Infection in the ICU: what can be done

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Infection in the ICU what can be done?

• Tim Walsh
• Edinburgh Royal Infirmary
• Scotland

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Diagnostic methods
Screening
Surveillance
Handwashing
VAP
Prescribing practice
MRSA infection
Bacteraemia
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Ventilator bundles
Diagnostic methods
Screening
Surveillance
Handwashing
Resistance
C Difficile
Bronchoalveolar lavage
VAP
Prescribing practice
Catheter bundles
MRSA infection
Bacteraemia
De-escalation
Antibiogram
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Ventilator bundles
Diagnostic methods
Screening
Surveillance
Quality Improvement
Handwashing
Resistance
C Difficile
Bronchoalveolar lavage
VAP
Patient Safety
Prescribing practice
Catheter bundles
MRSA infection
Bacteraemia
De-escalation
Antibiogram
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Current practice
Current outcomes
What to treat with
Implementing change
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Current practice
Current outcomes
What to treat with
Implementing change
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Diagnostic practices
Current practice
Current outcomes
What to treat with
Implementing change
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Antibiotic prescription practice in an intensive
care unit using twice-weekly collection of
screening specimens a prospective audit in a
large UK teaching hospital .  M . Warren , A .
Gibb , T . Walsh. Journal of Hospital
Infection 2005 59 90 95.

• 177 sequential admissions
• 183 prescription in ICU for suspected/proven
  sepsis
• 108 (59) were empirical prescriptions and only
  21 of these were subsequently changed.
• Wide range of antibiotics used
• 75 (41) prescriptions for specific organisms,
  28 targeted organisms isolated at least four
  days previously.
• Very low rate of BAL or targeted sampling at
  time of suspected infection
• Clinicians in our ICU reviewed the data and
  reached consensus that screening was associated
  with decision making that did not represent
  current evidence-based practice.

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Diagnostic practices

• VAP
• Invasive versus non-invasive techniques
• BAL/PBB versus tracheal aspirate
• Quantitative versus non-quantitative methods
• Infection definitions
• Clinician decision or standardised definitions

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Does diagnostic method matter?
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Standardised policies

• BAL for all suspected VAP unless clinical
  contraindication
• High PEEP
• High FiO2
• Coagulopathy
• Standardise BAL technique
• Standardises responses to results, including
  de-escalation
• Standardise infection screens
• Doctor driven
• Avoiding random sampling, especially tracheal
  aspirates.

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Diagnostic practices
Prescribing practice
Current practice
Current outcomes
What to treat with
Implementing change
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Benchmarking prescribing practice

• Triggers to starting antibiotics
• Regular sampling versus clinician guided
• Timing in relation to investigation
• Choice of antibiotic regimen
• Early empiric broad-spectrum cover versus narrow
  spectrum with escalation
• De-escalation practice
• Duration of prescription

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Harbarth S et al. Am J Med 2003
115529-535 Analysis of data from the lenercept
(antiTNF p55 fusion protein antibody RCT)
1342 patients enrolled with severe sepsis or
early septic shock
904 microbiologically confirmed infecting
organism (52 bloodstream)
If patient did not receive at least one
antimicrobial to which isolated organism
susceptible within 24 hours from diagnosis severe
sepsis considered inappropriate
211 inappropriate initial therapy What was the
outcome (28 days mortality) for appropriate
versus inappropriate groups?
Lenercept 24 vs 40 P 0.001 Placebo 25 vs 38
P 0.01 Overall 24 vs 39 P lt 0.001
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MacArthur RD et al. Clin Infect Dis 2004
38284-288 Analysis of data from the MONARCS
trial (antiTNF (afelimomab antibody RCT)
2634 patients enrolled with sepsis syndrome
Independent blinded committee classified patients
by primary site of infection, causative organism,
and adequacy of empiric antibiotic therapy
Broad definition of adequate empiric therapy
based on in vitro susceptibility and/or
initiation between 24 hours before to 72 hours
after enrolment (also considered no organism as
adequate)
Adequate empiric therapy Inadequate empiric
therapy Mortality 33 43 P lt
0.001 Difference present across virtually all
sub groups of organisms Greater difference shock
versus no shock
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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Current outcomes
What to treat with
Implementing change
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Preventive measures

• Handwashing compliance
• Ventilator bundle elements
• Catheter insertion bundles
• Curtain changing policies
• Cleaning frequencies
• Staff education

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Handwashing

• Standards
• an average of 6 hours hand washing audit will be
  carried out each month 100 of the time
• Compliance will be reported for the following
  every 3 months
• Cohorted nurses
• Non-cohorted nurses
• ICU medical
• Visiting medical
• Other AHPs
• 3. We will aim for gt65 hand hygiene compliance
  for all staff groups
• A report will be circulated within 1 month of
  completion of data collection

• Set standards
• Agree resource
• Audit cycles
• Regular review (Consultant meetings infection
  group meetings management meetings)

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How much time is needed for hand hygiene in
intensive care? A prospective trained observer
study of rates of contact between healthcare
workers and intensive care patients .  Journal
of Hospital Infection 2005 62 304 - 310 F .
McArdle , R . Lee , A . Gibb , T . Walsh
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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
What to treat with
Implementing change
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Screening

• Policy for MRSA screening at admission and
  discharge
• All admissions should receive admission screen
• All discharges alive screened if
• gt48 hours in ICU
• Not positive at admission
• (Deaths in ICU excluded)
• Collaboration with microbiology laboratory staff
  needed
• Audit of practice ERI
• 2002 admission 54 discharge no data
• 2006 admission 85 discharge 46

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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
Surveillance system
What to treat with
Implementing change
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Surveillance

Definition ..the ongoing systematic
collection, analysis and interpretation of
datawith the dissemination to those who need to
know (Centers for Disease Control (CDC) 1998)

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• Hospitals in
• Europe
• Link for
• Infection
• Control through
• Surveillance

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HELICS criteria

• All patients with LOS gt 2 calendar days
• Ventilated and self-ventilating patients
• No post discharge surveillance
• Infections under surveillance
• Pneumonia
• Blood stream infections
• Central venous catheter infections
• (MRSA and C Diff infections)

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ICU-acquired Pneumonia
Code Diagnostic Method   PN1 Positive
Quantitative culture from minimally contaminated
LRT specimen - BAL gt104 CFU   PN2 Positive
quantitative culture of tracheal aspirate
  PN3 Positive culture related to no other
source -positive pleural fluid culture OR
pulmonary abscess with positive needle aspiration
OR positive histology OR positive exams for
virus   PN4 Positive sputum culture or
non-quantitative LRT specimen culture   PN5 No
positive microbiology/ Culture result lt 104 CFU
Catheter-related infection CVC-related BSI BSI
occurring 48 hours before or after CVC removal
EITHER -CVC culturegt15 CFU OR positive blood
culture sample from CVC OR positive culture with
same organism from pus at insertion site
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Key issues related to surveillance

• Resource
• Dedicated infection control nurse
• 4-5 minutes per patient per day
• Database management
• Report generation and dissemination

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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
Surveillance system
Reporting methodology
What to treat with
Implementing change
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Reporting methodology

• New cases
• Raw data
• Statistical process control charts
• Sellick JA. Infection Control Hospital Epidem.
  1993 14 649
• Warning limits (2 SDs from mean)
• Control limits (3 SDs from mean)
• The clinical indicators support team
• http//www.indicators.scot.nhs.uk

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MRSA in Ward 118, 2005-7
C-chart Constant area of opportunity eg
monthly admissions to ICU who acquire MRSA
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Ventilator Associated Pneumonia Ward 118, 2005-7
U chart Variable area of opportunity, eg VAP
rates per total ventilator days each
month CRBSIs per 1000 catheter days each month
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Catheter Related Bloodstream infections Ward 118,
2005-7
G chart Used for rare/infrequent events Eg
numbers of patients between CRBIs
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Some tests of statistical control

• One point falls above or below the control limit
• 9 consecutive points on one side of the mean
• 6 consecutive points increasing or decreasing
• Important to be aware of assumptions of
  statistical approach to complex system

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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
Surveillance system
Reporting methodology
What to treat with
Local antibiogram
Implementing change
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Local Antibiogram

• Document patterns of common pathogens in your
  unit
• Document resistance patterns of those pathogens
  in your unit
• Guide empiric therapy protocols and specific
  protocols in your unit

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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
Surveillance system
Reporting methodology
What to treat with
What to treat with
PDSA methods
Implementing change
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PlanDoStudyAct

• Process change (QI versus EBM)
• Organisational Infrastructure
• Infection control team
• Intensivist(s), manager, microbiologist, ICU
  nurse, infection control nurse
• Minuted meetings
• Standing item on consultant management meetings
• Embedded feedback
• Posters in staff room
• E-mail circulars
• Monthly item at MM meetings
• Feedback via surveillance nurses

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Some key members of ERI team

• David Swann (ICU consultant)
• Brian Cook (ICU consultant)
• Ian Laurenson (Microbiologist consultants)
• Corrienne McCullough (Surveillance Nurse)
• Joan Bell (infection control nurse)
• Steve Walls Lynn Sermann (ICU nurses)

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PlanDoStudyAct

• Changing the system
• Stickers for notes
• Review of groups or individual cases (VAPwatch)
• Changing charts (eg. head up tilt, catheter
  insertion dates)
• Enabling staff
• Daily review of catheter placements/duration
• Removal of catheters
• Handwashing practice
• Audit projects/Special Study Modules

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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
Surveillance system
Reporting methodology
What to treat with
What to treat with
PDSA methods
Standards and Education
Implementing change
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Standards and education

• Handwashing audit
• Review of data
• Audit of MRSA screening
• Education sessions at Unit entry
• glow-box awareness of infection status bare
  below elbows
• All trainees as part of induction
• Nursing updates
• Cleanliness Champion programme

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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
Surveillance system
Reporting methodology
What to treat with
What to treat with
PDSA methods
Standards and Education
Implementing change
Infection control bundles
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Catheter related sepsis bundle

• Dedicated box
• Hat/gown/gloves for all persons in bed-space for
  all lines (including A-lines)
• Catheter-bundle sticker for all lines

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Ventilator bundle

• Surveillance enables assessment of new elements
  and potentially justify business cases (eg
  sub-glottic suction)
• IHI approach aims for staged introduction without
  progression until high level of compliance
  achieved

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Diagnostic practices
Prescribing practice
Current practice
Preventive measures
Screening
Current outcomes
Surveillance system
Reporting methodology
What to treat with
What to treat with
PDSA methods
Standards and Education
Implementing change
Infection control bundles
Celebration
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Celebration

• Unit report
• Clinical Governance committees
• Quality Improvement meetings
• Abstracts and papers

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Pneumonia

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Pneumonia

p0.013, chi-square
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Acquired Bacteraemias
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Acquired Bacteraemias
p0.006, chi-square
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CRBSI g-chart
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MRSA
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MRSA
p0.006, chi-square
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Clostridium difficile
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Conclusion

• Infection control can be done!
• It takes a lot of effort
• It needs team work, buy in, and a culture change
  among all staff groups
• It needs a structured multifaceted approach
• It benefits patients and your unit

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David Swann (ICU consultant) Brian Cook (ICU
consultant) Ian Laurenson Jorge Cepada
(Microbiologist consultants) Kirsty Everingham
(Surveillance Nurse) Joan Bell (infection control
nurse) Steve Walls Lynn Sermann (ICU nurses)
Escher Order and Chaos 1950