Chest

Chest

Volume 120, Issue 6, December 2001, Pages 2059-2093
Journal home page for Chest

Critical Care Reviews
Infection Control in the ICU

https://doi.org/10.1378/chest.120.6.2059Get rights and content

Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Section snippets

Definitions

NI schematically encompasses any infection that is neither present nor incubating on hospital admission. Precise definitions have been largely debated in the literature, but those proposed by the CDC in 19882728 have been validated and are now widely used. Minor adaptations are generally proposed for specific populations, but infections are considered to be hospital-acquired if they develop at least 48 h after hospital admission without proven prior incubation. If infections occur up to 3 days

Epidemiology of NIs

Epidemiologic data collected from surveillance activities are used to determine NI rates. Benchmarking then may be used to monitor their evolution and to detect any unusual variation that may be potentially suspect of outbreaks or high endemic rates of NI. Importantly, NI rates vary widely according to the type of ICU and the population served. They may also vary with the type of surveillance (Table 2).2224353637383940414243444546474849

A prevalence of 20.6% was reported by Vincent et al16 in

Impact of NIs

A significant correlation was found between the prevalence rate of ICU-acquired infection and mortality rate. In the European Prevalence of Infection in Intensive Care study, laboratory-proven bloodstream infection (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.25 to 2.41), pneumonia (OR, 1.91; 95% CI, 1.6 to 2.29), and clinical sepsis (OR, 3.75; 95% CI, 1.71 to 7.18) were independently associated with an increased mortality rate. Additional independent predictors of death were an

Risk Factors

Independent risk factors for NIs have been identified in several studies (Table 5).164256648182 Among them, the severity of underlying illness assessed by scoring systems such as APACHE II/III or simplified acute physiologic score II are the most widely used. However, these scores were designed to predict mortality and are less consistent predictors of NIs.6183 These general scores also may be of limited value in the field of sepsis. In a series84 of 88 consecutive patients with septic shock,

Pathophysiology of NIs

The colonization of the host by potentially pathogenic microorganisms is a prerequisite for the further development of most NIs and may occur from exogenous or endogenous sources. As a consequence of the severity of the underlying diseases with possibly impaired host defenses, and in the presence of risk factors, critically ill patients are particularly susceptible to a rapid colonization by endemic pathogens of the hospital flora.

The endemic transmission of exogenous staphylococci and other

Microbiology

A continuous shift toward more resistant strains of bacteria has been reported for several decades. Concern has focused on MRSA, VRE, ESBLs, fluoroquinolone-resistant Pseudomonas aeruginosa, and fluconazole-resistant Candida spp.100101 These pathogens have become the leading causes of NIs, particularly in ICUs where most were found to have a certain specificity according to the type of ICU.13102103 The predominant pathogens reported in the ICUs participating in the NNIS and in European

Surveillance of NIs

The surveillance of NIs was recognized to be a major component of infection control in the late 1970s. The Study on the Efficacy of Nosocomial Infection Control18 showed that NI rates decreased on average 32% in hospitals where surveillance programs were implemented, compared with an increase of 18% in other institutions over a 5-year period. The four key elements for successful prevention were the following: the presence of at least one epidemiologist for 1,000 beds; one specialized trained

Control and Prevention of NIs

Prevention plays a major role in the control of NIs, and consensus conference and expert panels have established numerous guidelines both in the United States and in European countries.100163164165166 These guidelines concern three main approaches, which can be schematized as follows. First, methods and techniques are needed to prevent cross-contamination and to control the potential sources of pathogens that could be transmitted from patient to patient or from HCW to patient. These methods and

Prevention of Ventilator-Associated Pneumonia

Research for effective measures to prevent ventilator-associated pneumonia have been recently reviewed elsewhere21266267268 and is only briefly summarized below.

A large proportion of cases of ventilator-associated pneumonia are related to the continuous aspiration of contaminated oropharyngeal secretions and/or possibly to gastric content.247269270 The simplest measure with which to decrease the aspiration of gastric contents in mechanically ventilated patients is to place them in a

Prevention of Infection in HCWs

The protection of HCWs from the acquisition as well the transmission of infectious agents and the management of postexposure care are important tasks for hospital infection control programs. Precise guidelines have been published by the CDC Hospital Infection Control Practice Advisory Committee and are available at http://www.cdc.gov/ncidod/hip/guide/infectcont98.htm.392 The prevention strategies included in these recommendations include immunization for vaccine-preventable diseases, isolation

Conclusion

The importance of nosocomial transmission in the ICU cannot be overemphasized. More than one third of NIs are acquired in ICUs, accounting for a crude incidence of 15 to 40% of hospital admissions, depending on the type of unit.158 Since more severely ill patients have higher risks for both acquiring NIs and for mortality, assessment of the mortality attributable to NIs in ICU patients is not straightforward. Nevertheless, NIs are definitely associated with substantial excess length of stay and

Acknowledgment

We thank R. Sudan for her editorial assistance.

References (398)

  • NA Khuri-Bulos et al.

    Nosocomial infections in the intensive care units at a university hospital in a developing country: comparison with National Nosocomial Infections Surveillance intensive care unit rates

    Am J Infect Control

    (1999)
  • R Finkelstein et al.

    Device-associated, device-day infection rates in an Israeli adult general intensive care unit

    J Hosp Infect

    (2000)
  • P Gastmeier et al.

    Device-associated nosocomial infection surveillance in neonatal intensive care using specified criteria for neonates

    J Hosp Infect

    (1998)
  • JM Weber et al.

    Nosocomial infections in pediatric patients with burns

    Am J Infect Control

    (1997)
  • R Gaynes et al.

    Meaningful interhospital comparisons of infection rates in intensive care units

    Am J Infect Control

    (1993)
  • RL Smith et al.

    Excess mortality in critically ill patients with nosocomial bloodstream infections

    Chest

    (1991)
  • CP Craig et al.

    Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality

    Am J Infect Control

    (1984)
  • O Keita-Perse et al.

    Severity of illness scoring systems to adjust nosocomial infection rates: a review and commentary

    Am J Infect Control

    (1996)
  • WO Tarnow-Mordi et al.

    Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit

    Lancet

    (2000)
  • AF Vicca

    Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit

    J Hosp Infect

    (1999)
  • DA Goldmann et al.

    Bacterial colonization of neonates admitted to an intensive care environment

    J Pediatr

    (1978)
  • SK Fridkin et al.

    Magnitude and prevention of nosocomial infections in the intensive care unit

    Infect Dis Clin North Am

    (1997)
  • L Kohn et al.

    To err is human: building a safer health system

    (1999)
  • TA Brennan et al.

    Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I

    N Engl J Med

    (1991)
  • LL Leape et al.

    The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II

    N Engl J Med

    (1991)
  • AR Localio et al.

    Relation between malpractice claims and adverse events due to negligence: results of the Harvard Medical Practice Study III

    N Engl J Med

    (1991)
  • EJ Thomas et al.

    Incidence and types of adverse events and negligent care in Utah and Colorado

    Med Care

    (2000)
  • LL Leape et al.

    Safe health care: are we up to it ?

    BMJ

    (2000)
  • CJ McDonald et al.

    Deaths due to medical errors are exaggerated in Institute of Medicine report

    JAMA

    (2000)
  • TA Brennan

    The Institute of Medicine report on medical errors: could it do harm?

    N Engl J Med

    (2000)
  • DG Wilson et al.

    Medication errors in paediatric practice: insights from a continuous quality improvement approach

    Eur J Pediatr

    (1998)
  • DW Bates et al.

    Patient risk factors for adverse drug events in hospitalized patients: ADE Prevention Study Group

    Arch Intern Med

    (1999)
  • L Archibald et al.

    Antimicrobial resistance in isolates from inpatients and outpatients in the United States: increasing importance of the intensive care unit

    Clin Infect Dis

    (1997)
  • CW Bryan-Brown

    Pathway to the present: a personal view of critical care

  • Centers for Disease Control and Prevention

    Public health focus: surveillance, prevention, and control of nosocomial infections

    MMWR Morb Mortal Wkly Rep

    (1992)
  • JL Vincent et al.

    The prevalence of nosocomial infection in intensive care units in Europe: results of the European Prevalence of Infection in Intensive Care (EPIC) Study

    JAMA

    (1995)
  • D Pittet et al.

    Prevalence and risk factors for nosocomial infections in four university hospitals in Switzerland

    Infect Control Hosp Epidemiol

    (1999)
  • RW Haley et al.

    The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals

    Am J Epidemiol

    (1985)
  • AF Widmer et al.

    Infection control and hospital epidemiology outside the United States

    Infect Control Hosp Epidemiol

    (1999)
  • DJ Cook et al.

    Risk factors for ICU-acquired pneumonia

    JAMA

    (1998)
  • MH Kollef

    The prevention of ventilator-associated pneumonia

    N Engl J Med

    (1999)
  • P Eggimann et al.

    Fluconazole prophylaxis prevents intra-abdominal candidiasis in high-risk surgical patients

    Crit Care Med

    (1999)
  • JY Fagon et al.

    Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: a randomized trial

    Ann Intern Med

    (2000)
  • The Society for Hospital Epidemiology of America et al.

    Consensus paper on the surveillance of surgical wound infections

    Infect Control Hosp Epidemiol

    (1992)
  • D Pittet et al.

    Automatic alerts for methicillin-resistant Staphylococcus aureus surveillance and control: role of a hospital information system

    Infect Control Hosp Epidemiol

    (1996)
  • S Harbarth et al.

    Impact of methicillin resistance on the outcome of patients with bacteremia caused by Staphylococcus aureus

    Arch Intern Med

    (1998)
  • S Harbarth et al.

    Nosocomial infections in Swiss university hospitals: a multi-center survey and review of the published experience; Swiss-Noso Network

    Schweiz Med Wochenschr

    (1999)
  • D Pittet et al.

    Candida colonization and subsequent infections in critically ill surgical patients

    Ann Surg

    (1994)
  • RP Wenzel et al.

    Principles of applied epidemiology for infection control

  • P Gastmeier et al.

    How to survey nosocomial infections

    Infect Control Hosp Epidemiol

    (2000)

    • Cited by (337)

    • Updates in the Use of Antibiotics, Biofilms

      2022, Veterinary Clinics of North America - Small Animal Practice

    • Infectious disease control in the ICU

      2022, Small Animal Critical Care Medicine

    • Hospital-associated infections and zoonoses

      2022, Small Animal Critical Care Medicine

    • Impact of hospital-acquired complications in long-term clinical outcomes after subarachnoid hemorrhage

      2020, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      Moreover, HACs like pneumonia have been shown to be independent risk factors for mortality or discharge to institutional care [6]. Although it is well known that HACs complicate clinical course and patient recovery [2,7] there is a paucity of literature on the impact that HACs have on long-term clinical outcomes in SAH patients. Therefore, we assessed whether HACs are a risk factor for poor clinical outcomes in the 12–18 months following a SAH episode.

    • Challenging the interprofessional epistemic boundaries: The practices of informing in nurse-physician interaction

      2020, Social Science and Medicine
      Citation Excerpt :

      Although early- and late-onset infections are ordinarily expected at CEICU as in any ICUs, CEICU clinical policy does not follow the “empirical therapy for suspected infections” suggested by the international guidelines. It rather favors the use of the “definite therapy for proven infections” (Eggimann and Pittet, 2001, p. 2074; see Hranjec et al., 2012), which is friendly labelled by the team the “watch and wait” approach. At CEICU, this radical choice (i.e. adopting a guideline-divergent clinical policy) implies a systematic and extremely vigilant everyday iteration of a diagnostic reasoning concerning the onset of infections to establish: a) if an infection is at stake; b) where it is located and c) the responsible germs (see Caronia and Chieregato, 2016; Caronia et al., 2017; Caronia and Saglietti, 2017).

    • Design for critical care

      2020, Design for Health: Applications of Human Factors
    View all citing articles on Scopus
    View full text
    Copyright © 2001 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.