[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.

22]

Review Article

Infection Control in Intensive Care Units

Chiranjay Mukhopadhyay1,2
1
Department of Microbiology, Kasturba Medical College, Department of Infection Control and Management, Kasturba Hospital, Manipal, Karnataka, India
2

Abstract
Infections acquired in the hospitals, especially in the intensive care unit  (ICU) settings, ranging between 15% and 20%, may further
lead to complications in  >40% in critically ill patients. The order of incidence may vary in different settings, but the most usual causes
are ventilator‑associated pneumonia, intravascular catheter‑associated bloodstream infection, catheter‑associated urinary tract infection,
posttraumatic intra‑abdominal infection, and surgical site infection. These can be prevented by adequate and appropriate application of preventive
strategies, which can be implemented strictly at the bedside. The basic norms for surveillance strategies, general preventive measures such as
standard and isolation precautions and monitoring of antibiotic use should be followed without fail. Specific practical measures for ICU‑related
infections should be in place, and the monitoring of activities should be documented regularly as “bundle‑care” in view of standardizing
the practice, irrespective of place or person. Adequate attention, unfortunately, has not been paid for infection control measures in India for
years. It is now mandatory that the essential practices are prioritized and integrated fully into regular hospital administrative procedure as a
continuous process for improving quality health care.

Keywords: Handwashing, hospital‑acquired infections, infection control, surveillance

Introduction Staphylococcus aureus (MRSA) bacteremia by 13% between

2011 and 2014. In 2011, there were an estimated 722,000 HAIs
Effective control of infection in the hospital, especially in
in USA acute care hospitals, out of which, about 75,000 patients
the intensive care unit (ICU) set up, is always challenging; it
died with HAIs occurred outside the ICUs. It has been
not only demands adequate awareness and constant vigilance
predicted that appropriate steps to control and prevent HAIs in
among the health‑care workers  (HCWs) but also needs a
a variety of settings, by creating awareness among individual
multidisciplinary approach to handle the management and
doctors and nurses may decrease some targeted HAIs (e.g.,
control of infection in every patient. The WHO estimates
CLABSI) by >70%.
that the rate of hospital‑acquired infections (HAIs) is
7%–12% among hospitalized patients all over the world, The burden of HAIs is more in the developing countries, with
where >1.4 million people had infection‑related complications highest prevalence in the ICUs. A prospective, multicentric,
during their stay in the hospital at any time.[1‑3] The recent and cohort surveillance study of device‑associated infection
Centers for Disease Control report about HAI rates among as conducted by International Nosocomial Infection Control
National Acute Care Hospitals in USA (2014 data, published Consortium  (INICC) in 55 ICUs of 8 developing countries
in 2016) informs us that there is a decrease in Central including India revealed the overall rate of 14.7% HAIs
Line‑Associated Bloodstream Infections (CLABSI) between corresponding to 22.5 infections/1000 ICU days.[5] In 2007,
2008 and 2014, whereas no change was observed in overall the INICC conducted prospective surveillance from 12 ICUs
Catheter‑Associated Urinary Tract Infection between 2009 and in 7 different cities showed that the overall HAI incidence rate
2014.[4] It is also reported that there is 17% decrease in surgical of 4.4% (9.06 infections per 1000 ICU days), where a total of
site infection  (SSI) related to 10 selected procedures, with
special mention of 17% decrease in abdominal hysterectomy Address for correspondence: Dr. Chiranjay Mukhopadhyay,
SSI, and 2% decrease in colon SSI in 6 years (2008–2014). Department of Microbiology, Kasturba Medical College, Manipal ‑ 576 104,
The rate of hospital‑onset Clostridium difficile infection has Karnataka, India.
come down by 8% and hospital‑associated methicillin‑resistant E‑mail: [email protected]

Access this article online This is an open access article distributed under the terms of the Creative Commons
Quick Response Code: Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
Website: and build upon the work non-commercially, as long as the author is credited and the new
www.ijrconline.org creations are licensed under the identical terms.

For reprints contact: [email protected]

DOI:
10.4103/ijrc.ijrc_9_17 How to cite this article: Mukhopadhyay C. Infection control in intensive
care units. Indian J Respir Care 2018;7:14-21.

14 © 2018 Indian Journal of Respiratory Care | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.22]

Mukhopadhyay: Infection control in the ICU

10,835 patients were studied for 52,518 days.[6] Indian data in a study, where cephalosporin‑based prophylaxis was
on HAI during 2004–2012 showed that the HAI rates vary given in 2,641 consecutive patients who had undergone heart
from 4.36% to 83.09% with infections per 1000 patient days surgery for over 5 years.[19] Prolonged prophylaxis (>48 h), as
ranging from 6.16 to 40.66.[7] HAIs account for major causes compared to short‑term prophylaxis, is not encouraged since
of disability of the patient’s functional aspects, economic it is not associated with decreased risk of SSI; it, on the other
burden, emotional suffering, and never the least, death among hand, is clearly associated with increased risk of colonization
the hospitalized patients.[2,8] The crude fatality rate in the with MDROs.
INICC survey in India and other developing countries varies
between 35.2% and 44.9%.[5] The HAIs are mostly due to
multidrug‑resistant (MDR) hospital environmental flora, which
Classification of Intensive Care Unit Infections
demands the use of higher antibiotics for a longer duration. Infections in ICUs are always crucial and need to be classified
As a consequence, there is more chance of developing higher for any surveillance program. A time cutoff of 48 h has generally
selection pressure and further development of resistance been accepted to distinguish between community‑acquired and
to reserved antibiotics, leading to increased length of stay HAIs from the practical point of view. However, it might not
for infected patients and increased chance of mortality.[9] be always a “true” HAI if it develops after 48 h of ICU stay,
Moreover, use of higher‑end antibiotics such as carbapenems, since the causative microorganism may not belong to the ICU
colistin, tigecycline, vancomycin, linezolid, and daptomycin to microbial ecology, rather imported by the patient as normal
combat MDR HAIs increase the health‑care cost immensely flora of his/her body. The “traditional” approach is challenged
due to an increased need for isolation and the use of additional with the concept of “carrier state,” when genotypically
laboratory and diagnostic tools. similar strains grew repeatedly at any concentration from
samples taken on admission and then afterward twice
In the European Prevalence of Infection in Intensive Care weekly from body sites such as throat or rectal swab taken
Study, increased mortality rate is independently associated for surveillance purpose to detect potentially pathogenic
with laboratory‑confirmed bloodstream infection, pneumonia,
microorganisms (PPMs).[20] On the other hand, clinical samples
and clinical sepsis.[10,11] However, other additional predictors
are collected from the superficial sites of suggestive infection
of mortality such as APACHE (acute physiology and chronic
and from internal organs which are normally sterile such as
health evaluation)–II score >20, prolonged (>21 days) ICU
lower respiratory tract, blood, and bladder while diagnosing
stay, age >60 years, the presence of organ failure or hospital
local infections or systemic infections, respectively.[20] The HAI
admission, and cancer as comorbidity also play a significant
has been classified on the basis of carrier status and diagnostic
role. The scoring systems (most widely used APACHE II/III)
cultures as follows:
are more suitable to predict mortality, rather than predicting
HAIs. On the other hand, understaffing and overcrowding Primary endogenous infections
in ICUs, type of nutrition (for example, catheter-related This is the most frequent form of infection in the ICUs, with
bloodstream infection (CRBSI) is apparently associated an incidence between 50% and 85%, that occurs usually early,
with total parenteral nutrition in critically ill patients), during the 1st week of ICU stay.[21‑26] These may consist of both
mechanical ventilation, length of stay, and ratio of nurse to normal and abnormal PPMs and may be imported in the ICUs
patient were found to be major independent contributors for during admission of the patient.
HAIs.[10] Cross‑transmission was facilitated by understaffing
and overcrowding, along with carriage of Gram‑negative fecal Secondary endogenous infections
flora, leading to outbreak.[12‑18] These usually occur after 1  week of ICU stay by aerobic
MDR Gram‑negative bacilli and Gram‑positive cocci,
especially MRSA and VRE. It accounts for one‑third of
Microbiology of Infections in Intensive Care Units all ICU infections.[21‑26] These PPMs are first colonized in
As microbiology and pathophysiology of infections the oropharynx, and subsequently, in the stomach and the
are common, there is a continuous shift toward more intestine, which can be prevented by the topical applications
resistant strains over years, which includes MRSA, of nonabsorbable antimicrobials.
vancomycin‑resistant enterococci (VRE), extended‑spectrum
beta‑lactamases  (ESBLs), carbapenems‑resistant Exogenous infections
Enterobacteriaceae  (CRE), colistin‑resistant acinetobacter, These are approximately 15% of all ICU‑acquired infections,
and fluconazole‑resistant Candida spp. These pathogens which are caused by the abnormal hospital PPMs at any
play a major role in HAIs, especially in ICUs, but the factors time during the patient’s stay in the ICU.[21‑26] Acinetobacter
responsible for this evaluation are yet to be understood infection of lower respiratory tract of the patients is the typical
fully. However, antibiotic pressure certainly plays a example, especially when the patient is on long‑standing
major role. Selective pressure due to prolonged antibiotic ventilator care. Surveillance samples may be negative for
exposure constitutes an independent risk factor which the microorganisms, but they readily appear in the clinical
determines the colonization and infection status of MDR samples. These type of infections are difficult to treat, rather
organisms (MDROs) in ICUs. It has been well‑emphasized more feasible to control by high level of hygiene.[23]

Indian Journal of Respiratory Care  ¦  Volume 7 ¦ Issue 1 ¦ January-June 2018 15

[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.22]

Mukhopadhyay: Infection control in the ICU

According to the criterion, ICU‑acquired infections are only microbiology laboratory while formulating antibiotic policy in
secondary endogenous and exogenous infections, whereas the hospital [Table 2].[10] There are a number of definite tools
primary endogenous infections are usually imported by the which are applied for infection control in ICU: Chart review,
patient while during admission. Laboratory Data, ICU Documents Review, Temperature,
Antibiotics Review, Readmission, and Autopsy [Table 2]. The
time required to implement these tools may vary according to
Surveillance of Infections in Intensive Care the number of beds under surveillance.
Units
In practical terms, optimal use of the resources in
The surveillance has been recognized as the major component resource‑limited settings, relentless monitoring of different
of infection control since late 1970s. It has been observed infections, especially due to MDROs, to detect and control
that there was a decrease in HAI rates on average 32% in outbreaks are essential for both specific and emergency
hospitals with well‑documented surveillance program in measures, which may further help design targeted programs
place over a 5‑year period as compared with an increase to reduce number of HAIs.[28]
of 18% in other hospitals without any such program.[27]
Epidemiological intervention following surveillance, control Critical care bundle therapy
at the administrative level for medical devices used for critical A “Bundle” is a structured way to improve patient care
patients as well as for the HCWs working in hospital setups, and outcomes by following straightforward, well‑defined,
and also, control of biomedical engineering parameters are checklist‑based set of evidence‑based practices and it is
among others, the major distinct surveillance components in an essential part of surveillance for infection in ICUs.
controlling HAIs HAIs [Table 1].[10] The bundles which are prepared as an objective, bedside
practice‑based approach with 3–5 elements in each have
There can be total surveillance all over the hospital, which shown significant reduction in HAIs and improvement in
includes routine collection, tabulation, analysis, and circulation patient outcomes. The Institute of Healthcare Improvement,
of data regarding the prevalence of HAIs in specified areas. USA has with the power of providing a reliable, best possible
Target‑oriented surveillance usually is restricted to objectives health care for patients without any chance of infection
on the priority basis as decided in the local settings, for from the setting itself, only when executed with complete
example, control of the spread of MDR Gram‑negative bacteria consistency. The bundles are derived from well‑established
in developing countries, MRSA in the developed countries practices. Failure of execution of bundles most often makes
or reduction of the incidence of CRBSI or urinary tract the treatment unreliable, at times idiosyncratic. There is a
infections, which are universal problem in every setting. Last clear‑cut impact of successfully implemented bundle if it is
but not the least, infection‑specific surveillance targets toward followed religiously and regularly as a continuous process.
particular types of infection‑related events, for example, It is all or none, for example, “Yes, I completed the ENTIRE
surveillance of outbreaks or generating antibiogram in the bundle” or “No, I did not complete the ENTIRE bundle.”

Table 1: Elements of surveillance applied to infection control in Intensive Care Units

Elements of surveillance Specific items
Engineering controls Adequate space around beds
Individualised cubicles (provided optimal nurse‑to‑patient staffing ratio is allocated
Adequate sink/hand hygiene facilties’ location
Isolation rooms in each ICU
Identified traffic circuits for clean and dirty equipment and/or activities
Administrative controls for Procedures for introduction of new materials/devices
medical equipment Written cleansing protocols for multiple use material
Routine application of guidelines for the appropriate use of medical devices
Administrative controls for Continuous postgraduate medical education to learn new technologies and the proper use of
healthcare personnel new medical devices and procedures
Maintain the presence of highly skilled HCWs by extensive training of replacement workers
In‑depth training on infection control procedure
Recommendation for nurse/patient staffing ratio
Monitoring quality of patient care using defined indicators
Administrative controls for Guidelines for ICU admission
patients Epidemiological surveillance of nosocomial infection rates and reporting
Total surveillance
Surveillance by objective (targeted to selected wards, infections or pathogens)
Outbreak surveillance and control
Computerised surveillance of lab data (targeted on resistance, device use)
Guidelines for patient isolation

16 Indian Journal of Respiratory Care  ¦  Volume 7  ¦  Issue 1  ¦  January-June 2018

[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.22]

Mukhopadhyay: Infection control in the ICU

Table 2: Concepts and tools for surveillance of hospital acquired infections

Surveillance Description Sensitivity (%) Time required h/wk/500 beds
Concepts
Total Routine collection, tabulations, analysis and dissemination of all
information on the occurrence of Nis in a specified ward and/or hospital
Target‑oriented Surveillance is restricted to priority‑specific objectives, such as the
control of the spread of MRSA or reduction of the incidence of catheter
related infections
Infection‑specific Surveillance is limited to particular types of infection such as outbreaks,
or to specific laboratory data dealing with the resistance pattern of
microbiological isolates
Tools
Chart review Complete review of all charts, including laboratory data 74‑94 36‑54
Laboratory data Identification of all patients with positive microbiological cultures 77‑91 23
Ward documents review Identification of patients at risk 75‑94 14‑22
Temperature Identification of all patients with a body temperature ≥37.8°C and 9‑56 8
receiving antibiotics
Antibiotics Review of all patients receiving antibiotics 57 14
Temperature and Review of all patients with a body temperature ≥37.8° C and receving 70 13
antibiotics antibiotics
Readmission Review of all patients readmitted S NA
Autopsy Review of all autopsied patients S 1
NA: Not available

Table 3: Requirements of standard precautions*

Requirement Field of application
Hand hygiene After direct contact with blood, body fluid, secretion, excretions and contaminated items,
immediately before gloving and after gloves removed
Between patient contacts and between dirty and clean body site contact in the same patient
Gloves For anticipated contact with blood, body fluid, secretion, excretion and contaminated items
For anticipated contact with mucus membranes and nonintact skin
Mask, eye protection, To protect mucous membranes of the eyes, nose and mouth during procedures and patient‑care
face shield activities likely to generate episodes or sprays of blood, body fluid secretions or excretions
Gowns To protect skin and prevent soiling of clothing during procedures and patient‑care activities
likely to generate splashes or spray of blood, body fluid secretions or excretions
Patient care Soiled devices, linen, or clothing should be handled to prevent skin and mucus membrane
equipment exposure and transfer of micro‑organisms to the environment
Reusable devices should be cleaned and reprocessed according to hospital policy
Sharp objects Avoid recapping used needles
Avoid removing used needles from disposable syringes by hand
Avoid bending, breaking, or manipulating used needles by hand
Place used sharp objects and needles in puncture‑resistant containers
*Also available online at http://www.cdc.gov/ncidod/hip/isolat/isolat.htm

There is no credit for partial completion  (doing few steps Ventilator bundle
for once or some days). Ventilator‑associated pneumonia is a well‑encountered
infection of lower respiratory tract, which may have a fatal
At least, there are two bundles which need to be implemented
outcome for the patients who are receiving mechanical
in all ICUs at the initial stage: ventilation, especially for longer duration. The ventilator
Central line maintenance bundle bundles have following steps:  (1) Elevation of the head
end of the bed between 30° and 40°,  (2) Mouth care with
The following steps may help prevent CLABSI:  (1) Daily
1%–2% Chlorhexidine (6 h), (3) Subglottic aspiration 1–2 h,
review of line necessity, (2) Hand hygiene before manipulation (4) Daily sedation vacation, (5) Daily assessment of readiness
of the intravenous  (IV) system,  (3) Daily inspection of the to wean,  (6) Daily spontaneous breathing trial,  (7) Peptic
insertion site, (4) Catheter‑site care, and (5) Alcohol scrub of ulcer disease prophylaxis, and  (8) Deep venous thrombosis
insertion hubs for 15 s before each use. prophylaxis.

Indian Journal of Respiratory Care  ¦  Volume 7 ¦ Issue 1 ¦ January-June 2018 17

[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.22]

Mukhopadhyay: Infection control in the ICU

Control and prevention of infections in intensive care units be enforced by self‑closing doors, which may help maintain
Prevention plays a major role in the control of infections in the correct pressure difference.
ICUs, which can be implemented through various guidelines.
Standard precautions
However, the main approaches are schematized as follows:
Ignaz Semmelweis, the obstetrician from Vienna >150 years
First, the potential sources of pathogens which may be
ago, used chlorinated lime water as the first ever example
responsible for transmitting infection from one patient to
of systemic hand disinfection while examining patients and
another, or to HCWs need to be identified and controlled, and
showed a dramatic reduction of mortality related to puerperal
the techniques to prevent cross‑contamination such as proper fever. Since then, routine hand washing before and after
cleaning, disinfection, and maintenance of various equipment patient contact remains the most important infection control
or devices need to be documented and practiced; second, measure.[30,31] Transmission of exogenous Staphylococcus
for selected group of patients, who need surgical antibiotic or other potential pathogens, especially in the ICUs where
prophylaxis or empirical therapy guidelines need to be in place patient care necessitates frequent contact, by the hands of
and strictly in use; third, appropriate strategies to restrict the HCWs is well‑documented.[18,32‑36] Higher contamination
use of higher antibiotics and prevent the emergence of MDROs was documented with handling of the body fluid secretions,
need to be implemented and followed up at regular interval to respiratory care, maintaining devices, or in any such
check the effectiveness. Added to this, some more measures occasions where the sequence of patient care is interrupted.
which are specifically targeted to curb the infections in ICUs Standard precautions like hand hygiene, wearing gloves,
are listed below: mask, protective gears, and gowns should be mandatory
Isolation practices requirements in any hospital setting [Table 3]. [10] Appropriate
It has been documented that  >50% patients while being hand disinfection before patient care may reduce 68 CFU
admitted in ICUs have already been colonized with the of bacterial load, independent of the types of care provided
potential pathogens that are responsible for infection in and the location of the hospital.[37] ICUs all over the world
due course subsequently.[10] A prospective observational have always had a low‑level compliance with hand hygiene,
study from a tertiary care center from the southern part of hardly exceeding 40%; lame excuses given are higher
India showed that there were 4.28% MRSA, 18.58% ESBL priority work over required hand‑wash procedures, less
Enterobacteriaceae, and 2.65% VRE asymptomatic carriers time, inconvenient approach to hand wash facility, allergy
among 210 newly admitted adult patients;[29] among them, or intolerance to hand‑hygiene solutions, lack of leadership
14.28% had monobacterial carrier stage. Although surgical from administration, etc.
admissions were more at risk (5.03 times; 95% CI: 1.3–19.6; Alcohol‑based hand rubs using antimicrobial agents such as
P = 0.023) than medical, and 55.5% MRSA carriers, 61.9% chlorhexidine, instead of hand washing with alcohol and soap
ESBL Enterobacteriaceae carriers, and 100% VRE carriers reduces the rate of HAIs more efficiently.[38,39] Gloves must
underwent invasive procedures including surgery, IV or be used for any anticipated contact with blood or body fluids,
urinary catheterization, there was no evidence of infection mucous membrane, nonintact skin, secretions, and moist body
due to their colonization status. However, some patients substances of all patients.[40] Gloves should be changed between
may acquire the infection from the hospital environment. contacts with the patients; in addition, gowns and masks may
Microorganisms can be transmitted by air‑borne, tiny droplets protect mucous membranes of the eyes, nose, and mouth from
or large‑particle droplets, or by direct contact. Patients who splashes or sprays of blood, body fluid secretions, and excretions
are detected as colonizer or carrier of MDROs through during procedures and patient care activity [Table 3].[41]
active surveillance are isolated, either by nurse cohorting
or contact isolation, so that the potential pathogens are not In addition to standard precautions, there were other precautions
transmitted to other patients. The responsibility lies with the such as airborne, contact, droplet to prevent transmission of
HCWs, who need to wear gown and gloves and wash their microorganisms. The droplet nuclei with <5 µm in size may
hands for all 5 moments as recommended by the WHO at remain suspended in the air for long periods and can travel
the bedside as a mandatory practice to prevent transmission long distance in patients with pulmonary tuberculosis, varicella
and disseminated zoster, acute viral hemorrhagic fever, H1N1
to other patients, especially to the patient who is designated
influenza, or measles. These patients should be placed in a
to be on contact precautions. Airborne infection isolation
private room with negative air pressure.[42] High‑efficiency
rooms are set at the negative pressure (> −2.5 Pa) with >12
masks such as N‑95 standard are required for HCWs or
air exchanges per hour for airborne disease patients to prevent
visitors, and also for the patient during transport outside the
transmission of airborne microorganisms from the room to
specified room.
the adjacent rooms or corridors. Protective environment
rooms housing severely neutropenic patients are set at the When the infective microorganisms can be transmitted
positive pressure (> +2.5 Pa) with  >12 air exchanges per by larger particles  (>5  µm in size) during coughing,
hour so that the airborne pathogens are not able to come sneezing and talking, or during invasive procedures such as
from adjacent rooms, spaces, or corridors to contaminate the bronchoscopy, pleural tap, endotracheal or tracheal aspiration,
airspace occupied by such high‑risk patients. It may further and suctioning, droplet precaution needs to be adopted. There

18 Indian Journal of Respiratory Care  ¦  Volume 7  ¦  Issue 1  ¦  January-June 2018

[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.22]

Mukhopadhyay: Infection control in the ICU

are cases with Haemophilus influenzae type B, meningococci, the high mortality and morbidity associated with nosocomial
MDR pneumococci or any other MDROs in respiratory infection with MDROs that early empirical broad‑spectrum
tract (e.g., MRSA, ESBLs, CRE), pharyngeal diphtheria, antimicrobial coverage for critically ill patients needs to be
mycoplasma pneumonia, and some viral diseases such as started. However, every empirical therapy should be guided
Adeno, Influenza, Mumps, Parvo B‑19, and Rubella, where by hospital antibiotic policy, prepared on the basis of local
the microorganisms may be inhaled or can be deposited on antibiotic susceptibility data, and has to be reevaluated
the mucous membrane of host’s eyes, nose, and mouth.[10] based on the initial culture results and clinical response of
However, a HCW must wear a mask when he/she comes in the patients after 48–72 h. In a study with patients suffering
contact within 60 cm to 1 m of any such patient. from pneumonia, either community or hospital‑acquired, it is
found that the mortality rate of patients receiving inadequate
If suitable isolation room or a private room is unavailable in
treatment  (52%) was significantly higher than that for
any hospital, the patient for airborne or droplet precautions
those receiving adequate treatment  (12%).[43] Guidelines
may be cared for in cohort with another patient infected
for systematic evaluation of fever in critically ill patients
with the same organism. However, like airborne precautions,
to recognize nosocomial infection at the earliest along with
special air handling and ventilation are not necessary in
implementation of antibiotic policy reduce cost and mortality
case of droplet precaution.[10] Few PPMs such as MRSA,
of the patients in medical and surgical ICUs. It is essential
VRE, ESBLs, CRE, or C. difficile can be transmitted by
to have a good knowledge of the total epidemiology and
direct physical contact or indirect contact with the patient’s
resistance profile of the hospital and community pathogens,
environment. It is mandatory for the HCWs that they should
and to have a multidisciplinary approach, which includes
wear gloves and gowns and discard them properly before
clinical microbiologists and experts in Infectious Diseases and
leaving the room. Systematic hand hygiene measures should
Infection Control to solve the challenging cases.
be strictly maintained before and after the examination or
procedure. Patient care devices such as stethoscopes, blood Attitudes of health‑care workers toward infection control
pressure cuffs, and knee hammer should be rigorously cleaned It has been emphasized that control of the HAIs is mainly
and disinfected before being used on another patient. If the related to teamwork and leadership. Moreover, there should be
patient is immunocompromised or severely neutropenic, effective communication in place and guidelines to be followed
separate isolation room facility in a private room with filtered to improve patient care. However, implementation is difficult
air instilled in positive pressure should be provided. However, in clinical practice, since most guidelines, requirements, and
due to lack of proper infrastructure in overcrowded hospitals measures are unpopular with HCWs, who have to practice them
in the developing countries, even shifting the patient to the at the bedside. It depends on the quality of a successful leader or
corner of the ward or ICU with strict barrier nursing practice the “Champion,” where an organized team under a leadership
may suffice the requirement. Patients who are readmitted brings the changes through interaction and communication
to the same hospital or are transferred from other hospital on daily basis. It is not as easy as it sounds and it is probably
are possibly carrying and transmitting MDROs. These because noncompliance is connected with the yearning of
patients should be screened on admission and be segregated human being for liberty.[44] Noncompliance as related to several
in isolation if they have any infection with PPMs during aspects of human behavior may include the false perception
readmission. of an impending risk, or the underestimation of individual
responsibility in the epidemiology of the institution, or passive
Control of antimicrobial uses attitudes regarding the increased complexity of the process of
The misuse of antimicrobial agents is one of the major
care, nor the least, the negative impact of the socioeconomic
determinants in the evolution of MDR strains in the hospital
constraints that are responsible for understaffing.[44]
settings. Several strategies such as optimal use of the
antimicrobial agents, strict implementation of antibiotic
policy, removal or restriction of higher/reserve antibiotics from Conclusion
routine use as empirical agents, use of antimicrobial agents in It is estimated that more than one‑third of HAIs are acquired
combination, and cycling of the antibiotics have been tried to in various ICUs, which roughly accounts for a crude incidence
curb the misuse of the antimicrobial agents and control the of 15%–40% of all hospital admissions.[45] Although infection
emergence of resistance. However, it is already established is not always the single most cause for mortality for patients in
that selection of antimicrobial agents is crucial at the bedside. ICUs, it is definitely associated with increased length of stay
There is always definitive therapy for proven infections, which and excessive hospital cost.[11,43,46,47] An improved knowledge of
is determined according to the antimicrobial sensitivity report. clinical epidemiology, microbial etiology, and pathophysiology
In few selective occasions, there is prophylaxis for specific of the disease will help understand the concepts of infection
infections, which is uniformly standardized all over the world. control, and thereby, the right use of antibiotics. In developing
In case of empirical therapy for suspicion of infection, which countries, where rapid turnover of workforce, lack of structured
constitutes the large majority of cases, there is always a chance ICUs, and inadequate awareness of infection control practices
of misuse of antibiotics, unless there is a local antibiotic policy are predominant, prevention of HAIs in the ICUs to provide
in place. It may be essential in a few occasions, considering better health care is always a challenge. Infection control in an

Indian Journal of Respiratory Care  ¦  Volume 7 ¦ Issue 1 ¦ January-June 2018 19

[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.22]

Mukhopadhyay: Infection control in the ICU

ICU or in a hospital can never be stand‑alone actions; rather it 17. Robert J, Fridkin SK, Blumberg HM, Anderson B, White N, Ray SM,
should be a part of everyday flow of work, where HCWs must et al. The influence of the composition of the nursing staff on primary
bloodstream infection rates in a surgical Intensive Care Unit. Infect
be focused on it as part of their essential duty, for the patients Control Hosp Epidemiol 2000;21:12‑7.
and for themselves as well. 18. Vicca AF. Nursing staff workload as a determinant of methicillin‑resistant
Staphylococcus aureus spread in an adult intensive therapy unit. J Hosp
Financial support and sponsorship Infect 1999;43:109‑13.
Nil. 19. Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic
prophylaxis after cardiovascular surgery and its effect on surgical site
Conflicts of interest infections and antimicrobial resistance. Circulation 2000;101:2916‑21.
There are no conflicts of interest. 20. Sarginson  RE, Taylor  N, van Saene  HK. Glossary of terms and
definitions. Curr Anaesth Crit Care 2001;12:2‑5.
21. Murray AE, Chambers JJ, van Saene HK. Infections in patients requiring
References ventilation in intensive care: Application of a new classification. Clin
Microbiol Infect 1998;4:94‑9.
1. WHO. Prevention of Hospital Acquired Infections: A Practical Guide. 22. Silvestri  L, Monti Bragadin  C, Milanese  M, Gregori  D, Consales  C,
2nd ed. World Health Organization; 2002. Available from: http://www. Gullo A, et al. Are most ICU infections really nosocomial? A prospective
who.int/csr/resources/publications/whocdscsreph  200212.pdf.[Last observational cohort study in mechanically ventilated patients. J Hosp
accessed on 2017 Mar 31]. Infect 1999;42:125‑33.
2. Patel  DA, Patel  KB, Bhatt  SK. Surveillance of hospital acquired 23. Petros AJ, O’Connell M, Roberts C, Wade P, van Saene HK. Systemic
infection in surgical wards in tertiary care centre Ahmedabad, Gujarat. antibiotics fail to clear multidrug‑resistant Klebsiella from a pediatric
Natl J Commun Med 2011;2:340‑5. ICU. Chest 2001;119:862‑6.
3. Saleem M, Kumar VA, Zafar IM, Arun SA, Agarwal J, Singh M, et al. 24. de La Cal  MA, Cerdá E, García‑Hierro  P, Lorente  L,
Pattern of nosocomial infection among patients admitted in medical Sánchez‑Concheiro M, Díaz C, et al. Pneumonia in patients with severe
and surgical wards of a secondary care hospital in north India, an burns: A  classification according to the concept of the carrier state.
epidemiological evaluation. Indian Journal of Community Health. 2013; Chest 2001;119:1160‑5.
24:285-90. 25. Silvestri  L, Sarginson  RE, Hughes  J, Milanese  M, Gregori  D,
4. CDC’s National Healthcare Safety Network  (NHSN). Available from: Van Saene  HK, et al. Most nosocomial pneumonias are not due to
https://www.cdc.gov/hai/surveillance/index.html#nhsn1.  [Last updated nosocomial bacteria in ventilated patients. Evaluation of the accuracy
on 2016 Oct 25]. of the 48  h time cut‑off using carriage as the gold standard. Anaesth
5. Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuera F, Intensive Care 2002;30:275‑82.
et al. Device‑associated nosocomial infections in 55 Intensive Care 26. Sarginson RE, Taylor N, Reilly N, Baines PB, Van Saene HK. Infection
Units of 8 developing countries. Ann Intern Med 2006;145:582‑91. in prolonged pediatric critical illness: A  prospective four‑year study
6. Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, based on knowledge of the carrier state. Crit Care Med 2004;32:839‑47.
et al. Device‑associated nosocomial infection rates in Intensive Care 27. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, et al.
Units of seven Indian cities. Findings of the international nosocomial The efficacy of infection surveillance and control programs in preventing
infection control consortium (INICC). J Hosp Infect 2007;67:168‑74. nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182‑205.
7. Ramasubramanian  V, Iyer  V, Sewlikar  S. Epidemiology of healthcare 28. Pittet  D, Safran  E, Harbarth  S, Borst  F, Copin  P, Rohner  P, et al.
acquired infection – An Indian perspective on surgical site infection and Automatic alerts for methicillin‑resistant Staphylococcus  aureus
catheter related blood stream infection. Indian J Basic Appl Med Res surveillance and control: Role of a hospital information system. Infect
2014;3:46‑63. Control Hosp Epidemiol 1996;17:496‑502.
8. Sensitizing People about Hospital‑ Acquired Infections; 09  February, 29. Albert RK, Condie F. Hand‑washing patterns in medical Intensive‑Care
2006. Available from: http://www.thehindu.com/2006/02/09/ Units. N Engl J Med 1981;304:1465‑6.
stories/2006020912040400.htm. [Last accessed on 2012 Mar 23]. 30. Vandana  KE, Varghese  G, Krishna  S, Mukhopadhyay  C, Kamath  A,
9. Ganguly  NK, Arora  NK, Chandy  SJ, Fairoze  MN, Gill  JP, Gupta  U, Ajith  V, et al. Screening at admission for carrier prevalence of
et al. Rationalizing antibiotic use to limit antibiotic resistance in India. multidrug‑resistant organisms in resource‑constrained settings:
Indian J Med Res 2011;134:281‑94. A hospital‑based observational study. J Hosp Infect 2010;76:180‑1.
10. Eggimann  P, Pittet  D. Infection control in the ICU. Chest 31. Goldmann  D, Larson  E. Hand‑washing and nosocomial infections.
2001;120:2059‑93. N Engl J Med 1992;327:120‑2.
11. Vincent  JL, Bihari  DJ, Suter  PM, Bruining  HA, White  J, 32. Huebner J, Pier GB, Maslow JN, Muller E, Shiro H, Parent M, et al.
Nicolas‑Chanoin MH, et al. The prevalence of nosocomial infection in Endemic nosocomial transmission of Staphylococcus epidermidis
Intensive Care Units in Europe. Results of the European prevalence of bacteremia isolates in a neonatal Intensive Care Unit over  10  years.
infection in intensive care  (EPIC) study. EPIC international advisory J Infect Dis 1994;169:526‑31.
committee. JAMA 1995;274:639‑44. 33. Coudron  PE, Mayhall  CG, Facklam  RR, Spadora  AC, Lamb  VA,
12. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, et al. Lybrand  MR, et al. Streptococcus faecium outbreak in a neonatal
A look into the nature and causes of human errors in the Intensive Care Intensive Care Unit. J Clin Microbiol 1984;20:1044‑8.
Unit. Crit Care Med 1995;23:294‑300. 34. Finkelstein  R, Reinhertz  G, Hashman  N, Merzbach  D. Outbreak of
13. Giraud T, Dhainaut JF, Vaxelaire JF, Joseph T, Journois D, Bleichner G, Candida tropicalis fungemia in a neonatal Intensive Care Unit. Infect
et al. Iatrogenic complications in adult Intensive Care Units: Control Hosp Epidemiol 1993;14:587‑90.
A prospective two‑center study. Crit Care Med 1993;21:40‑51. 35. Chang HJ, Miller HL, Watkins N, Arduino MJ, Ashford DA, Midgley G,
14. Tarnow‑Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality et al. An epidemic of Malassezia pachydermatis in an intensive care
in relation to staff workload: A 4‑year study in an adult Intensive‑Care nursery associated with colonization of health care workers’ pet dogs.
Unit. Lancet 2000;356:185‑9. N Engl J Med 1998;338:706‑11.
15. Haley RW, Bregman DA. The role of understaffing and overcrowding in 36. Goldmann DA, Leclair J, Macone A. Bacterial colonization of neonates
recurrent outbreaks of staphylococcal infection in a neonatal special‑care admitted to an intensive care environment. J Pediatr 1978;93:288‑93.
unit. J Infect Dis 1982;145:875‑85. 37. Pittet  D, Dharan  S, Touveneau  S, Sauvan  V, Perneger  TV. Bacterial
16. Haley  RW, Cushion  NB, Tenover  FC, Bannerman  TL, Dryer  D, contamination of the hands of hospital staff during routine patient care.
Ross  J, et al. Eradication of endemic methicillin‑resistant Arch Intern Med 1999;159:821‑6.
Staphylococcus aureus infections from a neonatal Intensive Care Unit. 38. Ehrenkranz NJ, Alfonso BC. Failure of bland soap handwash to prevent
J Infect Dis 1995;171:614‑24. hand transfer of patient bacteria to urethral catheters. Infect Control

20 Indian Journal of Respiratory Care  ¦  Volume 7  ¦  Issue 1  ¦  January-June 2018

[Downloaded free from http://www.ijrconline.org on Thursday, February 1, 2018, IP: 10.232.74.22]

Mukhopadhyay: Infection control in the ICU

Hosp Epidemiol 1991;12:654‑62. 43. Kollef  MH, Sherman  G, Ward  S, Fraser VJ. Inadequate antimicrobial
39. Doebbeling  BN, Stanley  GL, Sheetz  CT, Pfaller  MA, Houston  AK, treatment of infections: A  risk factor for hospital mortality among
Annis L, et al. Comparative efficacy of alternative hand‑washing agents critically ill patients. Chest 1999;115:462‑74.
in reducing nosocomial infections in Intensive Care Units. N Engl J Med 44. Farr BM. Reasons for noncompliance with infection control guidelines.
1992;327:88‑93. Infect Control Hosp Epidemiol 2000;21:411‑6.
40. Patterson  JE. Isolation of patients with communicable diseases. In: 45. Pittet  D, Harbarth  S. The Intensive Care Unit. In: Bennett  JV,
Mayhall  G, editor. Hospital Epidemiology and Infection Control. Brachman PS, editors. Hospital Infections. 4th ed. Boston, MA: Little,
Baltimore, MD: Williams & Wilkins; 1996. p. 1032‑51. Brown and Co.; 1998. p. 381‑402.
41. Garner JS. Guideline for isolation precautions in hospitals. The hospital 46. Pittet  D, Tarara  D, Wenzel  RP. Nosocomial bloodstream infection in
infection control practices advisory committee. Infect Control Hosp critically ill patients. Excess length of stay, extra costs, and attributable
Epidemiol 1996;17:53‑80. mortality. JAMA 1994;271:1598‑601.
42. Guidelines for preventing the transmission of Mycobacterium 47. Fagon JY, Chastre J, Vuagnat A, Trouillet JL, Novara A, Gibert C, et al.
tuberculosis in health‑care facilities, 1994. Centers for Disease Control Nosocomial pneumonia and mortality among patients in Intensive Care
and Prevention. MMWR Recomm Rep 1994;43:1‑32. Units. JAMA 1996;275:866‑9.

Indian Journal of Respiratory Care  ¦  Volume 7 ¦ Issue 1 ¦ January-June 2018 21