MAGNITUDE AND PREVENTION OF NOSOCOMIAL INFECTIONS IN THE INTENSIVE CARE UNIT

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It is estimated that only 5% to 10% of all hospital beds are in intensive care units (ICUs) but that nosocomial infections in ICU patients account for over 20% of all infections acquired in hospitals.7 The most common ICU–acquired infections include pneumonia, urinary tract infection, and bloodstream infection. Because the diagnosis and treatment of these infections may be problematic, ICUs should emphasize prevention strategies by incorporating established guidelines and novel techniques tailored to individual ICUs. This article reviews current rates of infection and the pathogens involved in ICU nosocomial infections and provides an overview of preventive strategies.

Section snippets

Cross Infection

Almost 150 years ago, Semmelweis observed a dramatic decrease in the rate of childbed fever after instituting hand-washing with a chlorinated lime solution, supporting his suspicions of a “contaminated carrier”—the health care worker.58 ICUs have a large number and wide variety of health care workers. Because these personnel may have a highly variable commitment to hand-washing, gloving, and gowning, there is ample opportunity for pathogens, at times in epidemic proportion, to be carried from

Pneumonia

Pneumonia is the most common nosocomial infection in ICU patients54 and is usually associated with mechanical ventilation (ventilator-associated pneumonia). It is often very difficult to diagnose nosocomial pneumonia definitively because patients have multiple causes for pulmonary infiltrates, including adult respiratory distress system, pulmonary hemorrhage or embolus, and cardiogenic shock. The Centers for Disease Control and Prevention (CDC) definition of nosocomial pneumonia relies heavily

PATHOGENS ASSOCIATED WITH INFECTIONS IN THE INTENSIVE CARE UNIT

There is a national surveillance system (the National Nosocomial Infection Surveillance [NNIS] System) that includes over 100 hospitals that report ICU surveillance data from over 600 ICUs using standardized methodology.11 Reports are made monthly to the CDC. Of the 610 ICUs reporting data from 1990 through 1995, 174 (29%) were identified as medical/surgical, 139 (23%) surgical, 91 (15%) medical, 87 (14%) coronary care, 56 (9%) pediatric, 30 (5%) neurosurgical, 15 (3%) trauma, 13 (2%) burn, and

Definitions of Infection Rates

It is common to express hospital infection rates as the number of infections per 1000 patient discharges or per 1000 patient-days (Table 7). These rates, however, do not account for the single overriding risk factor for nosocomial ICU infections—duration of use of invasive devices. Without controlling for device use, comparison of infection rates within and between hospitals can be very misleading.26

Device-Associated Rates

Calculation of device-associated rates controls for device use and allows inter–ICU comparison.

PREVENTION STRATEGIES

Infection control practices aimed at specific devices or procedures (e.g., ventilators, intravascular catheters, new surgical techniques) or specific pathogens (e.g., vancomycin-resistant enterococci, tuberculosis, Candida spp) are discussed elsewhere in this issue. More general measures are discussed here.15, 25, 31, 49

Pressure Transducers

Pressure-monitoring devices (transducers or gauges connected to a closed vascular space by a length of fluid-filled tubing) are used regularly for monitoring cardiovascular pressures of critically ill patients and can provide a portal of entry for microbial invasion. Contaminated monitoring devices have been the source of many outbreaks of gram-negative bacteremia and fungemia; however, this risk seems to have been reduced greatly in ICUs that use totally disposable transducer systems.34

Circulatory Assist Devices

A

ACKNOWLEDGMENTS

The authors would like to thank Olivia Keita-Perse, MD, Robert Gaynes, MD, Jonathan Edwards, MS, the National Nosocomial Infection Surveillance System, the Hospital Infections Program, and the Centers for Disease Control and Prevention for obtaining current data from the ICU component of NNIS, and also Diane Patton for administrative assistance.

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