Infections in the

intensive care unit

Wanida Paoin
Thammasat University
EPIDEMIOLOGY

 Contributing factors
 Patients in ICUs have more chronic comorbid
illnesses and more severe acute physiologic
derangements.
 The high frequency of indwelling catheters among
ICU patients
 The use and maintenance of these catheters
necessitate frequent contact with health care
workers, which predispose patients to colonization
and infection with nosocomial pathogens.
 Multidrug-resistant pathogens such as methicillin-
resistant Staphylococcus aureus (MRSA) and
vancomycin-resistant enterococci (VRE) are being
isolated with increasing frequency in ICUs
EPIDEMIOLOGY

 A multicenter, prospective cohort

surveillance study of 46 hospitals in Central
and South America, India, Morocco, and
Turkey.
 Rates of device-associated infection were
determined between 2002 and 2005; an
overall rate of 14.7 percent or 22.5
infections per 1000 ICU days was found.
 Specific devices:
 Ventilator associated pneumonia (VAP); 24.1
cases/1000 ventilator days (range 10.0-52.7)
 CVC-related bloodstream infections; 12.5/1000
catheter days (7.8-18.5)
 Catheter-associated urinary tract infections;
8.9/1000 catheter days (1.7-12.8)
CATHETER-ASSOCIATED UTI

 UTI is the most common nosocomial infection (> 40% of

all nosocomial infections)
 CAUTIs are the second most common cause of nosocomial
bloodstream infection, which have an attributable mortality
 Risk factors 
 The major risk factor is an indwelling urinary
catheter
 The risk increases directly with the duration of
catheterization.
 The daily incidence of catheter-associated
bacteriuria is approximately 5%
 After catheters have been in place for 1 week,
bacteriuria or candiduria develop in 25%; after
30 days, the great majority of patients will
have bacteriuria.
CATHETER-ASSOCIATED UTI

 Other important risk factors for

CAUTI
 Patients with other sites of active infection
 Long hospital stay
 Malnutrition
 Female sex
 Abnormal serum creatinine
 Improper catheter care (particularly placement of
the drainage tube above the level of the bladder)
Prevention

 The most effective method to prevent CAUTI is to

avoid unnecessary placement of indwelling urinary cath
eters and to limit the duration of catheterization once
a catheter is in place.
 Use of indwelling catheters should be limited to
 patients with anatomic or physiologic urinary obstruction;
 patients undergoing surgery of the genitourinary tract;
 patients requiring accurate monitoring of urine output (ie,
critically ill or postoperative patients);
 debilitated, comatose, or paralyzed patients.
 Once a catheter is in place, it should be removed as
quickly as possible, when it is no longer needed.
Prevention

 The condom catheter is a good alternative to

the indwelling catheter for men and is
associated with lower rates of bacteriuria
 Intermittent bladder catheterization has been
shown to reduce the incidence of UTI in long-
term spinal cord injury patients compared to
an indwelling catheter, this approach has not
been studied in patients with shorter-term
indwelling bladder catheters.
 Suprapubic catheters might be more
comfortable for patients and have been shown
to lower the incidence of bacteriuria
Catheter insertion and
maintenance
 Aseptic technique: handwashing, sterile gloves,
a sterile drape, antiseptic solution
 Once in place,
 M aintaining a closed drainage system
 The only part of the drainage system that
should be opened is the bag drainage tube
 The number of manipulations and accesses of
the drainage system should be minimized.
 The collecting tubing and bag should always be
placed below the patient and the tubing should
be maintained at a level above the drainage bag
Antimicrobial therapy

 Topical antimicrobials
P lace between the catheter and urethral mucosa
 Soaking catheters in, continuous irrigation of the bladder with an
anti-infective solution,
 P lacement of anti-infective solutions into the collection bag
 N ot been shown to effectively prevent CAUTI
 Systemic antimicrobial prophylaxis
 Can reduce the risk for CAUTI in short-term
catheterization;
 Increased long term risk for infections caused by
multidrug resistant organisms
 Treatment of asymptomatic bacteriuria does not
decrease the incidence of febrile episodes but
does increase the recovery of antibiotic-resistant
bacteria
Different catheter composition

 Catheters impregnated with antimicrobial agents (

m i n o c yc l i n e and r ifa m p in ) and the antiseptic
agent nitrofurazone have been demonstrated to reduce
CAUTI rates in small studies
 T he potential for selection of multidrug-resistant
pathogens
 The silver-hydrogel catheter prevents adherence of
bacterial and yeast pathogens to the catheter surface.
 Catheters coated with antiseptic silver compounds have
shown promise by some investigators but have been
ineffective in other large, well-controlled trials.
Strategies for Prevention of
CAUTI

Avoid unnecessary placement of indwelling urinary ++

+
catheters
R emove catheters as quickly as possible ++
+
Alternative condom catheter, ++
intermittent bladder catheterization +
Aseptic technique in catheter insertion ++
+
Appropriate catheter maintenance ++
Antimicrobial therapy -
Different catheter composition +