OPERATING DEVICE OR PROCEDURE ASSOCIATED INFECTIONS...

operating  device or procedure associated infections

INTRODUCTION

The device/procedure associated infections and preventive guidelines included in this chapter are ventilator associated pneumonia (VAP), catheter associated urinary tract infection (CAUTI), central line related blood stream infections (CRBSI) and surgical site infections (SSI). These are based on currently available centers for disease control and prevention (CDC) guidelines.

STANDARD OPERATING PROTOCOLS    

1. Ventilator associated pneumonia

VAP is one of the common health care associated infections in Intensive Care Units (ICUs). Clinical practice aimed at preventing VAP must be seen in the context of managing patients with respiratory failure and especially those who require artificial ventilation. VAP is pneumonia that occurs in a patient who was intubated and ventilated at the time of or within 48 hours before the onset of the pneumonia. A ventilator in this context is a device to assist or control respiration continuously, inclusive of the weaning period, through a tracheostomy or by entotracheal intubation. VAP arises when there is bacterial invasion of the pulmonary parenchyma in a patient receiving mechanical ventilation.

Strategies to prevent or minimize contamination of equipment used for caring patients receiving mechanical ventilation:

1.    Ensure hand hygiene before handling endotracheal tube (ETT) and ventilator circuits

2.    Follow asepsis during intubation and suctioning.

3.    Use sterile single use gloves and suction tubes.

4.    Use sterile water for humidification.

5.    Remove condensate from ventilator circuits frequently. It requires routine inspection. Take care not to allow condensate to drain towards the patient.

6.    Keep the circuits closed while removing condensate.

7.    Change the ventilator circuit and attached humidifier weekly unless it is found visibly soiled or malfunctioning.

8.    Thoroughly clean all equipment before sterilization or disinfection.

9.    Though high-level disinfection is adequate for semi critical items, first option adopted in this hospital is sterilization. Ventilator circuits are to be sterilized by hydrogen peroxide gas plasma sterilization. Autoclave laryngoscope blades. Use sterile water for rinsing ventilator accessories before sterilization and after chemical disinfection. Store sterilized items with utmost care that no recontamination takes place.

10. Orotracheal intubation is preferable to nasotracheal intubation as the later increases the chance of sinusitis which may increase the risk of VAP. Early ambulation of the patient helps him recover faster. Chest physiotherapy followed by drainage of secretion is initiated at the earliest and maintained throughout mechanical ventilation.

VAP prevention bundle

The ventilator care bundle is a series of interventions related to ventilator care that, when implemented together will achieve significantly better outcomes than when implemented individually.

1) Daily sedation vacation: Those patients who had daily interruptions/sedations are demonstrated to have reduced duration of ventilation and ICU stay. Each ICU has to examine their sedation practice and develop a system that allows a sedation hold policy. Sedation break should ideally occur before 10 AM. If possible switch it off early in the morning at the end of night shift. Though stopped, sedation is not disconnected from the patient.  Then allow the patient to wake up. If the patient is co-operative and able to understand commands leave the sedation off. Distressed or agitated patients may be recommenced on sedation but at half the previous rates. Sedation boluses may be administered as required to achieve safety. If possible it may be substituted by analgesics and attempt for this may be initiated before restarting sedation.

2) All patients will be assessed for weaning and extubation each day: Standardised weaning protocols could reduce ventilator stay. Daily screening of the respiratory function of ventilated patients followed by trials of spontaneous breathing in appropriate patients reduces duration of mechanical ventilation and is associated with fewer complications than usual. Avoid unplanned extubation and re-intubation.

3) Avoid supine position aiming to have the patient at least 300 head up: Sitting ventilator patients up reduces oesophageal reflex, pulmonary aspiration, and may prevent VAP. Avoidance of the supine position particularly in patients being enterally fed is more important than semi recumbency. Backrest elevation should be done whenever practicable during patient care. Though it is very difficult to achieve 45 degree head end elevation, for a number of patients due to their disease condition, elevation to nearly 30 degree is possible.

4) Prevent aspiration of gastric contents: Critically ill intubated patients lack the ability to defend their airway. Therefore, oesophageal reflux and aspiration of gastric contents along the endotracheal tube may lead to bronchial colonization and pneumonia. Supine position and length of time patients stayed in that position are risk factors for gastric aspiration. Gastric over distension also can cause aspiration. Check for residual volume routinely before each feed and withhold feeding for one hour if it exceeds 100 ml. Residual gastric contents could cause vomiting or aspiration and resultantly VAP.

5) Use chlorhexidine as part of daily mouth care: Meticulous oral hygiene using chlorhexidine in each shift reduces oro-pharyngeal colonization and hence ventilator associated pneumonia.

6) Frequent suctioning of subglottic secretions in patients on ventilators: Deep glottic drainage of potentially contaminated oro-pharyngeal secretions from above the tracheal tube cuff may prevent aspirations, lower airway colonization and hence pneumonia. Presence of pooled subglottic secretions between the cuff of the endotracheal tubes and trachea will contribute to aspiration and it may be colonized by hospital pathogens. As and when made available ET tubes with subglottic drainage ports may be used.

7) Stress ulcer prophylaxis / Reduce colonization of aero digestive tract: Stress ulceration is the most common cause of gastro intestinal bleeding in patients in intensive care units. Peptic ulcer disease prophylaxis is therefore necessary. It may also precipitate pneumonia due to the decreased bacterial killing in the low acid environment as acid suppressive therapy may increase the colonization density of the aero digestive tract with potentially pathogenic organisms. Though its association with VAP is unclear, when applied as a package of interventions for ventilator care, stress ulcer prophylaxis with selective drug seems to decrease the rate of pneumonia.

VAP is often fatal, and is associated with increased mortality and morbidity, increased duration of mechanical ventilation, prolonged ICU and hospital stay, and increased cost of hospitalization. VAP is preventable through the use of evidence-based strategies intended to minimize endotracheal intubation, duration of mechanical ventilation and, the risk of aspiration of oro pharyngeal secretions.

2. Catheter associated urinary tract infection

Urinary tract infections (UTI) are the most common type of healthcare associated infections accounting for more than 30% of total HAI. Virtually, all catheter associated urinary tract infection are caused by instrumentation of the urinary tract. Though, the mortality and morbidity from CAUTI is considered to be relatively low compared to other HAIs, the high prevalence of catheter use leads to a large cumulative burden of infections.

Microbial pathogens can enter the urinary tract either by the extraluminal route, by migration along the outside of the catheter in the periurethral mucous sheath, or by the intraluminal route, by movement along the internal lumen of the catheter from a contaminated collection bag or catheter drainage tube junction. Formation of biofilms by urinary pathogens on the surface of the catheter and drainage system occurs with prolonged duration of catheterization. Over time, the urinary catheter becomes colonized with microorganisms living within the biofilm, rendering them resistant to antimicrobial and host defenses.

Standard operating protocol for care of patients having indwelling urinary catheter

These guidelines apply to adults and children and should be used in conjunction with the guidance on standard precautions. The guidelines mainly focus on preventing infection. Catheter insertion, catheter change and care should be documented. It includes date and time of catheter insertion, indications for catheter insertion, individual who inserted the catheter, date and time of removal/ change of catheter, reason for change of catheter etc.

The recommendations are divided into five distinct interventions:

1. Assessing the need for catheterization

Indwelling urinary catheters should be used only after alternative methods of management have been considered. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk of CAUTI and patients with impaired immunity. The patient's clinical need for catheterization should be reviewed regularly. and the urinary catheter removed as soon as possible. Avoid urinary catheters for management of incontinence. Use urinary catheters in operative patients only as necessary rather than routinely and remove as soon as possible, postoperatively.

2. Catheter insertion

Unless otherwise clinically indicated, use the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma. Perform hand hygiene immediately before and after insertion or manipulation of the catheter device or site. Use sterile equipment and appropriate personal protective equipment (sterile gloves, drape, sponges, sterile antiseptic solution and lubricants) during catheterization. For urethral catheterization, the meatus should be cleaned before insertion of the catheter, with 10% povidone iodine /2% chlorhexidine gluconate. An appropriate sterile lubricant should be used during catheter insertion to minimize urethral trauma. The catheter balloon should be inflated with10 ml of sterile water in adults and 3-5 ml in children. Properly secure indwelling catheters after insertion to prevent its movement and urethral traction.

3. Catheter drainage options

Following aseptic insertion of the indwelling catheter, it should be connected to a sterile closed urinary drainage system.If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Maintain unobstructed urine flow. To ensure this keep the catheter and collecting bag below the level of bladder and the tubing free from kinking, at all times. Empty the collecting bag regularly using a clean collecting container avoiding splash and contact of the drainage spigot with the non-sterile collecting container. Do not change indwelling catheter or drainage bags at routine fixed intervals, rather change it based on clinical indications such as infection, obstruction, or when the closed system is compromised.

CDC does not recommend routine bladder irrigation with antimicrobial unless obstruction of the tube is anticipated. If obstruction occurs, closed continuous irrigation may be done to prevent obstruction. If intermittent catheterization is used, perform it at regular intervals to prevent bladder over distension. Intermittent catheterization is preferred to an indwelling catheter if it is clinically appropriate and it is a practical option for the patient.

4. Catheter maintenance

Hands must be decontaminated and wear a new pair of sterile gloves before manipulating a patient's catheter, and decontaminate  hands after removing gloves. Urine samples must be aspirated from the catheter hub under aseptic technique without disconnecting the system. The meatus should be washed daily with soap and water. Each patient should have an individual care regimen designed to minimize the problems of blockage and encrustation. The tendency for catheter blockage should be documented in each patient. Catheters should be changed only when clinically necessary or according to the manufacturer's current recommendations.

5. Education of healthcare personnel

Healthcare personnel should be educated about and trained in techniques of insertion of catheters, and catheter management like maintenance, and removal. Provide education about CAUTI, other complications of urinary catheterization, and alternatives to indwelling catheters etc. Healthcare personnel should be assessed for their competence to carry out these types of procedures.

3. Central line related blood stream infection (CRBSI)

Central line is an intravascular (IV) catheter that terminates at or close to the heart or in one of the great vessels, which is used for infusion, withdrawal of blood or hemodynamic monitoring. Infections related to central venous catheter (CVC) include insertion site infection, blood stream infection and exit site infection (in case of tunneled catheters).

The most important infection associated with IV devices is blood stream infection (bacteremia). Although peripheral venous catheters are the devices most frequently used for vascular access, the incidence of local or bloodstream infections (BSIs) associated with it is usually low. However, the majority of serious catheter-related infections are associated with CVCs.

CVC is a foreign body which produces a reaction in the host. Following insertion of this vascular device, microbial bio-films are formed at inner and outer surfaces of the catheter. The presence of the device impairs the activity of the neutrophils and protects micro organisms embedded in the bio-film from the effect of antimicrobial agents. Bacteria are therefore, able to multiply freely in the biofilm on the catheter surface from where they are released into the bloodstream. Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection for peripherally inserted, short-term catheters. Contamination of the internal surface of the catheter usually begins at the hub and contributes substantially to intraluminal colonization of long-term catheters. They are responsible for a significant proportion of catheter associated infection and it increases when more than one hub (e.g. multiple lumen catheter) is used.

Occasionally, catheters might become hematogenously seeded from another focus of infection. Rarely, infusate contamination also leads to CRBSI. Although most intravenous device-associated infections are acquired endogenously from micro-organisms colonizing the patient's skin, they may also be introduced in to the hub, lumen or administration set during its manipulation.

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