine leukocidin toxin has been known about for many years and its production by Staphylococcus aureus in infections is associated with invasive necrotising disease of several systems including skin and soft tissue, and pneumonia. Necrotising pneumonia is associated with high mortality despite provision of antimicrobials and affects predominately younger aged people. A combination of antimicrobial therapy including an agent which acts to inhibit bacterial protein synthesis (such as clindamycin, linezolid, or rifampicin) is the mainstay of therapy with intravenous immunoglobulin, a potentially useful adjunct. Contact screening and public health input is essential in preventing further cases and recolonisation. When PVL toxin producing staphylococcal infection is suspected, close liaison with medical microbiology is paramount to enable optimal treatment and suitable specimens to be sent to the reference laboratory for confirmation.     

Incidence of fungal infections in a solid organ recipients dedicated intensive care unit

Invasive fungal infections are a significant cause of morbidity and mortality for patients undergoing solid organ transplantation. Our aim was to evaluate the incidence of invasive fungal infections in solid organ recipients within a dedicated intensive care unit (ICU). MATERIALS AND METHODS: From May 2002 to May 2005, 278 patients undergoing solid organ transplantation (105 liver, 142 kidney, 20 lung, 2 combined liver-kidney, 9 combined pancreas-kidney) were admitted to our posttransplant intensive care unit. We retrospectively analyzed data obtained from the ICU stay. Fungal infection was defined by positivity of normally sterile biological samples and by elevated positivity of normally non sterile biological samples. We did not consider superficial fungal infections and asymptomatic colonizations. RESULTS: Forty-six patients (16.5%) developed a fungal infection; at least one mycotic agent was isolated from each patient. Candida albicans was the most common pathogen, isolated from 71 % of infected patients (33 of 46). Infected patients showed a mortality rate of 35%, while that for non infected recipients was 3.5%. Total length of ICU stay was the most significant risk factor among infected patients (30.26 days vs 5.04 days P < .0001). Mean time between transplantation and first positive samples was 6.17 days (SD 8.88). CONCLUSION: Fungal infections in solid organ transplant patients are a major issue because of their associated morbidity and mortality. Candida albicans was the most common pathogen and total length of ICU stay was the most important risk factor.     

Management of patients in a dedicated burns intensive care unit (BICU) in a developing country

Background

In Pakistan the practice of managing extensive burns in dedicated intensive care units is not well established. This audit aims to define the characteristics of the victims of major burns and factors that increase mortality and outcome of the protocol-based management in a dedicated burns intensive care unit (BICU).

Patients and methods

This prospective audit included all patients admitted to the BICU of Suleiman Dawood Burns Unit in Karachi from 1st September 2002 to 31st August 2011. Demographic information, type and place of burn, total body surface area burn (TBSA), type of organ support provided, length of ICU stay, any associated medical diseases, and out outcome were documented.

Results

A total of 1597 patients were admitted to the BICU in 9 years. Median age of the patients was 22 (IQR = 32–7). 32% victims were children <14 years and only 7% were >50 years old. Male to female ratio was 1.4:1. Fire was the leading cause of burns in adults (64%) and scald burns were most common in (64%) in children. 72.4% of the accidents happened at home, where kitchen was the commonest location (597 cases). Mean TBSA burnt was 32.5% (SD ± 22.95%, 95%CI: 31.36–33.61). 27% patients needed ventilatory support, 4% were dialyzed and split skin graftings were performed in 20% patients. Average length of ICU stay was 10.42 days. Epilepsy, psychiatric illness and drug addiction were not common associations with burns. Overall mortality was 41.30% but it decreased over the years from 75% to 27%.

Conclusions

Groups of people most vulnerable to sustain burn are young females getting burnt in the kitchen, young males getting burnt at work, and small children falling in pots of hot water stored for drinking or bathing. TBSA >40%, age >50 years, fire burn and female gender were associated with a higher risk of death.Carefully planned, protocol based management of burn patients by burn teams of dedicated healthcare professionals, even with limited resources reduced mortality.

Recommendations

Burn hazard awareness, prevention and educational programmes targeted at the vulnerable population, i.e. women and young children at home and men at their work place is the single most cost-effective way of reducing the incidence of burns in developing countries.     

Nursing audit in a neonatal intensive care unit.

The amount and quality of work conducted by nurses in a neonatal intensive care unit was assessed by analysing records of observations, investigations and treatment. Work had been standardised as much as possible to ensure continuity and to prevent mishaps. Seventy-seven infants were treated over a 5-month period and 6 died of causes unrelated to patient care. Nursing staff were responsible for all observations and for the collection of most specimens for investigations. They also performed 20% of emergency procedures, such as endotracheal intubation and the insertion of venous catheters. The only errors which could be detected were omissions in observations (2.9%), nursing procedures (2.9%), and drug doses (1.2%). The nurse-to-baby ratio of 1:3 was adequate for patient care but not for other recognised functions of an intensive care unit such as education programmes.     

外科加强治疗病房获得性真菌感染的分析

目的探讨外科加强治疗病房 (SICU)内获得性真菌感染的流行病学特点及与感染相关的危险因素。方法回顾性分析 88例病原学检查阳性的危重症患者的临床资料。结果 88例患者中单纯细菌感染 5 0例 ,真菌感染 38例 (均为SICU内获得性真菌感染 ) ,两组住SICU时间分别为 (12± 8)d ,(2 0± 2 4 )d(P <0 0 5 )。获得性真菌感染的部位主要为呼吸道 (6 5 8% ) ,主要致病菌株为白色念珠菌 (4 7 4 % )。结论SICU内获得性真菌感染的常见感染部位是呼吸道 ,常见致病菌为白色念珠菌 ,住SICU的时间长短与获得性真菌感染的发生密切相关。     

An intensive care unit in a rural area.

Factors that governed the setting up of a multipurpose, temporary Intensive Care Unit of six beds, in a remote area of Malaysia and the experience of operating it for more than two and a half years are outlined.