NOSOCOMIAL INFECTION IN THE SURGICAL INTENSIVE CARE UNIT

Supplementing hand washing with proper use of alcoholic hand rub in a special neonatal care unit in a large academic public health institute at Jabalpur, Madhya Pradesh, India

Objective

The purpose was to increase use of alcoholic hand rub (AHR) in specialised newborn care unit (SNCU) to improve hand hygiene in order to reduce neonatal sepsis and mortality at Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur.

Design

A prospective interventional and observational study.

Methodology

We formed a quality improvement (QI) team in our SNCU consisting of doctors, nurses, auxiliary staff and parents (a floating member) to improve proper use of AHR. To identify the barriers to the problem, we used fishbone analysis tool. The barriers which were not allowing the health providers to use AHR properly identified were amount of AHR in millilitres to be used per day per baby, how much and when the amount of AHR to be indented from the main store and what is the proper site to place the bottle. We used plan–do–study–act cycles to test and adapt solutions to these problems. Within 5–6 weeks of starting our project, AHR use increased from 44 mL to 92 mL per baby per day and this is sustained around 100 mL per baby per day for over 2 years now.

Results

Significant decrease in neonatal mortality was observed (reduced from median of 41.0 between August 2016 and April 2018 to 24.0 between May 2018 and December 2019). The neonates discharged alive improved from 41.2 to 52.3 as a median percentage value. The percentage of babies who were referred out and went Left Against Medical Advice (LAMA) deceased too.

Conclusion

Multiple factors can lead to neonatal deaths, but the important factors are always contextual to facilities. QI methodology provides health workers with the skills to identify the major factors contributing to mortality and develop strategies to deal with them. Improving processes of care can lead to improved hand hygiene and saves lives.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Surgical critical care: from old boundaries to new frontiers

The surgical specialty of critical care has evolved into a field where the surgeon manages complex medical and surgical problems in critically ill patients. As a specialty, surgical critical care began when acutely ill surgical patients were placed in a designated area within a hospital to facilitate the delivery of medical care. As technology evolved to allow for development of increasingly intricate and sophisticated adjuncts to care, there has been recognition of the importance of physician availability and continuity of care as key factors in improving patient outcomes. Guidelines and protocols have been established to ensure quality improvement and are essential to licensing by state and national agencies. The modern ICU team provides continuous daily care to the patient in close communication with the primary operating physician. While the ultimate responsibility befalls the primary physician who performed the preoperative evaluation and operative procedure, the intensivist is expected to establish and enforce protocols, guidelines and patient care pathways for the critical care unit. It is difficult to imagine modern surgical ICU care without the surgical critical care specialist at the helm.

Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection

OBJECTIVE

Health care-associated infections persist as a major problem in most neonatal intensive care units. Hand hygiene has been singled out as the most important measure in preventing hospital-acquired infection. However, hand hygiene compliance among health care workers (HCWs) remains low. The objective of this study was to assess the frequency and nature of patient contacts in neonatal intensive care units and observe the compliance and technique of hand hygiene among HCWs before and after the implementation of a multimodal intervention program.

METHODS

The nature and frequency of patient contacts, the hand hygiene compliance, and hand-washing techniques of HCWs were observed unobtrusively to reflect the baseline compliance and to investigate factors for noncompliance. The intervention consisted of problem-based and task-orientated hand hygiene education, enhancement of minimal handling protocol and clustering of nursing care, liberal provision of alcohol-based hand antiseptic, improvement in hand hygiene facilities, ongoing regular hand hygiene audit, and implementation of health care-associated infection surveillance. The observational study was repeated 6 months after the completion of the intervention program, which extended over 1-year period.

RESULTS

Overall hand hygiene compliance increased from 40% to 53% before patient contact and 39% to 59% after patient contact. More marked improvement was observed for high-risk procedures (35%-60%). The average number of patient contacts also decreased from 2.8 to 1.8 per patient per hour. There was improvement in most aspects of hand-washing technique in the postintervention stage. The health care-associated infection rate decreased from 11.3 to 6.2 per 1000 patient-days.

CONCLUSION

A problem-based and task-orientated education program can improve hand hygiene compliance. Enhancement of minimal handling and clustering of nursing procedures reduced the total patient contact episodes, which could help to overcome the major barrier of time constraints. A concurrent decrease in health care-associated infection rate and increase in hand hygiene compliance was observed in this study. The observational study could form part of an ongoing audit to provide regular feedback to HCWs to sustain the compliance.

Nurses' knowledge and attitudes about antibiotic therapy in critical care

PURPOSE

To assess critical care nurses' knowledge about antibiotic use in critical care settings, and attitudes concerning the role of the nurse in monitoring response to and appropriate use of antibiotic therapy.

METHOD

90 critical care nurses from 6 adult critical care units at a 780-bed academic, health sciences centre, completed an investigator-developed survey about their knowledge of antibiotic use and their attitudes concerning the role of the nurse.

RESULTS

The majority of respondents worked full time (83%) and were BSN (Bachelor of Science in Nursing) prepared (62%), with an average of 9 years' nursing experience and 7 years' experience in intensive care. Using a 100-mm visual analog scale, mean scores on knowledge and comfort with: (1) interpreting culture and sensitivity; (2) white blood cell (WBC) data; and (3) discussing results and therapy with physicians were all less than 50 mm. However, the mean score for nurses' belief of responsibility related to this collaborative role was 76. A knowledge quiz of lab interpretation and antibiotic therapy revealed a mean score of 53.8%. Beliefs about roles were correlated with comfort in discussing therapies with physicians rather than with knowledge. Although nurses value the collaborative surveillance role, they may lack the knowledge and confidence to enact it.

The role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation

OBJECTIVE

Nosocomial infection is an important contributor to morbidity and mortality in pediatric solid organ transplantation. The relative effect of protective gown and glove isolation was compared with strict handwashing in pediatric intensive care unit (PICU) patients with solid organ transplantation.

DESIGN/SETTING

A prospective, randomized design was used; children in a 23-bed PICU with solid organ transplantation were enrolled into a gown and glove protective isolation protocol or a strict handwashing protocol.

PATIENTS

All children admitted to the PICU immediately after solid organ transplantation, excluding renal transplantation, and at subsequent readmissions to the PICU were eligible for the study. Children with current infection or known exposure to varicella were excluded from the study initially or at readmission.

INTERVENTIONS

By using a block randomization design based on organ transplanted, age, and initial admission vs. readmission, each patient was randomized to either strict handwashing or protective gown and glove isolation intervention groups.

MEASUREMENTS

We analyzed demographics, infection outcomes (defined according to Centers for Disease Control criteria), and monitoring of patient contacts in compliance with protocols.

RESULTS

The infection rate in the overall PICU population did not change significantly from the year before the study compared with during the study (2.1 per 100 vs. 1.95 per 100 patient days; p =.4) The infection rate in the gown and glove group (2.3 per 100 patient days) was reduced significantly compared with the prestudy infection rate in the transplant population (4.9 per 100 patient days; p =.0008). Strict handwashing also significantly reduced the infection rate in the transplant population (3.0 per 100 patient days; p =.008). Compliance with gowning and gloving was 82% and compliance with handwashing was 76% (compared with 22% before study [p <.0001] and 52% after the study [p <.0001]). Despite an increased mean length of stay in the PICU in the gown and glove group (p =.014), there was a trend toward reduction in the incidence of infection (Fisher's exact test, p =.07; odds ratio,.76) in the gown and glove group.

CONCLUSIONS

Increased compliance with handwashing was associated with a reduction in nosocomial infections, and gown and glove isolation appeared to have an additional protective effect. Some nosocomial infections may be preventable in the pediatric solid organ transplantation population.

The gut: the 'motor' of multiple organ dysfunction syndrome?

Abnormal colonization, gut-origin infections, and bacterial translocation are all signs of gut dysfunction that may be implicated in the pathogenesis of multiple organ dysfunction syndrome (MODS). This review summarizes and updates relevant experimental and clinical data that have attempted to correlate these phenomena with the development of MODS and to answer whether or not the gut is the 'motor' of MODS. The presented data suggest that, in some patients, gut dysfunction may precede the development of MODS. However, in most patients, this relationship is less obvious. The gut may still be one of the motors of MODS; however, it does not appear that this motor is fueled by the systemic spread of bacteria. Bacteria may play a role on a local gut-associated level in initiating and perpetuating the production of local inflammatory mediators that may produce distant organ injury.

Risk factors for acquisition of Serratia marcescens in a surgical intensive care unit

Between January 1996 and May 1997, a four-fold increased rate of isolation of Serratia marcescens was observed amongst patients admitted to the surgical Intensive Care Unit (SICU) of the Leiden University Medical Center compared to the preceding years. Random amplification of polymorphic DNA showed the involvement of genotypically distinct strains, implicating multiple different sources. After improvement of hygienic measures the frequency of isolation of S. marcescens returned to baseline. A case-control study was performed to assess patient-related risk factors for acquisition of S. marcescens. Nineteen cases and 38 controls were included. Hospital- and SICU-stay were significantly longer in case patients than in controls. By univariate analysis, statistically significant differences were found in body weight, the duration of mechanical ventilatory support, the cumulative use of antimicrobial agents, the use of aminoglycosides, parenteral nutrition and tube feeding. The sum of the number of days per invasive device (deep intravenous lines, arterial lines, wound drains and urinary catheters) was higher in cases than in controls (P = 0.08). Categorically, a cumulative number of device-days > 25 was a statistically significant risk factor for acquisition of S. marcescens. Multivariable logistic regression analysis showed that body weight, parenteral feeding and mechanical ventilation were independent predictors of acquisition of S. marcescens. As transmission of S. marcescens appears to be by the hands of personnel, the identified risk factors may act by necessitating an increased frequency and intensity of direct contacts.

The clinical use of 99m-Tc-labeled WBC scintigraphy in critically ill surgical and trauma patients with occult sepsis

OBJECTIVE

To evaluate the clinical use of radionuclide-labeled white blood cell scintigraphy in the detection of focal sepsis.

DESIGN

Prospective clinical study.

SETTING

A medical/surgical 12-bed intensive care unit (ICU) in a university hospital.

PATIENTS

26 trauma and surgical patients affected by sepsis of unknown origin were studied.

MEASUREMENTS AND RESULTS

After the usual diagnostic approach, patients were submitted to a total body scan by using the patient's leukocytes labeled with technetium-99m (99m-Tc) HMPAO; three scintigraphy were performed within 20 h of tracer injection; the result of scan was completed with all clinical and instrumental data, including ultrasound (US) arnd computed tomography (CT), and the diagnostic efficacy was demonstrated for each patient on discharge from the ICU. The scan was able to detect 20 sites of infection; it was possible to rule out 11 suspected sites; only in two cases was the result considered to be false positive or false negative; in two cases the result was considered to be uncertain. These results show the high sensitivity (95%), specificity (91%) and accuracy (94%) of the method.

CONCLUSIONS

In ICU patients with sepsis, nuclear medicine can provide additional data, as the injection of radionuclide-labeled white blood cells (WBCs) allows the imaging of sites of infection. Analysis of our results suggests that scintigraphy with 99m-Tc-labeled WBCs can be considered a useful tool in the detection of the source of infection.

Clinical outcome and immunology of postoperative arginine, omega-3 fatty acids, and nucleotide-enriched enteral feeding: a randomized prospective comparison with standard enteral and low calorie/low fat i.v. solutions

In a prospective randomized trial in patients undergoing major abdominal surgery, the impact of a new enteral formula supplemented with arginine, omega-3 fatty acids, and nucleotides (A, n = 14) on immunological parameters was compared with a standard enteral formula (B, n = 14) and a low calorie/low fat intravenous solution (C, n = 13). Four days postoperatively, a statistically significant decrease in total leukocyte count (A, 9.0 +/- 2.9; B, 8.0 +/- 2.4; C, 11.1 +/- 3.5 x 10(6) cells/mL; A versus C, B versus C; p < 0.05), higher percentage of lymphocytes (A, 14.3 +/- 4.9; C, 8.2 +/- 6.1; p < 0.05), and decreased median CRP levels (A, 80.4 [69.9]; B, 70 [74]; C, 88.5 [142] in mg/L; A versus C, p < 0.05; B versus C; p < 0.05) were observed in the enteral nutrition groups. The expression of activated surface antigen HLA-DR was diminished on CD14+ cells over 4 d (A, 58.2 [39.2]; B, 52.2 [36.2]; C, 76.6 [25.2] in %; A versus C, p < 0.05; B versus C, p < 0.05) and 8-10 d (A, 37.9 [31.4]; C, 58.5 [37.6]; p < 0.05) postoperatively. Significantly enhanced median phagocytic activity of CD14+ monocytes and granulocytes was observed in group C 8-10 days postoperatively (A, 83.3 [11.8]; B, 71.6 [34.1]; C, 87.4 [10.8]; A versus B, B versus C, p < 0.05; and A, 75.7 [10.0]; B, 69.0 [37.8]; C, 80.0 [10.1] in %, B versus C, p < 0.05, respectively). Postoperative hospital and intensive care unit stay was similar among the three groups; however, infectious complications were less frequent in group A (A versus C, p = 0.15). Thus, a modified enteral nutritional support and supplementation may influence the immune competence toward a more efficient defense response.

Nosocomial bacteremia-induced increases in abscess formation correlate with in vitro upregulation of macrophage procoagulant activity

OBJECTIVE

To evaluate the hypothesis that sublethal exposure to common nosocomial pathogens can alter the host response to a later, distant infectious insult (peritonitis and intraperitoneal abscess formation), and that these changes are related to the induction of macrophage procoagulant activity.

DESIGN

A multiexperiment, randomized, controlled trial.

SETTING

Animal research laboratory of a university medical center.

SUBJECTS

One hundred sixty-five Balb/c mice, weighing 20 to 25 g, were used for in vivo experiments and as the source of peritoneal macrophages for in vitro experiments.

INTERVENTIONS

Nine groups of mice (n = 10 to 18 per group) were twice systemically preexposed to sublethal amounts of live Escherichia coli, Enterobacter cloacae, Pseudomonas aeruginosa, Staphylococcus epidermidis, Enterococcus faecalis, or Candida albicans, or to 2.5 or 5.0 micrograms E. coli lipopolysaccharide O26:B6. One week later, mice underwent the induction of mixed E. coli/Bacteroides fragilis peritonitis, leading to abscess formation. In parallel experiments in vitro, 10(6) mouse peritoneal macrophages were incubated with similar amounts of nosocomial pathogens or lipopolysaccharide to determine the induction of macrophage procoagulant activity.

MEASUREMENTS AND MAIN RESULTS

The three Gram-negative bacilli tested significantly upregulated both abscess formation and macrophage procoagulant activity, with a strong linear correlation between abscess formation and procoagulant activity. These effects were not seen with the Gram-positive cocci or with C. albicans. Pre-exposure of mice to endotoxin alone did not alter later abscess formation, but did increase macrophage procoagulant activity.

CONCLUSIONS

Sublethal exposure to some Gram-negative nosocomial pathogens can significantly alter a host's response to a later, distant, infection, even when caused by different bacteria. In the case of peritonitis and intraperitoneal abscess formation, these changes may be mediated by the upregulation of macrophage procoagulant activity. The presence of endotoxin alone does not completely explain these phenomena.