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CHAPTER 4: Infection Prevention and Surveillance in the Intensive Care Unit 31

the eyes and nasal mucosa by the hands after handling objects or to patients, by creating herd immunity in health care environments and
touching surfaces contaminated by respiratory secretions. Infants have reducing the risk of health care worker infection. Although mandatory
been shown to shed high titers of RSV in respiratory secretions for up vaccination for health care workers remains controversial, it has been
to several weeks, and the virus is stable in the environment for up to successfully implemented in some health care facilities. 96
24 hours. RSV can be transmitted in pediatric wards via contaminated
prevention measures for RSV include placing infected young children, ■ CORONAVIRUS
hands or equipment or by infected health care workers. Infection
infants, and immunocompromised adults on contact precautions. In 2003, the world experienced an outbreak of a viral illness capable
Personnel with respiratory illnesses during RSV outbreaks should not of producing a rapidly progressive respiratory illness—severe acute
care for children and immunocompromised adults at risk for severe respiratory syndrome (SARS) that spread from China to southeast Asia,
RSV infection. 90 Singapore, and Canada resulting in over 800 cases with 744 deaths.
98
■ MENINGOCOCCUS The causative agent was proven to be a coronavirus. More recently
another coronavirus infection was identified in Saudia Arabia in a
Patients with meningitis and bacteremia caused by N. meningitidis fre- patient with pneumonia and a new syndrome described—Middle East
respiratory syndrome secondary to coronavirus (MERS-CoV). This
99
quently require admission to the ICU for circulatory collapse and airway illness also spread outside of the region in which it was originally
management. Often the diagnosis is suspected but not confirmed until identified.
the organism is isolated in culture. Patients with known or suspected These experiences outline a number of points concerning the
meningococcal infection should be handled using droplet precautions interface of critical care with emerging diseases. In the case of SARS,
because this organism is typically carried in the nasopharynx and spread meticulous barrier and airborne infection control measures helped
by respiratory secretions and large respiratory droplets. Personnel contain this disease and avert a pandemic. In the case of MERS, we
should wear a surgical mask when caring for infected patients and either are still learning about the mechanisms of transmission of the agent
goggles or a face shield when performing procedures capable of generat- but that early identification and appropriate isolation of patients with
ing droplets. Precautions can be discontinued after the patient has been respiratory and other organ failures that do not fit a readily identifiable
on effective antibiotic therapy for at least 24 hours. pattern and diagnosis is an important part of the job of the intensiv-
The admission of a patient with suspected or known meningo- ist, who may find themselves on the front line of treating these new
coccal disease can generate a significant amount of anxiety among infectious diseases
personnel. Cases of meningococcal health care–associated infection
in health care workers have been associated with close contact with
respiratory secretions (eg, mouth-to-mouth resuscitation) without
the use of precautions. However, transmission resulting in disease in
91
health care workers is rare, and the risk of transmission from casual KEY REFERENCES
contact with a patient is likely negligible. The incubation period for
meningococcal disease after exposure can range between 2 and 10 • Bouadma L, Luyt CE, Tubach F, et al. Use of procalcitonin to
days but is commonly 3 to 4 days. Therefore, the decision to give reduce patients’ exposure to antibiotics in intensive care units
antibiotic prophylaxis for a case of meningitis does not need to be (PRORATA trial): a multicentre randomised controlled trial.
made emergently, but can made after more information on the cause Lancet. 2010;375:463-474.
of the infection is available. Infection prevention and occupational • Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of
health staff should evaluate all potential employee exposures, educate antibiotic therapy for ventilator-associated pneumonia in adults: a
staff on the risk of infection, and determine if antibiotic prophylaxis is randomized trial. JAMA. 2003;290(19):2588-2598.
needed on a case-by-case basis. Ciprofloxacin-resistant meningococci • de Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of
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antimicrobial prophylaxis should be chosen, with regional suscepti- 2009;360(1):20-31.
bility patterns in mind. • Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screen-
■ INFLUENZA VIRUS ing for methicillin-resistant Staphylococcus aureus at hospital
admission and nosocomial infection in surgical patients. JAMA.
Influenza virus is a challenging topic for infection prevention. 2008;299(10):1149-1157.
Recommended infection prevention practices have varied for seasonal • Harris AD, Pineles L, Belton B, et al. Universal glove and gown
influenza, avian influenza (H5N1), and the 2009 H1N1 pandemic influ- use and acquisition of antibiotic-resistant bacteria in the ICU: a
enza strains. Although the mode of transmission is likely the same for randomized trial. JAMA. 2013;310(15):1571-1580.
each of these influenza A strains, the recommended preventive measure • Huang SS, Septimus EI, Kleinman K, et al. CDC Prevention
have differed, because of uncertainty in disease attack rate and mortality Epicenters Program and AHRQ DECIDE Network. Targeted ver-
in three strains. Current recommendation for the precaution of seasonal sus universal decolonization to prevent ICU infection. New Eng/J
influenza is droplet precaution. For H5N1 (avian) influenza, airborne Med. 2013;368:2255-2265.
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precaution (use of N95 mask, goggles and negative pressure room) is
recommended. Recommended infection control strategies for H1N1 • Kollef MH, Afessa B, Anzueto A, et al. Silver-coated endotracheal
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influenza remains controversial and can differ between professional tubes and incidence of ventilator-associated pneumonia: the
organizations and government agencies. The CDC announced that the NASCENT randomized trial. JAMA. 2008;300(7):805-813.
condition of H1N1 influenza is currently in postpandemic status (as of • Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines
September 2010). The most recent interim guidelines from the CDC (as for the diagnosis and management of intravascular catheter-
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for H1N1 influenza. 94,95 Updated recommendation from various orga- tions. Ann Intern Med. 2000;132:391-402 (erratum in Ann Intern
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personnel is an important method to prevent transmission of influenza

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