1. Infection Control in the ICU
Holly A. Murphy, MD, MPH&TM
Consultant, Clinical Infectious Diseases
CIWEC Travel Medicine Center, Kathmandu
Co-Director GeoSentinel Surveillance Network, Kathmandu Site
Adjunct Asst. Prof, Tulane Medical Center, New Orleans, LA USA

2. Infection Control Issues in Asia

3. Aim:
To discuss “most important” Infection Control practices for Intensive Care Units (ICUs) in Nepal
To address the problems of:
antimicrobial resistance,
hospital-acquired infections (HAIs) and
related morbidity and deaths.

4. Hospital Acquired Infections
Nosocomial infections/ hospital acquired infections (HAIs)= infections which develop during hospital stay which were not present before admission
Common HAIs include:
Surgical Site Infections
Catheter associated bloodstream infections
Ventilator associated pneumonia
Catheter related urinary tract infection
ICU: more devices, more vulnerable patients, more HAIs

5. Antimicrobial Resistance =
Natural process of selection when microorganisms exposed to antibiotics
Causes:
Use of antibiotic for inappropriate indication (wrong drug) Ex. Azithromycin for Strep Throat
Unnecessarily broad spectrum (‘higher level’) antibiotic use Ex. Ceftriaxone for Surg Prophylaxis
Incorrect dose or dosing interval resulting in subtherapeutic levels in the body Ex. 750mg Vancomycin in adult
Inappropriate duration of antibiotic treatment (too long or too short) Ex. Quick switch to oral drug for osteomyelitis
Transfer of organisms (or their genetic material) within the environment (healthcare and community settings)

6. Collateral damage of antibiotics
“VRE” vancomycin resistant enterococci – associated with vancomycin/cephalosporin use
“MRSA” methicillin-resistant Staph aureus – assoc with quinolone/cephalosporin use
“ESBL” extended spectrum beta-lactamase expression by gram-negative organisms – assoc with ceftriaxone/quinolone use

7. Emergence of resistance to “reserve” antibiotics
Quinolones (ex. levofloxacin), carbapenems (ex. meropenem), vancomycin, colistin
Limited to no alternatives, antimicrobial “pipeline” limited
Untreatable infections with high morbidity and mortality

8. Hospital Acquired Infections
Developed countries: 5-10% of admissions experience HAI
2-20 times higher in resource-poor settings
Frequently involve drug resistant organisms (“superbugs”)
MDR Acinetobacter
ESBL-producing E coli
MRSA
PREVENTABLE!
Hospital acquired infections kill nearly 100,000 Americans/year with 2 million patients needing treatment that costs >25 billion USD/ year. ~CDC 2009
BBC News Dec 2014

9. What is infection control?
Hospital-wide program to prevent the spread of infectious disease within the hospital
Administration
Food Service
Engineering
Housekeeping/Laundry
Multidisciplinary - participation of:
Central Supply/Sterilization
Medical staff (doctors)
Nursing
Laboratory/microbiology
Pharmacy

10. Potential Activities of Infection Control
Quantify antibiotic resistance and HAIs
Antibiograms
Drug Resistance Index (DRI) : measure that combines the ability of antibiotics to treat infections with the extent of their use in clinical practice.
Develop protocols for:
Appropriate use of antibiotics
Procedures with high risk of HAIs (central line insertion, urinary catheter placement)
Develop standardized isolation procedures
Respiratory isolation (droplet vs. resp)
Contact isolation, i.e. gowns used appropriately
Assess and strengthen hand hygiene practices
Antimicrobial stewardship program

11. What is antimicrobial stewardship?
Assure appropriate choice, dosing and duration of antibiotics
Approval of restricted antibiotics requires verification of correct dose, route, frequency and duration
Serves as patient safety and quality care function
Core components
Restriction of certain antibiotics
Prospective auditing and feedback on a case-by-case basis
Appropriate use of antimicrobials delay the emergence of resistance and minimize resistance prevalence once it emerges

12. Antimicrobial Stewardship
Strategies
Provider education
Hospital treatment guidelines for infectious diseases
Antimicrobial order sets
Prospective review of patients receiving restricted antibiotics to encourage de-escalation of therapy
Encourage transition from IV to oral antibiotics when the agent has excellent oral bioavailability

13. THE BASICS
Lab-DR link: antibiogram, well-defined “isolation” pathogens
Key patogens (MDR Acinetobacter)/key diseases (ie TB)
Signs designating isolation (I.E. CONTACT PRECAUTIONS, AIRBORNE or DROPLET PRECAUTIONS)
Hand washing/hand sanitizer – wall mounted sanitizer/sinks accessible before and inside ICU
Gloves for patient contact, Ex ventilator manipulation
DESIGNATED GOWNS and stethoscope
Antibiotic Stewardship

14. Comprehensive Infection Control
Some new concepts for Nepal (ex. gowns, antibiotic restrictions)
Sensitize doctors, nurses, pharmacists and administration
Limitations: hospital-based pharmacy, facility (communal ICU)
Learning curve: Clinical Infectious Diseases
Training
Administrative support is CRITICAL

15. Even with critical advances in Infection Control, we will not stop antimicrobial resistance, only slow it down.
BBC News, Dec 2014

16. “First do no harm” We are in the business of “health”…
We have a responsibility to prevent HAIs and HAI-related deaths.

17. Thank you… For making Infection Control a priority!!
Thank you Dr. Andrew Trotter– TUTH/Grande Hospital and Tufts Univ (USA) for shared slides