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

Infection Control Issues in Asia

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.

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

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)

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

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

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

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

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

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

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

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

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

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

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

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