Update: Infection Prevention and Control ic ha chiangrai.pdf · Update: Infection Prevention and...

Nongyao Kasatpibal

RN, MNS (Infection Control), PhD (Epidemiology)

Faculty of Nursing, Chiang Mai University, Thailand

August 2, 2014

Update: Infection Prevention and Control

Outline

Introduction

MDROs

Targeted surveillance update

Definition

Prevention and control strategies

Summary

Semmeleweis found the body to

contain diseased tissue similar to

that of the dead pregnant mothers.

Semmeleweis knew that mothers, in

the ward with the high death rate,

were normally treated by students

coming from the post-mortem room

and concluded that the students

could be carrying the disease from

the cadaver to the mothers.

Ignaz Philipp Semmeleweis (1818-1865)

He insisted that those

doctors who worked for

him must wash their hands

in calcium chloride solution

before & after each

operation and before

visiting a new patient.

Death rate on the wards that Semmelweis was in charge of

fell from 12% to 1%. But despite this, he had to face the

conservatism of those who dominated Hungarian medicine.

His findings were ignored.

Joseph Lister (1827-1912)

• Professor of Surgery at

Glasgow University, he was

very aware that many people

suffer the trauma of an

operation, especially wound

infections.

• He made the link between

lack of cleanliness in hospitals

and deaths after operations.

Father of Antiseptic Surgery

Death by gangrene was common after an accident. Lister covered the wound made with lint soaked in carbolic acid. His success rate for patients’ survival was very high.

Lister developed a machine that pumped out a fine mist of carbolic acid into the air around an operation.

8

Years Total cases

Recovered Died Death rate

1864 - 1866 35 19 16 45.7%

1867 - 1870 40 34 6 15.0%

The proportion of patients operated by Lister who died fell dramatically.

OR = 0.21 (95% CI = 0.06-0.71)

9

Florence Nightingale ( 1820-1910)

In 1863, Nightingale wrote a book entitled, “Notes on Hospitals.”

“...association between sanitation and post-operative infections.”

Antibiotic era

• 1928 Alexander Fleming discovered penicillin

• Howard Florey and Ernst Chain conducted

further researches on penicillin

Fleming Florey Chain

Antibiotic era

• 1944 Florey got an American drugs company

to mass produce penicillin

• Penicillin got nicknamed "the wonder drug“

• 1945 Fleming, Chain and Florey were

awarded the Nobel Prize for Medicine

• Post-1945 was the era of the antibiotics

Pioneer in surgical infection control

William A. Altemeier

• Concerned with the nature, causes,

and control of surgical infection

• Investigated the frequency and

importance of bacteria in surgery

• Successively evaluated of

antibiotics in the prevention and

treatment of posttraumatic and

postoperative infections

• Concerned with the evolution of a

hospital reservoir of penicillin-

resistant staphylococci (1910)

• 1935-1947 staphylococcal bacteremia

• 1938-1940 staphylococcal pneumonia

• 1950-1960 staphylococcal pandemic

Staphylococcal pandemic

14

• Increased morbidity and mortality

• Staphylococcus surveillance by the

American Hospital Association

Staphylococcal pandemic

• National Nosocomial Infection Surveillance (NNIS) System

• Established in 1970

• To monitor and report the trends of nosocomial infection

• National Healthcare Safety Network (NHSN) was

established in 2005 to integrate and supersede three legacy

surveillance systems at CDC: the NNIS, the Dialysis

Surveillance Network, and the National Surveillance System

for Healthcare Workers, about 2500 participating hospitals

United States (US)

Landmark study

• Study of the Efficacy of Nosocomial Infection

Control (SENIC)

• Initiated in 1974 but joined by 338 hospitals in the

US during 1975-1976

• To describe the infection rates

• To demonstrate the components of infection

surveillance and control program

17

Core components

• Organized surveillance and control activities

• An adequate number of trained infection

control staff (1 : 250 hospital beds)

• A system for reporting SSI rates to surgeons

• These strategies could reduce approximately

one third of SSI

European counterparts

• HELICS (Hospitals in Europe Link for Infection Control

through Surveillance)

• Started in 1995 with 16 countries

• To monitor and describe the epidemiology of HAI

• To identify and follow-up risk factors of HAI

• To improve surveillance methodology, data validation

and utilization

• To compare the rates among participating hospitals

(“benchmarking”) and international

Thailand

Year No. of Hospital Prevalence rate (%)

1988 23 11.7

1992 33 7.3

1998 44 7.6

2000 44 7.8

2001 42 6.4

2006 20 6.5

2011 47 7.4

Chain of infection

Host

Environment

Agent

Epidemiological triad

Gordis, L. (2004). Epidemiology. Philadelphia: Elsevier Saunders.

To prevent its occurrence

To control its spread

Main goals of infection prevention and control

23

Comprehensive approaches

Principles of infection prevention and control

Improve immunity Improve nutrition

Prevention of entry of organisms

Host

Decrease the number of pathogens to a minimum

Reduce the risk of transmission of pathogens to

humans

Disinfectant solution

Antiseptic solution

Antibiotic

Disinfection

Sterilization

Agent

Environment

Decrease the pathogens in the environment

Minimize the propagation of pathogens

27

1. Policy

2. Man power

3. Money

4. Management

Success factors of infection prevention and control

Enhanced collaborative network and trans-disciplinary approach

MDROs

Global MDROs

MDROs crisis in Thailand

MDROs subcommittee

Hospital environment

Five contact precautions

Acinetobacter baumannii

National Antimicrobial Resistance Surveillance of Thailand

National Antimicrobial Resistance Surveillance of Thailand

Highest priority of MDROs bacteria in tertiary care hospital

1. Colistin-resistant A. baumannii

2. Colistin-resistant P. aeruginosa

3. Carbapenem-resistant Enterobactereceae

4. Vancomycin-resistant Enterococci (VRE)

5. Vancomycin-resistant S. aureus (VISA)

6. Cotrimoxazole and Levofloxacin resistant Stenotrophomonas maltophilia

• คณะอนุกรรมตามยุทธศาสตร์ของแผนยุทธศาสตร์เตรียมความพร้อม ป้องกัน และแก้ไขปัญหาโรคติดต่ออุบัติใหม่แห่งชาติ (พ.ศ. 2556-2559) ทั้ง 5 ยุทธศาสตร์

• คณะอนุกรรมการขับเคลื่อนยุทธศาสตร์เตรียมความพร้อม ป้องกัน และแก้ไขปัญหาโรคติดต่ออุบัติใหม่แห่งชาติ

• คณะอนุกรรมการที่ปรึกษาด้านวิชาการและยุทธศาสตร์ เพื่อเตรียมความพร้อม ป้องกัน และแก้ไขปัญหาโรคติดต่ออุบัติใหม่แห่งชาติ

• คณะอนุกรรมการป้องกัน ควบคุม และแก้ไขการดื้อยาต้านจุลชีพของเชื้อก่อโรค

MDR bacteria strategies

1. Minimize drug resistance

• ATB stewardship (healthcare & agriculture industry)

2. Prevent cross-transmission

• New design of hospital equipment & environment

• Hand hygiene & Contact precautions

• Active surveillance & Rapid alert system

• Decolonization & Decontamination

MDR bacteria strategies

3. Prevent infections

• Good clinical practice

• Device-associated bundle

4. Develop newer antibiotics

Antibiotic Stewardship

•An activity that includes

– Appropriate selection, dosing, route, and

duration of antimicrobial therapy

Dellit TH. Clin Infect Dis 2007; 44: 159-77.

Antimicrobial stewardship

Antibiotic Stewardship • Goals

– Primary:

•To optimize clinical outcomes

•Minimizing unintended consequences of

antimicrobial use

– Toxicity

– Selection of pathogenic organisms (e.g. C. difficile)

– The emergence of resistance

– Secondary:

•To reduce health care costs without adversely

impacting quality of care (cost-effectiveness)

Clin Infect Dis 2007; 44: 159-77.


Antibiotic Stewardship

• Multidisciplinary team

– Infectious diseases physician

– Clinical pharmacist with infectious diseases training

– Clinical microbiologist

– Information system specialist

– Infection control professional

– Hospital epidemiologist

– Hospital administrative personnel

Dellit TH. Clin Infect Dis 2007; 44: 159-77.


Treatment Options for MDR-pathogens

• Case by case basis

– Based on individual patient characteristics,

causative organism, site of infection, and

pharmacokinetic and pharmacodynamic

characteristics of the drug.


Neely, Alice N. Infection Control Resource Vol. 4, No. 4.

Nosocomial pathogens can survive on surfaces for long period

Organisms Duration of persistence

Acinetobacter spp. 3 days to 5 months

C. difficile spore 5 months

Enterococcus spp. including VRE 5 days to > 46 months

Pseudomonas aeruginosa 6 hours-16 months On dry floor 5 weeks

Serratia marcescens 3 days to 2 months On dry floor 5 weeks

Staphylococcus aureus 7 days to 7 months

Kramer et al. BMC Infectious Diseases 2006 6:130 Wagenvoort et al. Hosp Infect, 77 (2011), pp. 282–283

Important characteristics of surfaces

in the health care setting

•Ease of maintenance and repair

•Clean ability

•Inability to support microbial growth

•Surface porosity

•Absence of seams

Assessment of environment cleanliness

•Direct practice observation

•Swab cultures

•Agar slide cultures

•Fluorescent markers

•ATP bioluminesence

Environmental cleaning methods

Author/ year

Targeted organisms

Methods % of cleanliness p-value

Pre- Post-

Goodman, et al., 2008

MRSA, VRE UV lamp 44% 71% <0.001

Hota, et al., 2009

VRE Direct observe 49% 85% <0.001

Carling, et al., 2010

- Fluorescent 49.5% 82% <0.0001

Hulsage k., et al. Infect Control Hosp Epidemiol 2010 Aug;31(8):850-3

Five surfaces were defined as high-touch

•Bed rails

•Bed surface

•Supply cart

•Over-bed table

•Intravenous pump

Sources of MDROs bacteria from HCWs

• Gowns esp. long sleeves

• Ring

• Wristwatch

• Necktie

• Smart phone

• etc.

“Bare below the elbows: BBE”

http://www.marcoport.com/neckties/necktie1/

Contamination of White Coats

• Patient’s preference

• Some HCP:“unhygienic”

• The degree of contamination of white coats was correlated with

– more frequent usage of the coat

– Recent work in the inpatient setting

– Sampling certain parts of the uniform

•Areas that contact with patient

• HCP engaged in direct patient care (including house staff and students) should possess 2 or more white coats and have access to a convenient and economical means to launder white coats (e.g., institution-provided on-site laundering at no cost or low cost).

• Institutions should provide coat hooks that would allow HCP to remove their white coat prior to contact with patients or a patient's immediate environment.

Mandate of White Coats

Neckties • Neckties may be colonized with pathogenic bacteria –

Higher burden than the front shirt pocket of the same subject

• 2 reports found that up to 70% of physicians admitted having never cleaned their ties

• Due to limited evidence: cannot recommend limiting the use of other specific items of HCP apparel (such as neckties)

• If neckties are worn, they should be secured by a white coat to prevent them from coming into direct contact with the patient or near-patient environment.

Laundering of clothes

From a study

• Nonsurgical provider laundered their scrubs

every 1.7+0.1 days

• White coats: 12.4+1.1 days (p <0.001)

Please launder your coat everyday

Control of Bacterial Resistance

Control of Bacterial

Resistance Infection Control

Improve Diagnostics

Develop New Drugs and Vaccine

Education Research

Reduce Resistance Reservoir

Antimicrobial Stewardship

Computer-based

surveillance

Control of bacterial resistance

Adapt from Neil Fishman. Antimicrobial Stewardship Workshop SHEA 2010

Update definition 2013, 2014

• Present on Admission (POA) Infections

• Healthcare-associated infection (HAI)

CDC/NHSN Definition 2014

NOTE: This classification should not be applied to SSI, VAE, or LabID Events.

• Infections associated with complications or extensions of infections already present on

admission (see POA definition), unless a

change in pathogen or symptoms strongly

suggests the acquisition of a new infection.

Infections are not considered healthcare associated


• Infections in infants that have been acquired transplacentally (e.g., herpes simplex, toxoplasmosis,

rubella, cytomegalovirus, or syphilis) and become

evident on the day of birth or the next day.

• Reactivation of a latent infection (e.g., herpes zoster [shingles], herpes simplex, syphilis, or tuberculosis).

Infections are not considered healthcare associated


• Colonization, which means the presence of microorganisms on skin, on mucous membranes, in open wounds, or in excretions or secretions but are not causing adverse clinical signs or symptoms.

• Inflammation that results from tissue response to injury or stimulation by noninfectious agents, such as chemicals.

Conditions are not infection

Definition of surgical site infection (SSI) 2013

http://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf

Definition of Surgical Site Infection (SSI)

• Provides further required criteria for the

specific infection types that constitute

organ/space SSI. e.g.

• mediastinitis [MED] that may follow a

coronary artery bypass graft

• intra-abdominal abscess [IAB] after colon

surgery

Definition of surgical site infection (SSI) 2013

Definition

Classification of SSI

• Superficial incisional surgical site infection

– Superficial Incisional Primary (SIP)

– Superficial Incisional Secondary (SIS)

• Deep incisional surgical site infection

– Deep Incisional Primary (DIP)

– Deep Incisional Secondary (DIS)

• Organ/space surgical site infection

Coronary artery bypass graft

CABG or CBGB

Timing of surgical site infection: SSI

• Occurs within 30 days post-operation

- SIP, SIS SSI

- DIP, DIS SSI

- Organ/space SSI

• Occurs within 90 days post-operation

- DIP, DIS SSI

- Organ/space SSI

Organ/Space SSI

ค าแนะน าในการรายงาน การติดเชื้อที่ต าแหน่งรอยบาดแผลผ่าตัดชั้นตื้น

Stitch abscess ไม่รายงานว่าเป็น SSI

การติดเชื้อเล็กน้อยรอบ drain ไม่รายงานว่าเป็น SSI แต่ถ้ามีหนองออกมาจาก drain ต้องรีบรายงาน


Localized stab wound infection ไม่รายงานว่าเป็น SSI

รายงานเป็น skin or soft tissue infection ขึ้นกับความลึกของการติดเชื้อ


Pin site infection ไม่รายงานว่าเป็น SSI

รายงานเป็น skin or soft tissue infection ขึ้นกับความลึกของการติดเชื้อ


Cellulitis ไม่รายงานว่าเป็น SSI

http://en.wikipedia.org/wiki/File:Cellulitis3.jpg

Report burn infection: BURN


Report circumcision infection: CIRC


SSI bundle

SHEA’s strategies to prevent SSI 2014 update

• Basic practices that should be adopted by all acute care hospitals.

• Special approaches that can be considered for use in locations and/or populations within hospitals when HAIs are not controlled by use of basic practices.

Basic practices for preventing SSI

• Administer antimicrobial prophylaxis (I)

• Do not remove hair at the operative site unless the presence of hair will interfere with the operation. Do not use razors (II)

• Control blood glucose during the immediate postop period for cardiac surgery patients (I) and non-cardiac surgery patients (II).

Maintain postoperative blood glucose < 180 mg/dL

18-24 hours after anesthesia end time.


• Maintain normothermia (35.5 oC or more) (I)

• Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation (I)

• Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (I)

• Alcohol is contraindicated for

Procedures in which the preparatory agent

may pool or not dry (e.g. involving hair)

due to fire risk.

Procedures involving mucosa, cornea, or ear


The most effective disinfectant to combine with alcohol is unclear.

Wound edge protection device

Pinkney T D et al. BMJ 2013;347:bmj.f4305

©2013 by British Medical Journal Publishing Group

Use impervious plastic wound protectors for GI and biliary tract surgery (I)


• Use a checklist based on the WHO checklist

• Perform surveillance for SSI

• Increase the efficiency of surveillance through utilization of automated data

• Provide ongoing feedback of SSI rates to surgical and perioperative personnel and leadership

• Educate surgeons and team

• Educate patients and their family

• Implement policies and practices


Special approaches for preventing SSI

• Screen for S. aureus and decolonize surgical patients with antistaphylococcal agent in the preoperative setting for high-risk procedures, including some orthopedic and CVT procedures (II)

• Perform antiseptic wound lavage (II)

• Perform an SSI risk assessment (III)

• Observe and review OR personnel and the environment of care the OR (III)

• Observe and review proactives in the postanesthesia care unit, SICU, and/or surgical ward (II)

Approach that should not be considered a routine part of SSI prevention

• Do not routinely use vancomycin for antimicrobial prophylaxis (II)

• Do not routinely delay surgery to provide parenteral nutrition (I)

• Do not routinely use antiseptic-impregnated sutures as a strategy to prevent SSIs (II)

• Do not routinely use antiseptic drapes as a strategy to prevent SSIs (I)

Unresolved issues

• Preoperative bathing with CHG-containing products

• Preoperative intranasal and pharyngeal chlorhexidine

• Use of gentamicin-collagen sponges

• Use of bundles

The 2014 update of CDC/HICPAC guidelines for SSI prevention (draft)

• IA - A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefit and harms

Antimicrobial prophylaxis

Glycemic control (<180 mg/dL)

Normothermia

Optimize tissue Oxygen delivery

Intraoperative skin preparation –alcohol-based antiseptic

Approach that should not be considered a routine part of SSI prevention

• Do not routinely use vancomycin for antimicrobial prophylaxis (II)

• Do not routinely delay surgery to provide parenteral nutrition (I)

• Do not routinely use antiseptic-impregnated sutures as a strategy to prevent SSIs (II)

• Do not routinely use antiseptic drapes as a strategy to prevent SSIs (I)

• Laboratory - Confirmed Bloodstream Infection (LCBI)

• Mucosal Barrier Injury Laboratory- Confirmed Bloodstream Infection (MBI - LCBI)

Bloodstream Infection (BSI)

1. Report organisms cultured from blood as BSI–LCBI

when no other site of infection is evident.

2. Catheter tip cultures are not used to determine

whether a patient has a primary BSI.

3. When there is a positive blood culture and clinical

signs or symptoms of localized infection at a

vascular access site, but no other infection can be

found, the infection is considered a primary BSI.

Reporting Bloodstream Infection (BSI)

4. Purulent phlebitis confirmed with a positive semi-

quantitative culture of a catheter tip, but with either

negative or no blood culture is considered a CVS-VASC ,

not a BSI, SST- SKIN, or a ST infection.

5. Occasionally a patient with both peripheral and central IV

lines develops a primary bloodstream infection (LCBI) that

can clearly be attributed to the peripheral line (e.g., pus at

the insertion site and/or matching pathogen from pus and

blood). In this situation, enter “Central Line = No” in the

NHSN application. But include the patient’s central line

days in the summary denominator count.


6. If your state or facility requires that you report healthcare-

associated BSIs that are not central line -associated, enter

“Central Line = No” in the NHSN application when

reporting these BSIs. You should, however, include all of

the patient’s central line days in the summary

denominator count.


Before insertion

1. Provide easy access to an evidence-based list of indications

for CVC use to minimize unnecessary CVC placement (III)

2. Require education of healthcare personnel involved in insertion, care, and maintenance of CVCs about CLABSI prevention (II)

3. Bathe ICU patients over 2 months of age with a

chlorhexidine preparation on a daily basis (I)

Strategies to Prevent CLABSI: 2014 Update

At insertion

1. Have a process in place to ensure adherence to infection prevention practices at the time of CVC insertion in ICU and non-ICU settings, such as a check-list (II)

2. Perform hand hygiene prior to catheter insertion or manipulation (II)

3. Avoid using the femoral vein for central venous access in obese adult patients when the catheter is placed under planned and controlled conditions (I)

4. Use an all-inclusive catheter cart or kit (II)


At insertion

5. Use ultrasound guidance for internal jugular catheter

insertion (II)

6. Use maximum sterile barrier precautions during CVC

insertion (II)

7. Use an alcoholic chlorhexidine antiseptic for skin

preparation (I) (more than 0.5% CHG)


After insertion

1. Ensure appropriate nurse-to-patient ratio (at least 1:2) and limit the use of float nurses in ICUs (I)

2. Disinfect catheter hubs, needleless connectors, and

injection ports before accessing the catheter (II)

3. Remove nonessential catheters (II) 4. For nontunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every 5–7 days or immediately if the dressing is soiled, loose, or damp; change gauze dressings every 2 days or earlier if the dressing is soiled, loose, or damp (II)


After insertion

5. Replace administration sets not used for blood, blood

products, or lipids at intervals not longer than 96 hrs. (II)

6. Use antimicrobial ointments for hemodialysis catheter-

insertion sites (I)

7. Perform surveillance for CLABSI in ICU and non-ICU

settings (I) : measure, report, compare, audit


1. Use antiseptic- or antimicrobial-impregnated CVCs in

adult patients (I)

2. Use chlorhexidine-containing dressings for CVCs in

patients over 2 months of age (I)

3. Use an antiseptic-containing hub/connector cap/port

protector to cover connectors (I)

4. Use silver zeolite–impregnated umbilical catheters in

preterm infants (in countries where it is approved for

use in children) (II)

Special approaches for preventing CLABSI

5. Use antimicrobial locks for CVCs (I)

6. Use recombinant tissue plasminogen activating factor

once weekly after hemodialysis in patients undergoing

hemodialysis through a CVC (II)

Special approaches for preventing CLABSI

1. Do not use antimicrobial prophylaxis for short-term or

tunneled catheter insertion or while catheters are in situ (I)

2. Do not routinely replace central venous or arterial catheters

(II)

Approaches that should not be considered a routine part of CLABSI prevention

1. Routine use of needleless connectors as a CLABSI prevention

strategy before an assessment of risks, benefits, and

education regarding proper use

2. Intravenous therapy teams for reducing CLABSI rates

3. Surveillance of other types of catheters (e.g., peripheral

arterial or venous catheters)

4. Estimating catheter-days for determining incidence

density of CLABSI.

Unresolved issue

5. Use of silver-coated catheter connectors are associated with

reduced intraluminal contamination in ex vivo catheters.

6. Standard, nonantimicrobial transparent dressings and

CLABSI risk.

7. Impact of the use of chlorhexidine-based products on

bacterial resistance to chlorhexidine.

Unresolved issue

VAP: Definition update 2014

• Ventilator-Associated Events (VAEs)

• Ventilator-Associated Condition (VAC)

• Infection-related ventilator-associated complications (IVAC)

• Possible ventilator-associated pneumonia (VAP)

• Probable ventilator-associated pneumonia (VAP)

Developing new definitions based on objective, quantitative

criteria to increase the reliability, reproducibility,

comparability, and efficiency of surveillance.

VAP: Definition update 2014

• VAC and IVAC were developed to be appropriate

for public reporting.

• Possible and probable VAP were developed for

healthcare facilities to use for internal quality

improvement purposes only.

Recommendations for Prevention of VAP and other VAEs

A. Avoid intubation if possible.

1. Use noninvasive positive pressure ventilation (NIPPV)

whenever feasible (I)

B. Minimize sedation

1. Manage ventilated patients without sedatives whenever

possible (II)

2. Interrupt sedation once a day (spontaneous awakening

trials) for patients without contraindications (I)

Adult patients


B. Minimize sedation

3. Assess readiness to extubate once a day (spontaneous

breathing trials) in patients without contraindications (I)

4. Pair spontaneous breathing trials with spontaneous

awakening trials (I)

Adult patients


C. Maintain and improve physical conditioning

1. Provide early exercise and mobilization (II)

D. Minimize pooling of secretions above the

endotracheal tube cuff

1. Provide endotracheal tubes with subglottic secretion

drainage ports for patients likely to require greater than

48 or 72 hours of intubation (II)

Adult patients


E. Elevate the head of the bed

1. Elevate the head of the bed to 300–450 (III)

F. Maintain ventilator circuits

1. Change the ventilator circuit only if visibly soiled or

malfunctioning (I)

2. Follow CDC/Healthcare Infection Control Practices

Advisory Committee guidelines for sterilization and

disinfection of respiratory care equipment (II)

Adult patients

Special approaches

1. Use selective decontamination of the oropharynx to

decrease the microbial burden of the aerodigestive tract (I)

2. Perform oral care with chlorhexidine (II)

3. Administer prophylactic probiotics (II)

4. Use ultrathin polyurethane endotracheal tube cuffs (III)

5. Provide automated control of endotracheal tube cuff

pressure (III)

6. Instill saline before tracheal suctioning (III)

7. Provide mechanical tooth brushing (III)

Generally not recommended for routine VAP prevention

1. Silver-coated endotracheal tubes (II)

2. Kinetic beds (continuous lateral rotational therapy

and oscillation therapy) (II)

3. Prone positioning (II)

Definitively not recommended for VAP prevention

1. Stress ulcer prophylaxis (II)

2. Early tracheotomy (II)

3. Monitoring residual gastric volumes (II)

4. Early parenteral nutrition (II) – cut point 48 hrs.

Not recommended or discouraged for VAP prevention

1. Closed endotracheal tube suctioning systems (II)

Definition Urinary Tract Infection

1. Asymptomatic Bacteremic Urinary Tract Infection

(ABUTI)

2. Other Urinary Tract Infection (OUTI) (kidney,

ureter, bladder, urethra, or tissue surrounding the

retroperitoneal or perinephric space)

3. Symptomatic Urinary Tract Infection (SUTI)

Most contents similar to the previous version.

Add details in some issues to clarify unclear information

in the previous version.

Recommended strategies for CAUTI prevention

A. Provide appropriate infrastructure for preventing

CAUTI

1. Provide and implement written guidelines for catheter use, insertion, and maintenance (III)

2. Ensure that only trained, dedicated personnel insert

urinary catheters (III)

3. Ensure that supplies necessary for aseptic technique for

catheter insertion are available and conveniently located (III)


A. Provide appropriate infrastructure for preventing

CAUTI

4. Implement a system for documenting in the patient record

(III)

5. Ensure that there are sufficient trained personnel and

technology resources to support surveillance for catheter

use and outcomes (III)


B. Perform surveillance for CAUTI if indicated on the

basis of facility risk assessment or regulatory

requirements

1. Identify the patient groups or units in which to conduct

surveillance on the basis of risk assessment, considering

frequency of catheter use and potential risk (e.g., types of

surgery, obstetrics, critical care) (III)

2. Use standardized criteria, such as NHSN definitions, to

identify patients who have a CAUTI (numerator data) (III)


3. Collect information on catheter-days and patient-days

(denominator data) and indications for catheter insertion

for all patients in the patient groups or units being

monitored (III)

4. Calculate CAUTI rates and/or standardized infection ratio

(SIR) for target populations (III)

5. Use surveillance methods for case finding that are

documented to be valid and appropriate for the institution

(III)

6. Consider providing unit-specific feedback (III)


C. Provide education and training

1. Educate healthcare personnel involved in the insertion,

care, and maintenance of urinary catheters about CAUTI

prevention, including alternatives to indwelling catheters,

and procedures for catheter insertion, management, and

removal (III)

2. Assess healthcare professional competency in catheter use,

catheter care, and maintenance (III)


D. Use appropriate technique for catheter insertion

1. Insert urinary catheters only when necessary for patient care

and leave in place only as long as indications remain (II)

2. Consider other methods for bladder management, such as

intermittent catheterization, where appropriate (II)

3. Practice hand hygiene (based on CDC or WHO guidelines)

immediately before insertion of the catheter and before and

after any manipulation of the catheter site or apparatus (III)

4. Insert catheters following aseptic technique and using

sterile equipment (III)


D. Use appropriate technique for catheter insertion

5. Use sterile gloves, drape, and sponges; a sterile or antiseptic

solution for cleaning the urethral meatus; and a sterile

single-use packet of lubricant jelly for insertion (III)

6. Use as small a catheter as possible consistent with proper

drainage, to minimize urethral trauma (III)


E. Ensure appropriate management of indwelling

catheters

1. Properly secure indwelling catheters after insertion to

prevent movement and urethral traction (III)

2. Maintain a sterile, continuously closed drainage system (III)

3. Replace the catheter and the collecting system using

aseptic technique when breaks in aseptic technique,

disconnection, or leakage occur (III)


4. For examination of fresh urine, collect a small sample

by aspirating urine from the needleless sampling port

with a sterile syringe/cannula adaptor after cleansing

the port with disinfectant (III)

5. Obtain larger volumes of urine for special analyses

aseptically from the drainage bag (III)

6. Maintain unobstructed urine flow (III)

7. Employ routine hygiene; cleaning the meatal area with

antiseptic solutions is unnecessary (III)

Maintain unobstructed urine flow

a. Keep the collecting bag below the level of the bladder

at all times; do not place the bag on the floor (III)

b. Keep catheter and collecting tube free from kinking (III)

c. Empty the collecting bag regularly using a separate

collecting container for each patient. Avoid touching

the draining spigot to the collecting container (III)

Special approaches for preventing CAUTI

1. Implement an organization-wide program to identify

and remove catheters that are no longer necessary using

one or more methods documented to be effective (II)

2. Develop a protocol for management of postoperative

urinary retention, including nurse-directed use of

intermittent catheterization and use of bladder scanners (II)

3. Establish a system for analyzing and reporting data on

catheter use and adverse events from catheter use (III)

Approaches that should not be considered a routine part of CAUTI prevention

1. Do not routinely use antimicrobial/antiseptic-impregnated

catheters (I)

2. Do not screen for asymptomatic bacteriuria in catheterized

patients (II)

3. Do not treat asymptomatic bacteriuria in catheterized

patients except before invasive urologic procedures (I)

4. Avoid catheter irrigation (II)

5. Do not use systemic antimicrobials routinely as prophylaxis

(III)

6. Do not change catheters routinely (III)

Unresolved issues

1. Use of antiseptic solution versus sterile saline for meatal

cleaning before catheter insertion.

2. Use of urinary antiseptics (e.g., methenamine) to prevent UTI.

3. Use of catheters with valves.

4. Spatial separation of patients with urinary catheters in place

to prevent transmission of pathogens that could colonize

urinary drainage systems.

5. Antimicrobial prophylaxis at catheter removal to prevent

symptomatic infection.

Summary

• Coming together is a beginning.

• Keeping together is progress.

• Working together is success.

- Henry Ford

Summary

We can make a difference in

infection prevention and control

Take home message

African Proverb

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