Page 59 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

28 PART 1: An Overview of the Approach to and Organization of Critical Care

antimicrobial therapy (8 or 15 days) for the treatment for ventilator- potential concern for C difficile transmission, due to the inactivity of
associated pneumonia, and among patients who developed recurrent alcohol against C difficile spores; however, studies examining C difficile
infection; those with the shorter treatment less frequently developed incidence before and after the introduction of these products have failed
multidrug-resistant pathogens. Cycling empirical antibiotics usually to show an increase.
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requires the use of only a single antibiotic for the empirical treatment Other recommendations for ICU personnel concerning proper hand
of suspected health care–associated infection, followed by a switch to hygiene include avoiding the wearing of artificial fingernails as out-
another agent after a predetermined time period. Although several breaks of health care–associated infections have been associated with
studies suggested a potential benefit of antibiotic cycling, confounders these products, performing hand hygiene before and after using gloves,
(eg, improving hand hygiene) in these studies make it difficult to con- and providing staff with hand lotions to minimize the risk of irritant
clude the reduction in detection of MDR organism was entirely due to contact dermatitis.
antibiotic cycling. Current guidelines do not recommend antibiotic Besides proper hand hygiene, a novel strategy has evolved to reduce
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cycling as a part of antimicrobial stewardship. 74 the transmission of health care–associated pathogens. In a multicentered
Increased interest in computer-assisted physician order entry has quasi-experimental study, daily antimicrobial bathing (ie, chlorhexidine
allowed for the development of physician ordering support systems. solution) appears to reduce the acquisition of MRSA and VRE among
A prospective study of a computerized antibiotic management program ICU patients. 82
in one ICU found that patients treated using the computerized support
system had a lower incidence of mismatches between antibiotics pre-
scribed and the susceptibility of isolated bacteria. The computerized PREVENTING TRANSMISSION OF PATHOGENS
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support system was also associated with shorter durations of antibiotic
use. Further studies need to be performed to see if the reduction in over- BETWEEN ICU PERSONNEL AND PATIENTS
all antibiotic use by this method can reduce the prevalence of antibiotic- Health care workers in the ICU are potentially at risk of being exposed
resistant bacteria. to infectious agents during the course of caring for patients. Likewise,
Newer approaches for reducing antimicrobial use in the ICU have health care workers can spread infectious agents, particularly antibiotic-
evolved. Biomarkers, such as procalcitonin may distinguish bacterial resistant bacteria, to patients. A primary goal of infection control is to
infection from conditions mimicking bacterial infections. It potentially prevent both. Transmission of infectious agents in the ICU is currently
leads to reduced antimicrobial use and the emergence of MDR organ- prevented by what has been termed by the CDC as standard precautions
isms. Procalcitonin is a precursor of calcitonin and it is released in and transmission-based precautions (ie, airborne, droplet, and contact
response to exposure to bacterial toxins. A multicenter, open-labeled precautions). 83
trial demonstrated that using procalcitonin levels to help guide the
decision to initiate antimicrobial therapy in the ICU, reduced antimi- ■
crobial exposure among ICU patients without increasing mortality. STANDARD PRECAUTIONS
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Comprehensive management by a multidisciplinary team is another The concept of standard precautions arose from efforts to prevent
important strategy for reducing antimicrobial use in the ICU. Daily ICU patient-to-health care worker transmission of blood-borne pathogens.
rounds with clinical pharmacists reduce the unnecessary antimicro- The concept of standard precautions is based on the assumption that
bial use in the ICU. Other health care workers should be involved in all body substances (ie, blood and other body fluids, secretions, and
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patients’ care to improve antimicrobial stewardship. excretions) and certain body sites (ie, nonintact skin and mucous mem-
■ HAND HYGIENE branes) are potential sources of infectious agents. Therefore, health care
workers should use the same basic precautions, regardless of whether a
Proper hand hygiene has been known to be fundamental in prevent- patient is known to have a particular infection. Standard precautions are
ing nosocomial infections since the studies of puerperal fever by designed to minimize the risk of transmission of both recognized and
Semmelweis in the mid-19th century. After contact with patients, health unrecognized sources of infection in hospitals and include (1) wearing
care workers’ hands can become transiently colonized with pathogenic clean gloves when there is the potential for contact with blood, body flu-
and antibiotic-resistant bacteria, which are then transferred to other ids, secretions, excretions, contaminated items, mucous membranes, or
patients. Hand soaps containing an antiseptic agent, such as chlorhexi- nonintact skin, (2) washing hands immediately after gloves are removed
dine, or alcohol-based hand rubs have been shown to effectively reduce or when body fluids are inadvertently contacted, (3) wearing a gown,
bacterial counts on hands when used properly. mask, and eye protection or a face shield when there is the potential for
Despite the known benefit of proper hand hygiene in preventing splashing or spraying with bodily substances, (4) avoiding practices that
health care–associated infections and the transmission of antibiotic- increase the risk of exposures and injuries, such as recapping or remov-
resistant bacteria, observed compliance with hand hygiene among ICU ing used needles from syringes.
personnel remains low. Hand hygiene adherence for physicians was
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riers to compliance with hand hygiene are time and accessibility. An ■ TRANSMISSION-BASED PRECAUTIONS
generally lower than for other health care workers. The greatest bar-
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outbreak of Enterobacter cloacae infections in a neonatal ICU coincided Current CDC guidelines for isolation precautions are based on the
with a period of patient overcrowding and short staffing of nurses. known modes of transmission of either highly contagious or epidemio-
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During this time, adherence to hand hygiene was 25% and subsequently logically significant pathogens (Table 4-5). Institution of transmission-
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increased to 70% when staffing and patient census returned to normal based isolation for an ICU patient should occur when infection or
levels. Accessibility to sinks in the ICU may be limited, particularly in carriage of one of these pathogens is either confirmed or suspected.
older units. When personnel do wash their hands with antiseptic soap, Transmission-based categories of isolation include airborne, droplet,
it is often for a shorter period of time than the duration used to test the and contact isolation. The transmission-based precautions require that
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product’s effectiveness. patients be placed in either a private room or be cohorted with patients
Waterless alcohol-based hand rubs improve health care workers’ who have the same infection, if necessary. Transport of the patient out of
compliance with hand hygiene in the ICU. Compared with using the room should be limited to procedures that are medically necessary
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traditional antiseptic soap and water, alcohol-based products require and cannot be performed in the room. When patients must be trans-
less time to use and are more convenient. Antiseptic soap and water ported out of the room, the area receiving the patient should be notified
should still be used, however, when hands are visibly soiled. There is of their isolation status, and special precautions (such as a surgical mask

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