The Modern Approach to Infection Control
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The Modern Approach to
Infection Control
Professor Didier Pittet, MD, MS,
Infection Control Program
University of Geneva Hospitals, Switzerland
Division of Investigative Science
Imperial College, London, UK
Lead, 1st Global Patient Safety Challenge,
World Health Organization (WHO) Patient Safety
Florence Nightingale, 1820 - 1907 from Notes on Hospitals published in 1863
The very first
requirement in a
hospital is that it Ignaz Philipp Semmelweis
should do the
sick no harm
1
Maternal mortality rates,
First and Second Obstetric Clinics,
GENERAL HOSPITAL OF VIENNA, 1841-1850
(%)
Semmelweis IP, 1861
Maternal mortality rates,
First and Second Obstetric Clinics,
Early times of infection control
GENERAL HOSPITAL OF VIENNA, 1841-1850
Intervention 1847
May 15, 1847
1863
Semmelweis IP, 1861
Infection Control and Quality Healthcare in the New Millenium
Are there lessons to be learned ? Does infection control
Recognize
Explain
Act
control infections ?
Pittet D, Am J Infect Control 2005, 33:258
2
SENIC study
Study on the Efficacy of Nosocomial Infection Control SENIC
Study on the Efficacy of Nosocomial Infection Control
Haley RW et al. Am J Epidemiol 1985;121(2):182-205
per 110 beds
Relative change in NI in a 5 year period (1970-1975)
30% Without infection control 26% • 1 infection control nurse per 200 to 250 beds
19% 18%
20% 14%
10%
9% • 1 hospital epidemiologist per hospital (1000
LRTI SSI UTI BSI Total
0% beds)
-10% • Organized surveillance for nosocomial
-20%
infections
-30% -27%
-31% -32%
-40% -35% -35% • Feedback of nosocomial infection rates
Haley RW et al. Am J Epidemiol 1985;121(2):182-205
With infection control
1st principle of infection
Approach to infection control
prevention
1847
at least 35-50% of all healthcare-associated infections
1863 are associated with only 5 patient care practices:
1958
1970 • Use and care of urinary catheters
• Use and care of vascular access lines
1980
• Therapy and support of pulmonary functions
• Surveillance of surgical procedures
• Hand hygiene and standard precautions
Pittet D, Am J Infect Control 2005, 33:258
1st principle of infection Healthcare-Associated Urinary
prevention Tract Infection
at least 35-50% of all healthcare-associated infections
are associated with only 5 patient care practices: • Urinary tract infection (UTI) causes
~ 40% of hospital-acquired infections
• Use and care of urinary catheters • Most infections due to urinary catheters
• Use and care of vascular access lines
• Therapy and support of pulmonary functions • 25% of inpatients are catheterized
• Surveillance of surgical procedures • Leads to increased morbidity and costs
• Hand hygiene and standard precautions
3
Prevention of Catheter-Associated
Urinary Tract Infection (CA-UTI)
Infect Control Hosp Epidemiol . 2008 Suppl 1:S41-50.
Two main principles
J Hosp Infect. 2007 65 Suppl 1:S1-64
Avoid unnecessary catheterization
Limit the duration of catheterization
Int J Antimicrob Agents
2008 Suppl 1:S68-78.
Indications for the use of indwelling
Is one catheter better than another?
urethral catheters
• Indications • No significant difference between latex and
– Perioperative use for selected surgical procedures silicone catheters
– Urine output monitoring in critically ill patients
– Management of acute urinary retention and urinary obstruction
• What about coated / impregnated catheters?
– Assistance in pressure ulcer healing for incontinent residents • The concept: prevention of biofilm formation
– As an exception, at patient request to improve comfort
• Urinary incontinence is not an accepted indication for
urinary catheterization EM pictures of biofilms
– 21 to 50 percent of urinary catheters not indicated on silver coated catheters
Lo et al. (2008) Infect Control Hosp Epidemiol Suppl 1:S41-50 Morgan et al. (2009) Urol Res 37:89–93.
Antimicrobial-coated urinary catheters Catheter insertion and maintenance
Proportion of participants (or catheters) developing catheter-associated bacteriuria
• Practice hand hygiene (A-III)
– before insertion of the catheter
– before and after any
nes manipulation of the catheter site
guideli
of the
d e d b y any + + )
men costs
recom ence,
tly not fficient evid
Curren (i n s u
Some effect, but studies mostly of poor quality
Useful in high-risk groups?
Johnson et al. (2006) Ann Intern Med 14:116-26 http://www.who.int/gpsc/tools/en/
4
Catheter insertion and maintenance
Catheter insertion and maintenance
• Maintain unobstructed urine flow (A-II)
• Insert catheters by use of aseptic technique and sterile • Empty the collecting bag regularly, using a separate col-
equipment (A-III) lecting container for each patient, and avoid allowing the
• Cleanse the meatal area with antiseptic solutions is draining spigot to touch the collecting container (A-II)
unnecessary (A-I) • Keep the collecting bag below the level of the bladder at all
– routine hygiene is appropriate
times (A-III)
• Properly secure indwelling catheters after insertion to • Do not routinely use silver-coated or other antibacterial
prevent movement and urethral traction (A-III) catheters (A-I)
• Maintain a sterile, continuously closed drainage system • Do not screen for asymptomatic bacteruria in catheterized
(A-I) patients (A-II)
• Do not disconnect the catheter and drainage tube unless • Do not treat asymptomatic bacteruria in catheterized patients
the catheter must be irrigated (A-I) except before invasive urologic procedures (A-I)
Lo et al. (2008) Infect Control Hosp Epidemiol Suppl 1:S41-50 Lo et al. (2008) Infect Control Hosp Epidemiol Suppl 1:S41-50
What you should not do to prevent CAUTI Incidence of UTI, before and after a
multimodal intervention
Stéphan F. et al D, Clin Infect Diseases 2006, 42:1544
• Do not use (avoid) catheter irrigation (A-I)
Pre-intervention Post-intervention RR
UTI period period (95%-CI)
(n=280) (n=259)
• Do not use systemic antimicrobials routinely as
prophylaxis (A-II) N ID* C
N ID*
Overall 39 27.0 17 12.0 0.44 (0.24-0.81)
• Do not change catheters routinely (A-III)
Orthopedic surgery 34 45.8 10 18.6 0.41 (0.20-0.79)
Intervention group
Digestive surgery 6 9.0 3 5.6 0.62 (0.14-2.50)
Control group
Lo et al. (2008) Infect Control Hosp Epidemiol Suppl 1:S41-50
* ID: episodes per 1000 catheter-days
Stéphan F. et al D, Reduction of UTI and antibiotic use after surgery:
a controlled, prospective, before-after intervention study
1st principle of infection
Clin Infect Diseases 2006, 42:1544 prevention
• Incidence density of UTI decreased by 60%
at least 35-50% of all healthcare-associated infections
after orthopedic surgery following a are associated with only 5 patient care practices:
multimodal intervention
C
• Use and care of urinary catheters
• Results were maintained after 2 years
• Use and care of vascular access lines
• Less indwelling urinary catheters placed in • Therapy and support of pulmonary functions
the operating room • Experience with surgical procedures
• Decrease UTI antibiotic-related consumption • Hand hygiene and standard precautions
5
Reported incidence rates of catheter-
Sources of the catheter-associated
associated bloodstream infections in
bloodstream infection
surveillance networks in ICUs:
Intraluminal from NHSN: 2.7 per 1000 catheter-days
(1.5/1’000 – 6.8/1’000) National Healthcare Safety Network
tubes and hubs
Michigan: 2.7 per 1000 catheter-days
Hematogenous
(median before intervention)
from distant sites
Germany: 2.1 per 1000 catheter-days
Skin Extraluminal from
18 developing International Nosocomial Infection Control Consortium
Vein skin (INICC) 2002-2007
countries: 8.9 per 1000 catheter-days
Edwards RJ. Am J Infect Control 2007; 35:290 – Gastmeier P. J Hosp Infect 2006; 64: 16
Pronovost P. N Engl J Med 2006; 355:26 – Rosenthal V. Am J Inf Control, 2008:36:627-637
Education-based, multimodal
Prevention of vascular prevention strategy of CRI
access line infection
in intensive care
University of Geneva Hospitals Eggimann and Pittet Sepsis Monitor 2000
Prevention of vascular access line infection Education-based prevention of vascular
Medical intensive care unit catheter-associated bloodstream infection
Incidence density 12 Primary bacteremia / 1000 CVC-days Sherertz
episodes/1’000 patient-days Ann Intern Med 2000
10
12 11.3
8 112 MICUs (NNIS) Coopersmith et al.
10 9.2
CCM 2002
1997 reduction
8 8.2 6 146 SICUs (NNIS)
19981999 Warren et al.
CCM 2003
6 3.8* -67% primary BSI% 4
4 3.3* -68% clinical sepsis
3.1 2.6* 2 Eggimann et al.
-63% microbiologically doc. BSI
Lancet 2000
2 1.2* -64% insertion site infection -74%
0
0 Eggimann et al.
1996 1997 1999 1995 1996 1997 1998 1999 2000 2001 2002 Ann Intern Med
NNIS Am J Infect Control 1999 2005
Eggimann et al. Lancet 2000; 355:1864
* P < 0.05 Average rate is not necessarily the best you can get
6
Multimodal intervention strategies to reduce Efficacy of multimodal intervention strategies:
catheter-associated bloodstream infections:
Baseline Intervention
- Hand hygiene
Eggimann 3.1/1000 catheter-days 1.2/1000 catheter-days
- Maximal sterile barrier precaution at insertion Lancet 2000
Ann Intern Med 2005
- Skin antisepsis with alcohol-based chlorhexidine-
containing products Pronovost * 7.7/1000 catheter-days * 1.4/1000 catheter-days
NEJM 2006
- Subclavian access as the preferred insertion site
- Daily review of line necessity Zingg 3.1/1000 catheter-days 1.1/1000 catheter-days
- Standardized catheter care using a non-touch technique Crit Care Med 2009
*mean pooled CRBSI-episodes per 1’000 catheter-days
- Respecting the recommendations for dressing change
Eggimann P. Lancet 2000; 35: 290
Eggimann P. Ann Intern Med 2005; 142: 875 – 5 year follow-up
Eggimann P. Lancet 2000; 35: 290
Pronovost P. N Engl J Med 2006; 355: 26
Pronovost P. N Engl J Med 2006; 355: 26
Zingg W. Crit Care Med 2009; 37: 2167
Zingg W. Crit Care Med 2009; 37: 2167
Chlorhexidine-Impregnated Sponges and
Less Frequent Dressing Changes for
Could we do better ? Prevention of Catheter-Related Infections in
Critically Ill Adults
Chlorhexidine
gluconate- Multi-centre randomized controlled trial
impregnated
sponge - 3’778 catheters
- 28’931 catheter-days
- Baseline rate of major catheter-related infections:
1.4/1000 catheter-days!
Timsit JF. JAMA 2009; 301: 1231
Chlorhexidine-gluconate impregnated dressings
decreased major catheter-related infections: Efficacy of multimodal intervention strategies:
1.40 per 1000 Baseline Intervention
catheter-days
Control
Eggimann 3.1/1000 catheter-days 1.2/1000 catheter-days
dressings
Cumulative Risk
HR = 0.39; Pronovost * 7.7/1000 catheter-days * 1.4/1000 catheter-days
p=0.03
ChG Zingg 3.1/1000 catheter-days 1.1/1000 catheter-days
dressings
Timsit 1.4/1000 catheter-days 0.6/1000 catheter-days
0.60 per 1000
catheter-days *mean pooled CRBSI-episodes per 1’000 catheter-days
Catheter-days
Eggimann P. Lancet 2000; 35: 290
Pronovost P. N Engl J Med 2006; 355: 26
Zingg W. Crit Care Med 2009; 37: 2167
Timsit JF. JAMA 2009; 301: 1231 Timsit JF. JAMA 2009; 301: 1231
7
1st principle of infection
Prevention of vascular prevention
access line infection
at least 35-50% of all healthcare-associated infections
are associated with only 5 patient care practices:
• Use and care of urinary catheters
y • Use and care of vascular access lines
rateg
l st
• Therapy and support of pulmonary functions
o d a • Experience with surgical procedures
u ltim • Hand hygiene and standard precautions
Am
Risk factors for Ventilator-
General precautions
Associated Pneumonia (VAP)
Patient • Staff education, hand
Devices
hygiene, isolation
• Age • Invasive ventilation
precautions (I)
• Burns • Duration of invasive
• Coma ventilation
• Lung disease • Surveillance of infection and
• Reintubation
resistance with timely
• Immunosuppression • Medication
feedback (II)
• Malnutrition • Prior antiobiotic
• Blunt trauma treatment
• Adequate staffing levels (II)
• Sedation
ATS Guidelines 2005
Effect of staffing level in late onset VAP
Hugonnet S, et al. Crit Care Med 2007;35(1):76
8
Intubation and ventilation Is there a role for oral antiseptics ?
• Avoid intubation and reintubation - I
• Prefer non-invasive ventilation - I
• Prefer orotracheal intubation & orogastric
tubes - II
• Continous subglottic aspiration - I
• Cuff pressure > 20 cm H2O - II
• Avoid entering of contaminate consendate
into tube/nebulizer - II
• Use sedation and weaning protocols to
reduce duration – II
• Use daily interruption of sedation and avoid
paralytic agents - II ATS Guidelines 2005
ATS Guidelines 2005
Oral decontamination
Is there a role for oral antiseptics ?
Chlorhexidine
VAP
Mortality
• Oral chlorhexidine application reduces
VAP in one study but not for general
use – I
Schlebiki MP et al. Crit Care Med 2007;35:595-602
ATS Guidelines 2005
Stress bleeding, transfusion, hyperglycemia
Systemic and enteral antibiotics • Trend towards less VAP with sucralfate (vs
H2 blockers) but increased gastric bleeding
> individual choice - I
• Selective decontamination of the digestive tract
• Prudent transfusion, leukocyte-depleted red
(SDD) reduces the incidence of VAP & helps to
blood cell transfusion - I
contain MDR outbreaks – I • Intensive insulin therapy to keep glucose 80
• But SDD not recommended for routine use – II - 110 mg/dl - I
• Prior systemic antibiotics helps to reduce VAP in Aspiration, body position
selected patient groups but increases MDR – II • Semirecumbent position (30 - 45°) especially
• 24-hour AB prophylaxis helps in one study but when receiving enteral feeding - I
• Enteral nutrition is preferred over parenteral
not for routine use - I
ATS Guidelines 2005
because of translocation risk - I
ATS Guidelines 2005
9
VAP Prevention
Crit Care Med 2010: volume 38 in Press
1. Hand hygiene before and after patient contact,
1. Adherence to hand hygiene preferably using alcohol-based handrubbing
2. Adherence to glove and gown use 2 year intervention study: 2. Avoid endotracheal intubation if possible
3. Backrest elevation maintenance Compliance with
preventive measures
3. Use of oral, rather than nasal, endotracheal tubes
4. Correct tracheal-cuff maintenance increased 4. Minimize the duration of mechanical ventilation
5. Orogastric tube use VAP prevalence rate
decreased by 51%
5. Promote tracheostomy when ventilation is needed
6. Gastric overdistention avoidance for a longer term
7. Good oral hygiene
6. Glove and gown use for endotracheal tube manip
8. Elimination of non-essential tracheal suction
VAP Prevention (con’t) 1st principle of infection
prevention
7. Avoid non-essential tracheal suction
8. Oral hygiene with chlorhexidine at least 35-50% of all healthcare-associated infections
9. Backrest elevation 30-45o are associated with only 5 patient care practices:
10. Maintain tracheal tube cuff pressures (>20) to
prevent regurgitation from the stomach • Use and care of urinary catheters
11. Avoid gastric overdistension • Use and care of vascular access lines
12. Promote enteral feeding • Therapy and support of pulmonary functions
13. Careful blood sugar control in patients with • Experience with surgical procedures
l
od a
diabetes
ltim gy • Hand hygiene and standard precautions
14. SDD in selected cases u
A m trate
s
Patient-related factors
Strategies to prevent SSI • Diabetes - Recommendation (IDSA/SHEA)
• Objectives – Preoperative
• Control serum blood glucose; reduce HbA1C levels toProcedure-related risk factors Antimicrobial prophylaxis
– Hair removal technique
• Recommendations (A-I)
– Preoperative infections
– Surgical scrub
– Administer within 1 hour of incision to
– Skin preparation
maximize tissue concentration
– Antimicrobial prophylaxis • Once the incision is made, delivery to the wound is
– Surgeon skill/technique impaired
– Asepsis
– Operative time
– Operating room characteristics
Antimicrobial prophylaxis
• Duration of prophylaxis (A-I)
– Stop prophylaxis
• within 24 hours after the procedure
• within 48 hours after cardiac surgery
– To:
• Decrease selection of antibiotic resistance
• Contain costs
• Limit adverse events
Bratzler et al Arch Surg 2005, 140:174-82
Harbarth S et al. Circulation 2000;101:2916–2921
Surgeon Skill and Technique Active surveillance
• Excellent surgical technique reduces the
risk of SSI (A-III)
• Includes
– Gentle traction and handling of tissues
– Effective hemostasis
– Removal of devitalized tissues
– Obliteration of dead spaces
– Irrigation of tissues with saline during long
procedures
– Use of fine, non-absorbed monofilament
suture material
– Wound closure without tension
– Adherence to principles of asepsis
Courtesy: Astagneau, SFHH 2007
11Examples of Multimodal approach(es)
Summary: Relative SSI reduction to reduce SSI
- Active surveillance 38% Haley et al, Am J Epidemiol 1985
55%
Rioux et al, J Hosp Infect 2007
Timely antibiotic prophylaxis, strict glycaemia
- Multimodal intervention 27% 100k lives campaign control, no shaving
57%
Trussel et al, Am J Surg 2008
SSI 1.5% vs. 3.5% in controls
- Correct and timely 18%
Saxer et al, Ann Surg 2009 Trussel et al, Am J Surg 2008
antibiotic prophylaxis
- Normothermia 13% Kurz et al, NEJM 1996
100k lives campaign
- Normoglyceamia 38% Ambiru et al, J Hosp Infect 2008 (antibiotic prophylaxis, glycaemia control,
- Chlorhexdidine-alcohol? 41% Darouiche et al, NEJM 2010
normothermia)
- Suppl. oxygen? 25% Qadan et al, Arch Surg 2009
SSI from 2.3% to 1.7% (-27%)
- Nasal mupirocin for MSSA? 58% Bode et al, NEJM 2010
100k lives campaign
- Surgical hand
antisepsis no data no random Widmer et al, J Hosp Infect 2010
1st principle of
infection prevention
at least 35-50% of all nosocomial
infections are associated with
patient care practices:
• Use and care of urinary catheters
• Use and care of vascular access lines Compliance < 40%
• Therapy and support of pulmonary functions
• Experience with surgical procedures
• Hand hygiene and standard precautions
Handwashing … Alcohol-based
an action of the past hand rub at
(except when hands are visibly soiled)
the point of
The University
care of Geneva
Hospitals, 1995
1. Recognized
2. Explained
3. Act Alcohol-based
hand rub Before and after any patient contact
is standard of care After glove use
In between different body site care
12The University of Geneva Hospitals (HUG), 1995 The University of Geneva Hospitals (HUG), 1995 - 1998
« Talking walls »
BEFORE AFTER
Results Hospital-wide nosocomial infections;
Alcohol-based handrubbing
trends 1994-1998
Handwashing (soap + water)
12/94 12/95 12/96 12/97
www.hopisafe.ch
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
Pittet D et al, Lancet 2000; 356: 1307-1312
The University of Geneva Hospitals (HUG), 8 years follow-up
« Success story – Key Parameters »
• System change
• Education of healthcare workers
• Monitoring and feedback of
performance
• Administrative support
Rub • Leadership and culture change
hands…
it saves
• Associated with reduction in cross-
money transmission and infection rates
Pittet D et al, Inf Control Hosp Epidemiol 2004; 25:264
131. System change
Alcohol-based Access to safe,
• The 5
core
handrub at point of
care
continuous water
supply, soap and
towels
components of the +
WHO Multimodal 2. Training and Education
Hand Hygiene +
Improvement 3. Observation and feedback
Strategy +
4. Reminders in the hospital
+
5. Hospital safety climate
“My 5 Moments for Hand Hygiene”
A multimodal strategy
Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. J Hosp Infect 2007;67:9-21
Infection Control and Quality Healthcare in the New Millenium
Evolving to new Multidisciplinary team approach
challenges in infection
control and patient safety 1847
1863
- Team and multidisciplinary team work 1958
- Successful interventions 1970
- Adaptability of actions 1980
- Scaling up
1990
- Sustainability of actions / interventions
2000
- Leadership commitment / Governance
Pittet D, Am J Infect Control 2005, 33:258
14Infection Control and Quality Healthcare in the New Millenium
Where are we going ? Registered health-care facilities – May
2009 on…
Work in progress….
Healthcare system:
-Hospitals
-Ambulatory services
-Nursing homes
-Long-term care facilities
-Home care delivery
systems
International Financing Patient safety
State/country
surveillance bodies promotion
epidemiology
program systems
The global impact of SAVE LIVES: Clean Your Hands - Jan 2010
5996 health-care facilities from 126 countries
Pittet & Sax, Infectious Diseases. Cohen textbook (2nd ed.), chap.85, 2004
Aiming at… 10 000 registered health-
care facilities by May 2010 SAVE LIVES: Clean YOUR Hands
5 May 2009-2020
A WHO Patient Safety Initiative 2009
Encourage health-care facilities to show their
commitment by signing up now on:
Clean Care is Safer Care
The countdown has started! Global Patient Safety Challenge
WHO Patient
Safety
WHO
Collaborating
Centres
r
SAVE
safe
Country
campaigns & LIVES ry car
e
th
eal
activities
Facility
g h
kin
campaigns &
activities including
Ma
evaluation and
feedback
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