MAGNITUDE AND PREVENTION OF NOSOCOMIAL INFECTIONS IN THE INTENSIVE CARE UNIT
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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Address reprint requests to Sharon F. Welbel, MD Division of Infectious Disease, Durand Bldg, 1st Floor Cook County Hospital 1835 W. Harrison Street Chicago, IL 60612