Critical Care Reviews |

Infection Control in the ICU* FREE TO VIEW

Philippe Eggimann, MD; Didier Pittet, MD, MS
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*From the Medical Intensive Care Unit (Dr. Eggimann) and the Infection Control Program (Dr. Pittet), Department of Internal Medicine, University of Geneva Hospitals, Geneva, Switzerland.

Correspondence to: Didier Pittet, MD, MS, Infection Control Program, Department of Internal Medicine, University Hospitals of Geneva, 1211 Geneva 14, Switzerland; e-mail: didier.pittet@hcuge.ch

Chest. 2001;120(6):2059-2093. doi:10.1378/chest.120.6.2059
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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.

According to the Institute of Medicine1in Washington, DC, preventable adverse events in the United States, including hospital-acquired infections, are responsible for 44,000 to 98,000 deaths annually and represent a cost of $17 to $29 billion. As precise epidemiologic data about these events are sparse, this estimation was extrapolated from two studies only.25 This report has generated a considerable debate in the medical literature.69 Nevertheless, data1012 have suggested that the likelihood of the occurrence of these events may increase by 6% for each day spent in the hospital, and they were found to be more frequent among patients in ICUs.

During the last decade, the growing emphasis on outpatient medical management has resulted in a marked reduction of beds in many health-care institutions, and this policy has been responsible for an increasing severity of illness among hospitalized patients. Data from the Centers for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance (NNIS) system show a 17% increase in the number of ICU beds at the 117 participating hospitals from 1988 through 1995, as compared with a slight decrease in the total bed capacity.13Although representing only 5 to 15% of hospital beds, ICUs accounted for 10 to 25% of health-care costs, corresponding to 1 to 2% of the gross national product of the United States.14

Nosocomial infections (NIs) affect > 2 million persons annually in the United States and concern 5 to 35% of patients who are admitted to ICUs.15They are viewed as an inexorable tribute to pay to the more aggressive management of the population, characterized by the use of sophisticated technologies and invasive devices. The pathophysiology of NIs includes colonization of the host by potentially dangerous pathogens, such as microorganisms from exogenous or endogenous sources, including resistant strains such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), azole-resistant Candida spp, and extended-spectrum β-lactamase (ESBL) Gram-negative pathogens. Ventilator-associated pneumonia, catheter-related bloodstream infections, surgical site infections (SSIs), and urinary catheter-related infections account for > 80% of NIs.17

The Study on the Efficacy of Nosocomial Infection Control15,1819 from the CDC has suggested that at least one third of NIs are preventable through infection control programs, which have been implemented in most centers during the last 2 decades. Risk factors are well-identified and have been the target of efficient preventive measures. This may explain why NI rates are now included in the criteria used for assessing the quality of patient care in many institutions. Control and prevention include general measures such as hand hygiene, isolation and restriction of antibiotic use, and more specific measures that have been demonstrated to be efficient in reducing particular types of NIs.2026