Tokom svoje dugogodišnje karijere diplomiranog medicinskog tehničara susretao sam se sa mnogim pacijentima koji su imali nozokomijalne infekcije tokom svoje hospitalizacije. U ovom radu ćemo prezentirati uobičajene uzročnike intrahospitalnih infekcija kod pacijenata na intenzivnoj njezi, kao i primjere najboljih strategija prevencije širom svijeta. Također će biti prezentirane stope mortaliteta među pacijentima hospitaliziranim na jednicima intenzivne njege u razvijenim u odnosu na zemlje u razvoju. Kao važan segment u radu je obrađen rad na edukaciji medicinskog i nemedicinskog osoblja u prevenciji infekcija i najbolje strategije u smanjenju stope ovih infekcija među pacijentima. Kao zaključak možemo reći da je veoma bitno razgovarati o ovoj temi sa svim pružaocima medicinskih usluga, jer se na taj način može spriječiti nepotrebno produljenje hospitalizacije kao i moguće komplikacije za pacijente.
Ključne riječi: intrahospitalne infekcije, prevencija, edukacija
INTRAHOSPITAL INFECTIONS IN ICU
During my lengthy career as a Registered Nurse I have encounter many patient cases that acquired nosocomial infections while being hospitalized. In this paper I will be presenting common causes of intra-hospital infections among patients in critical care setting. Also, the best practices in prevention strategies worldwide. Will also present mortality rates among ICU patients in industrial versus developing countries. Additionally is important to discuss education of medical and non-medical staff in infection prevention and what strategies are best to decrease rates of these infections among patient population. In conclusion we can say that it is very important to discuss this matter among all medical and health care providers, because this way we can decrease unnecessary prolongation of hospitalization and possible complications.
Keywords: Intrahospital infections, prevention, education
I have been in healthcare industry for over ten years and during all these years I have encounter many patients in critical care units that have been impacted by intrahospital infections. These infections have impacts on direct patient care and financial burden on healthcare system. As nurse we need to educate the public about these infections and how to prevent them. One of the important steps of the prevention chain is frequent and proper hand washing techniques. According to Bjerke, “Handwashing is a fundamental principle and practice in the prevention, control, and reduction of healthcare-acquired infection” (1, p295).
The most common complication threatening hospitalized patients today, nosocomial infections affect approximately 2 million patients each year and kill 90,000. In acute care hospitals, up to 10% of patients acquire one or more of these infections. By understanding how the causative pathogen is identified and tested for antibiotic sensitivity, you can help ensure that your patient gets effective treatment. (2)
The burden of antibiotic usage is very high in intensive care units. Nosocomial intensive care unit-acquired infections and antimicrobial resistance are global problems, and many epidemiological studies are carried out, especially from developed countries. However, available data of patient population and characteristics of intensive care units are very limited in developing countries. The prevalence of infection and mortality rates are higher in countries with limited resources associated with the quality of care. Infection control strategies such as hand hygiene, rational antibiotic utilisation, continuous education and performance feedback demonstrated a significant reduction in the infection rates in these countries. Acinetobacter baumannii is common cause of nosocomial infections worldwide. In recent years, interest in infections caused by A. baumannii has gradually increased, and current studies indicate that this pathogen is more resistant and virulent, becoming a serious nosocomial threat.
Patients in intensive care units (ICUs) are a significant subgroup of all hospitalised patients, accounting for about 25% of all hospital infections (3). The prevalence of ICU-acquired infections is significantly higher in developing countries than in industrialised countries, varying between 4.4% and 88.9% (3). Furthermore, device-associated infection rates in developing countries, especially ventilator-associated pneumonia (VAP) followed by central venous catheter-related bloodstream infections (CRBSIs) occur at a higher frequency than in European countries and USA (3). The major problems associated with increased nosocomial infections in these countries are low compliance of hand hygiene, excessive number of patients and workload, inadequate staff and personal protective equipment and late establishment of infection control programmes. According to Hughes, (2006) “Since the early 19th century, hand washing has been known to be the single most effective method of halting the spread of disease. Compliance rates for proper hand hygiene among health care workers are reported to be unacceptably low—from 14% to less than 50%” (4, p96). Also, according to Bjerke (2004), “The fundamental principle of hand hygiene is the single most effective measure to break the chain of infection. The goal of hand hygiene is to suspend and remove soil, debris, bio burden, and transient microorganisms; to inhibit, kill, and remove transient and resident skin flora; and to inhibit regrowth of microbes” (1, p296).
Increasing drug resistance and spreading of multidrug-resistant (MDR) pathogens in the ICU environment results in limited therapeutic options and prolonged hospitalisations.
Consequently, ICU-acquired infections have been associated with significant morbidity, mortality and rising healthcare costs in developing countries with limited resources. Acinetobacter baumannii is a common cause of nosocomial infections worldwide. In recent years, interest in infections caused by A. baumannii has gradually increased, and current studies indicate that the pathogen is more resistant and virulent, becoming a serious nosocomial threat. The aim of this review is to assess the problems associated with infections prevalent in ICUs in developing countries. While the nosocomial ICU infections and antimicrobial resistance are global problems, there have been many epidemiological studies carried out especially in western countries (3). Such studies have provided valuable information about the prevalence and epidemiology of infection in critically ill European patients (3). Additionally, these studies emphasised that adherence to infection control measures significantly reduced the prevalence of these infections. VAP, CRBSI and CAUTI are the most important nosocomial infections in the ICUs worldwide. Lack of data collection and absence of policies and guidelines of infection control are the major problems to estimate the burden of ICU infections and adherence to infection control measures in developing countries (3). Therefore, International Nosocomial Infection Control Consortium (INICC) aimed to provide surveillance data and gives performance feedback to reduce the infection rates focusing on education, hand hygiene and other basic infection control measures in developing countries (3). INICC is an international non-profit, open, multicentre, collaborative healthcare-associated infection control program with a surveillance system based on that of the US National Healthcare Safety Network. Several developing countries including Argentina, Turkey, Colombia, India, Mexico, Brazil, and Peru have participated in INICC. The surveillance data from academic teaching, private community and public hospitals get involved. By type of the ICUs, patients were mostly hospitalised in medical, surgical, coronary, paediatric and newborn units. According to the INICC data, device-associated infection rates reported in ICUs in developing countries were 19.5 for VAP, 9.2 for CRBSI and 6.5 for CAUTI in 1000 device days. Compared with the National Nosocomial Infections Surveillance of USA, these rates were 3.1, 2.3 and 1.5, respectively (3).
The results of INICC studies also concluded that infection control strategies significantly reduced infection rates in developing countries. After multidimensional approach interventions (education, bundles, performance feedback, etc.), implemented reduction rates from the reported baseline were 55.8 % in VAP, 54 % in CRBSI and 37% in CAUTI. Available information about epidemiology and surveillance of ICU-acquired infections in most African countries are still lacking and underestimated, reflecting the limited resources and serious economic problems of this continent. After the implementation of WHO’s hand hygiene improvement strategy, favourable results were reported and demonstrated that these promotions are effective in low-income settings (3).
The European Prevalence of Infection in Intensive Care study has mostly included data from western European countries. The most common site of infection was the respiratory system (64%), followed by abdomen (20%), bloodstream (15%) and genitourinary system (14%). The causative agents of infections were 47% gram-positive pathogens, 62% gram-negative pathogens and 19% fungal pathogens. Staphylococcus aureus (20%) was the most common gram-positive pathogen, while Pseudomonas species (20%) and Escherichia coli (16%) were the most common gram-negatives pathogens reported in patients. This study also concluded that the infection rates were related to healthcare spending, with higher rates of infection reported in countries that had a lower proportion of gross domestic product devoted to healthcare (3). More recently, another study from Turkey reported changing prevalence and antibiotic susceptibility of pathogens in ICUs. A. baumannii (21.8%) was the most common gram-negative pathogen with an increasing carbapenem resistance. On the other hand, S. aureus is still the most prevalent gram-positive pathogen, but the incidence decreased from 18.6% to 4.8%. Methicillin resistance decreased in S. aureus from 96% to 54% (3).
Although it is difficult to solve some problems associated with financial hardship in developing countries, most solutions are simple and not resource demanding. Hand hygiene is the most important component reducing the spread of infections in ICUs. In countries with limited resources, structured training in hand hygiene and hand hygiene promotion campaigns have been reported to improve the adherence among healthcare workers. Initial empirical therapy with broad-spectrum antibiotics is a life-saving strategy, which improves clinical outcome and minimise selection of resistant organisms. It is also recommended to de-escalate these antibiotics according to culture and antibiotic susceptibility results. Antibiotic cycling is also an effective approach to control antibiotic resistance. Strict antibiotic policies in ICUs prevent the use of long term, unnecessary antibiotics and shorten the duration of the antimicrobial therapy. Conducting infection surveillance and control activities in ICUs and rational antibiotic utilisation policies are valuable measures for infection control. These measures provide current knowledge about antibiotic resistance patterns, early recognition and management of outbreaks, which is essential for infection control. Several healthcare settings have succeeded in reducing the risk by implementing these simple, low-cost interventions. Healthcare facilities should provide periodical educational programmes to ICU staff for infection control and evaluate for effectiveness. Surveillance activities, hand hygiene promotions, rational use of antibiotics and other isolation procedures need to be regularly supported and encouraged by good role models in institutions, local and governmental managers and other infection control organisations; these should be extensively encouraged in developing countries. Risk factors of Acinetobacter infection are already known and acute vaccination and antibody-based immune therapies for patients at the risk of these infections looks promising to prevent infections and improve outcomes.
In summary, nursing and medical profession in general needs to follow basic steps in infection prevention process. This can be achieved by simple hand washing that is done correctly and frequently. Modern medicine needs to return to one basic step and that is hand washing, this step will lead to lesser percentage of intrahospital infections among critical care patients. According to Daft, (2013), “leadership is an influence relationship among leaders and followers who intend real changes and outcomes that reflect their shared purpose” (5, p 5).
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- Avalos-Bock, S. & Campbell, V. (2014). COMBATING INFECTION: Knocking out nosocomial infections Nursing 2014. Volume 34 Number 11 Pages 24 – 25. Available from http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=531167&Journal_ID=0&Issue_ID=0
- Ulu-Kilic, A et al. (2013). Challenge of intensive care unit-acquired infections and in developing countries. OA Critical Care 2013 Mar 01;1(1):2. Available from https://www.oapublishinglondon.com/article/382
- Hughes, N. (2006). Health & Safety: Handwashing: Going back to basics in infection control. American Journal of Nursing. Volume 106 Number 7. Available from http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=650957&Journal_ID=54030&Issue_ID=650872 Daft, R. The Leadership Experience (5th ed.) Mason, Ohio: South-Western Cengage Learning.(2011)