1. Infection Control Measures in the ICU: A day in the life of a bacterium in the ICU
B. Taylor Thompson, MD
Director, MICU
Massachusetts General Hospital
Associate Professor of Medicine
Harvard Medical School

2. Presentation Outline Nosocomial transmission
Where bacteria live and how they get around
Infection Control in the ICU:
Central role for and hygiene
Review the MGH experience

3. WHO Global Safety Challenge
First Target ( )
Health Care Associated Infections
Hand Hygiene as cornerstone

4. 5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 2006

5. ICU patients are rapidly colonized with pathogenic bacteria
Skin colonized in hours to days
Staph. aureus, Proteus mirabilis, Klebsiella spp CFU /cm2 skin
Perineal/inguinal > axilla > trunk > upper extremities and hands
Dialysis/CRF, diabetes, dermatitis, broad spectrum Abx increase risk
Patients shed 106 squames/day -> widespread contamination of the room
Reviewed in Pittet et al Lancet Infect Dis 2006

6. 5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 2006

7. Transmission to Hands from Skin and Environment
Pittet et al Lancet Infect Dis 2006

8. Transfer to the hands of health care workers (HCWs) hands: I
“Clean Activities” (lifting, taking radial artery pulse, measuring blood pressure)
Up to cfu from HCWs hands
HCWs intercepted before hand wash in MRSA colonized patient
17% of worker’s gloves positive
Phillips, BMJ 1977; McBride, J Hosp Inf 2004

9. Transfer to the hands of health care workers (HCWs) hands: II
Surveillance cultures of HCWs hands in ICU
21% of MDs; 5% of nurses positive (n=328)
Serial Cultures of NSICU HCWs hands
100% positive for GNR and 64% positive for staph aureus at least once
Rings, artificial or long nails, dermatitis increase frequency of hand contamination of HCWs
Daschner, J Hosp Inf 1988; Maki, Ann Int Med 1978; Trick, Clin Inf Dis 2003

10. More contamination with more care
Pittet, Arch Int Med 1999

11. Contamination of Healthcare Workers with VRE during Routine Patient Examinations
At least one site 33/49 (67%)
Gloves (Hands) 31/49 (63%)
Gowns 18/49 (37%)
Stethoscopes 15/49 (31%)
All three sites 12/49 (24%)
Stethoscope after wipe 1/49 (2%)
Zachary, Infect Control Hosp Epidemiol

12. 5 Essential Steps for Cross Transmission 
Pittet et al Lancet Infect Dis 2006

13. Bacterial Survival times on hands
Acinetobacter spp 60 min
E. coli 6 min (mean)
Klebsiella spp 2 min (mean)
VRE min
Pseudomonas sp 30 min; 180 in sputum
Rotavirus % survive 20 min;
2% survive 60 min

15. Contamination of ICU Patient Charts
Sterile swab of outside of binders/charts kept outside the ICU room
Percent of ICU charts culture positive by organism
Panhotra Am J Infect Control 2005

16. 5 Essential Steps for Cross Transmission  
Pittet et al Lancet Infect Dis 2006

17. Hand washing compliance rates by occupation
Pittet D et al. Ann Intern Med 1999; 130:126

18. 5 Essential Steps for Cross Transmission   
Pittet et al Lancet Infect Dis 2006

19. MGH Nosocomial MRSA

20. Strategies to decrease transmission
Proven or Proposed Strategies
Antibiotic stewardship
Proper hand hygiene
Cohorting patients
Reducing LOS
Gowns and gloves
Isolation of patients
Appropriate staffing ratios
Antibiotic crop rotation
Surveillance cultures
Decolonization of patients (chlorhexidine body washes, muciprocin)
Decolonization of health care worker carriers
Paucity of RCTs on efficacy of individual approaches
Efficacy of an individual approach may vary by pathogen
Near eradication of a pathogen from a hospital (or a country) requires a bundle of approaches (eg. “Search and Destroy” in the Netherlands)

21. Compulsive Antibiotic Prescribing (CAP)
CAP is a widespread and serious affliction
First year medical students are free of the disease
Interns and first year residents are severely afflicted…life-long habit difficult to break
CAP is supported by a well organized group of antibiotic pushers
Antibiotics Anonymous
Self help group, available 24 hours, will talk you through the urge to prescribe more than two antibiotics, other abuses
Lockwood et al, NEJM p , 1974

22. Is isolation safe for the patient?
Cases: Consecutive patients admitted and isolated for MRSA
Controls: Patients in the same room immediately before and after a case
Similar baseline characteristics
Cases
More likely to have unrecorded vital signs, absent MD progress notes, and to complain about their care
Twice the rate of preventable adverse events
Similar mortality (17% cases vs 10% controls, p=0.16)
Stelfox , JAMA 2003

23. Communication Campaign

24. MGH Hand Hygiene (HH) Campaign
2000 HH Task Force (D. Hooper and P. Wright)
Cal stat dispensers hospital wide
2002 Poster/Educational Campaign
2004
8% wash before contact, 48% after contact
HH Champions on each floor -> Pizza
New Poster Campaign
Monitoring and feedback of HH rates by unit/floor, RN/MD

25. MGH Hand Hygiene Campaign
Benchmark against peers (more peer pressure)
“On the spot” Coffee Central coupons
Patients as advocates: patient learning center
2007
HH Quality incentive program: if rates of HH before and after patient contact > 90% on a given floor/ICU, monetary bonus paid at years end to RNs, MDs. Rates/reminders sent to units monthly

26. MGH Quarterly Hand Hygiene rates: 2004-07
Before contact
After contact
*with the patient or patient’s environment
High: 93%
High: 90%
47% 8%
JCAHO expectation: 90% Target for 2007: 90% MGH goal: 100%

28. Conclusions
Nosocomial transmission of pathogenic bacteria creates a major health burden
Multifaceted interventions are needed for high level control: proper hand hygiene is the cornerstone of prevention efforts
Isolation of patients may place them at risk for errors of omission

29. Thank you