Infection Prevention in the Neurointensive Care Unit: A Systematic Review

Epidemiological characteristics of ventilator-associated pneumonia in neurosurgery: A 10-year surveillance study in a Chinese tertiary hospital

Background

Ventilator-associated pneumonia (VAP) is a significant and common health concern. The epidemiological landscape of VAP is poorly understood in neurosurgery patients. This study aimed to explore the epidemiology of VAP in this population and devise targeted surveillance, treatment, and control efforts.

Methods

A 10-year retrospective study spanning 2011 to 2020 was performed in a large Chinese tertiary hospital. Surveillance data was collected from neurosurgical patients and analyzed to map the demographic and clinical characteristics of VAP and describe the distribution and antimicrobial resistance profile of leading pathogens. Risk factors associated with the presence of VAP were explored using boosted regression tree (BRT) models.

Results

Three hundred ten VAP patients were identified. The 10-year incidence of VAP was 16.21 per 1000 ventilation days. All-cause mortality was 6.1%. The prevalence of gram-negative bacteria, fungi, and gram-positive bacteria among the 357 organisms isolated from VAP patients was 86.0%, 7.6%, and 6.4%, respectively; most were multidrug-resistant organisms. Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa were the most common pathogens. The prevalence of carbapenem-resistant A. baumannii, P. aeruginosa, and K. pneumoniae was high and increased over time in the study period. The BRT models revealed that VAP was associated with number of days of ventilator use (relative contribution, 47.84 ± 7.25), Glasgow Coma Scale score (relative contribution, 24.72 ± 5.67), and tracheotomy (relative contribution, 21.50 ± 2.69).

Conclusions

Our findings provide a better understanding of the epidemiology of VAP and its risk factors in neurosurgery patients.

Beyond the brain: General intensive care considerations in pediatric neurocritical care

Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients. The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.

External ventriculostomy-associated infection reduction after updating a care bundle

BACKGROUND

Despite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients' characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017.

RESULTS

From 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements.

CONCLUSIONS

A care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.

Ventilator-associated pneumonia in neurocritically ill patients: insights from the ENIO international prospective observational study

BACKGROUND

Acute brain injured (ABI) patients are at high risk of developing ventilator-associated pneumonia (VAP). However, incidence, risk factors and effects on outcome of VAP are not completely elucidated in this population. The primary aim of this study was to determine the incidence of VAP in a cohort of ABI patients. The secondary objectives included the identification of risk factors for development of VAP, and the impact of VAP on clinical outcomes. Clinical outcomes were defined as intensive care unit length of stay (ICU-LOS), duration of invasive mechanical ventilation (IMV), and ICU mortality.

METHODS

Pre-planned sub-analysis of the Extubation strategies in Neuro-Intensive care unit (ICU) patients and associations with Outcomes (ENIO) international multi-center prospective observational study. Patients with available data on VAP, who received at least 48 h of IMV and ICU-LOS ≥ 72 h were included.

RESULTS

Out of 1512 patients included in the ENIO study, 1285 were eligible for this analysis. The prevalence of VAP was 39.5% (33.7 cases /1000 ventilator-days), with a high heterogeneity across countries and according to the type of brain injury. VAP was significantly more frequent in male patients, in those with smoke habits and when intraparenchymal probe (IP), external ventricular drain (EVD) or hypothermia (p < 0.001) were used. Independent risk factors for VAP occurrence were male gender, the use of IP, hypothermia, and the occurrence of tracheobronchitis during ICU stay. VAP was not an independent risk factor for ICU mortality (Hazard Ratio, HR = 0.71 95%CI 0.43-1.16, p = 0.168), but was independently associated with longer ICU stay (OR = 2.55 95%CI 2.01-3.23, p < 0.001).

CONCLUSIONS

VAP is common in ABI patients. Male gender, IP and EVD insertion, tracheobronchitis, and the use of therapeutic hypothermia were significantly associated with VAP occurrence. VAP did not affect mortality but increased ICU-LOS.

Reducing External Ventricular Drain (EVD) Associated Ventriculitis: An improvement project in a Level 1 Trauma Center

BACKGROUND

External ventricular drain (EVD)-associated infections have a negative impact on healthcare cost and patient outcomes. Practice variation in EVD management may place patients at increased risk for EVD-associated infection. This project aimed to evaluate the impact of implementing an interprofessional evidence-based EVD bundle of care on reduction of EVD-related ventriculitis rates.

METHODS

An interprofessional team developed an evidence based EVD care bundle and order set to eliminate practice inconsistencies. Standardization of EVD equipment and optimization of the electronic health record occurred. Education and competency validation were completed with neurosurgical providers and nurses. Interprofessional rounds occur weekly for observation, recognition, and in-the-moment education.

RESULTS

A pre/post intervention design was used to show that the rate of EVD-associated ventriculitis decreased from 8.8 per reported EVD days in 2019 to 0 per reported EVD days in 2021 after implementation of the EVD care bundle.

CONCLUSION

Through an interprofessional team approach, reduction in EVD-associated infection rates is feasible with implementation of an evidence based EVD care bundle.

Quality Improvement in Neurocritical Care: a Review of the Current Landscape and Best Practices

Purpose of Review

The field of neurocritical care (NCC) has grown such that there is now a substantial body of literature on quality improvement specific to NCC. This review will discuss the development of this literature over time and highlight current best practices with practical tips for providers.

Recent Findings

There is tremendous variability in patient care models for NCC patients, despite evidence showing that certain structural elements are associated with better outcomes. There now also exist evidence-based recommendations for neurocritical care unit (NCCU) structure and processes, as well as NCC-specific performance measure (PM) sets; however, awareness of these is variable among care providers. The evidence-based literature on NCC structure, staffing, training, standardized order sets and bundles, transitions of care including handoff, prevention of bounce backs, bed flow optimization, and inter-hospital transfers is growing and offers many examples of successful performance improvement initiatives in NCCUs.

Summary

NCC providers care for patients with life-threatening conditions like intracerebral and subarachnoid hemorrhages, ischemic stroke, and traumatic brain injury, which are associated with high morbidity, complexity of treatment, and cost. Quality improvement initiatives have been successful in improving many aspects of NCC patient care, and NCC providers should continue to update and standardize their practices with consideration of this data. More research is needed to continue to identify high-risk and high-cost NCCU structures and processes and strategies to optimize them, validate current NCC PMs, and encourage clinical adoption of those that prove to be associated with improved outcomes.

Endotracheal tube microbiome in hospitalized patients defined largely by hospital environment

Background

Studies of the respiratory tract microbiome primarily focus on airway and lung microbial diversity, but it is still unclear how these microbial communities may be affected by intubation and long periods in intensive care units (ICU), an aspect that today could aid in the understanding of COVID19 progression and disease severity. This study aimed to explore and characterize the endotracheal tube (ETT) microbiome by analyzing ETT-associated microbial communities.

Methods

This descriptive study was carried out on adult patients subjected to invasive mechanical ventilation from 2 to 21 days. ETT samples were obtained from 115 patients from ICU units in two hospitals. Bacteria isolated from endotracheal tubes belonging to the ESKAPE group were analyzed for biofilm formation using crystal violet quantification. Microbial profiles were obtained using Illumina sequencing of 16S rRNA gene.

Results

The ETT microbiome was mainly composed by the phyla Proteobacteria, Firmicutes and Bacteroidetes. Microbiome composition correlated with the ICU in which patients were hospitalized, while intubation time and diagnosis of ventilator-associated pneumonia (VAP) did not show any significant association.

Conclusion

These results suggest that the ICU environment, or medical practices, could be a key to microbial colonization and have a direct influence on the ETT microbiomes of patients that require mechanical ventilation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02086-7.

Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations

Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.

Pulmonary complications and respiratory management in neurocritical care: a narrative review

ABSTRACT

Neurocritical care (NCC) is not only generally guided by principles of general intensive care, but also directed by specific goals and methods. This review summarizes the common pulmonary diseases and pathophysiology affecting NCC patients and the progress made in strategies of respiratory support in NCC. This review highlights the possible interactions and pathways that have been revealed between neurological injuries and respiratory diseases, including the catecholamine pathway, systemic inflammatory reactions, adrenergic hypersensitivity, and dopaminergic signaling. Pulmonary complications of neurocritical patients include pneumonia, neurological pulmonary edema, and respiratory distress. Specific aspects of respiratory management include prioritizing the protection of the brain, and the goal of respiratory management is to avoid inappropriate blood gas composition levels and intracranial hypertension. Compared with the traditional mode of protective mechanical ventilation with low tidal volume (Vt), high positive end-expiratory pressure (PEEP), and recruitment maneuvers, low PEEP might yield a potential benefit in closing and protecting the lung tissue. Multimodal neuromonitoring can ensure the safety of respiratory maneuvers in clinical and scientific practice. Future studies are required to develop guidelines for respiratory management in NCC.

Failure mode and effects analysis on the control effect of multi-drug-resistant bacteria in ICU patients

OBJECTIVE

The failure mode and effect analysis of the prevention and control in intensive care unit (ICU) patients with multi-drug-resistant (MDR) bacterial infection were explored and analyzed in this research.

METHODS

A total of 251 critically ill patients who were hospitalized in the ICU from June to December 2019 were selected as the control group, and another 258 patients who were hospitalized in the ICU from January to June 2020 were set as the observation group. The control-group patients received conventional ICU care, the observation group was treated by the failure mode and effects analysis (FMEA), and then the prevention and control effect of the two nursing modes on multi-drug-resistant bacteria infection in the two groups were compared accordingly.

RESULTS

The RPN values of the five highest-level factors in the nursing process were critically lower after the improved interventions than before the improvement. The infection rate of MDR bacteria in the observation group was obviously lower than that in the control group (14.73%, 26.69%, χ² =11.1233, P=0.0009). In addition, the mortality rate of patients with MDR in the observation group was remarkably lower than that in the control group, and the difference was statistically significant (5.26%, 22.39%, χ² =5.2405, P=0.0221). The satisfaction of the observation group with the ICU treatment was critically higher than that of the control group, and the difference was statistically significant (89.53%, 76.49%, χ² =15.4094, P=0.0001).

CONCLUSION

Through the application of FMEA to prevent MDR bacterial infection in ICU patients, nursing staff can accurately pay attention to the keynotes in nursing process, and as such reduce the proportion and mortality of MDR infection in ICU patients and promote the patients' satisfaction with nursing, which are all worthy of clinical application.

Preventing Catheter-Associated Urinary Tract Infections with Incontinence Management Alternatives: PureWick and Condom Catheter

Catheter-associated urinary tract infections (CAUTI) have a high financial and human impact on patients and society at large, making CAUTI prevention strategies essential. A shift has occurred where nurses play an increased role in infection prevention. Nurses promote staff and patient education on CAUTI prevention, identification of appropriate urinary incontinence management, and implementation of bundles and patient care strategies to minimize complications from urinary incontinence management. Because they understand the severity of CAUTI and current recommendations, nurses at the bedside are in the best position to identify appropriate indications of indwelling urinary catheters and external urine collection devices for patients.

Impact of a nutrition support therapy on hospital-acquired infections: A value analysis

BACKGROUND

Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed.

METHODS

An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted.

RESULTS

The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs.

CONCLUSION

Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.

Impact of Continuous Education and Training in Reduction of Central Line-associated Bloodstream Infection in Neurointensive Care Unit

Background

Patients in the neurointensive care unit have high utilization of devices, thereby increased chance of getting device-associated infection (DAI). Central line-associated bloodstream infection (CLABSI) remains one of the most important DAI. Education remains an important part of the hospital infection control and improves the infection-control practices.

Materials and methods

To evaluate the effectiveness of a quality initiative in reducing incidence of CLABSI, a prospective study (January 2017–December 2018) was done estimating CLABSI incidence before and after the intervention. Continuous teaching and training for hand hygiene practice and central-line catheter hub care were used as the tool for this study.

Results

The quality improvement (QI) initiative achieved a 48% reduction in the CLABSI rate from the baseline rate of 8.7 to 4.5 per 1000 catheter days. The overall mortality showed a reduction from 1.5 to 0.05% during the post-intervention period. There was a significant improvement in compliance with the hand hygiene practice and catheter hub care in the post-intervention period.

Discussion and conclusion

This study demonstrates adherence to hand hygiene and catheter hub care with continuous teaching, training, and supervision was highly effective in reducing the CLABSI rate.

Clinical significance

Central line-associated bloodstream infection is one of the most important DAI causing significant morbidity and mortality in critically ill patient. Our findings support that continuous educational intervention of hand hygiene with and training on the catheter hub care are two most important preventive measures in the reduction of CLABSI incidence.

How to cite this article

Mohapatra S, Kapil A, Suri A, Pandia MP, Bhatia R, Borkar S, et al. Impact of Continuous Education and Training in Reduction of Central Line-associated Bloodstream Infection in Neurointensive Care Unit. Indian J Crit Care Med 2020;24(6):414–417.

Prevention of surgical site infections after brain surgery: the prehistoric period to the present

In this historical vignette, the authors discuss the prevention of surgical site infections (SSIs) after brain surgery from the prehistoric period to the present. Although the mechanism for infection was not fully understood until the 19th century, records demonstrate that as early as 10,000 bc, practitioners used gold, a biocidal material, for cranioplasties and attempted to approximate wounds by tying a patient's hair across the incision. Written records from the Egyptian and Babylonian period depict the process of soaking head dressings in alcohol, an antibacterial agent. In the Greek and Early Byzantine period, Hippocrates argued against the formation of pus in wounds and continued to champion the use of wine in wound management. In the 16th century, intracranial silver drains were first utilized in an effort to prevent postoperative infections. The turning point of SSI prevention was in 1867, when Joseph Lister illustrated the connection between Louis Pasteur's discovery of the fermentation process and the suppuration of wounds. Today, there are ongoing investigations and debates about the optimal techniques to prevent SSI after brain surgery. Although tremendous progress in the field of SSI prevention since the prehistoric period has been made, SSI continues to affect morbidity and mortality after brain surgery.

Subtherapeutic piperacillin concentrations in neurocritical patients

PURPOSE

Increased renal elimination is the leading cause for subtherapeutic concentrations of renally cleared antibiotics and it has been hypothesized that brain damaged patients in the intensive care unit (ICU) are particularly at risk. The objective of this study is to determine the prevalence of subtherapeutic piperacillin concentrations in neurocritical patients and to investigate if having a neurocritical diagnosis is a risk factor for this.

MATERIALS AND METHODS

Single center retrospective analysis of a prospective cohort study of adult ICU patients receiving continuous infusion piperacillin/tazobactam. Patients were categorized as either having a neurocritical diagnosis or not. An unbound piperacillin concentration > 4× the epidemiologic cut-off value (ECOFF) of Pseudomonas aeruginosa was selected as the PKPD target of choice. Multivariable logistic regression was performed to identify risk factors for subtherapeutic piperacillin concentrations.

RESULTS

356 patients had a measured creatinine clearance (mCrCl) and matched piperacillin concentration, 52 of which had a neurocritical diagnosis. Subtherapeutic piperacillin concentrations were reported significantly more frequent in neurocritical patients. In multivariate analysis, the only risk factor identified for subtherapeutic piperacillin concentration was an increasing mCrCl.

CONCLUSION

Subtherapeutic piperacillin concentrations are common in neurocritical patients yet having a neurocritical admission diagnosis was not identified as an independent risk factor.