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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 32-35

Multiple site screening to prevent infections in patients admitted to Intensive Care Unit in a tertiary care center


1 Department of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Emergency Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission05-Sep-2015
Date of Acceptance05-Oct-2015
Date of Web Publication9-Nov-2015

Correspondence Address:
Reba Kanungo
Department of Microbiology, Puducherry Institute of Medical Sciences, Puducherry - 605 014
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

Background: The emergence of endogenous flora as a cause of hospital acquired infections in patients admitted in Intensive Care Unit (ICU) is of concern. They pose a serious therapeutic challenge, as most of these organisms are multidrug resistant.
Methodology: Sterile moist swabs were collected from patients prior to admission to ICU from the anterior nares, throat both axilla and groin. Patients were monitored every day for the full length of their stay for detecting any signs of infection. In case of infection, routine cultures were done and reports were reviewed. The results were correlated with the screening results and analyzed.
Results: Of the 100 patients who were screened, 10 patients had clinical infection caused by Acinetobacter baumannii. Among these 10 patients, 7 of them had their antibiotic sensitivity pattern similar to that of colonizers.
Conclusion: Screening for multidrug resistant organisms, prior to admission to ICU followed by effective decolonization may prove to be effective to curb the infections caused by these organisms.

Keywords: Decolonization, endogenous flora, multi drug resistant


How to cite this article:
Zachariah L, Seralathan SE, Karnam AH, Kanungo R. Multiple site screening to prevent infections in patients admitted to Intensive Care Unit in a tertiary care center. J Curr Res Sci Med 2015;1:32-5

How to cite this URL:
Zachariah L, Seralathan SE, Karnam AH, Kanungo R. Multiple site screening to prevent infections in patients admitted to Intensive Care Unit in a tertiary care center. J Curr Res Sci Med [serial online] 2015 [cited 2021 Oct 26];1:32-5. Available from: https://www.jcrsmed.org/text.asp?2015/1/1/32/168921


  Introduction Top


Hospital acquired infections in the Intensive Care Unit (ICU) results in increased morbidity and mortality among critically ill patients. Attempts have been made to minimize infection by strict adherence to infection control practices and antibiotic stewardship. However, despite these measures, infections in ICUs continue to take a toll on morbidity and mortality. Patients' endogenous flora has been strongly incriminated in these infections. Decreasing the burden of colonizing bacteria from the body surface could possibly lower the incidence of infection among critically ill patients in the ICUs.[1] Active screening from multiple sites for methicillin-resistant Staphylococcus aureus (MRSA) has shown to have 95% sensitivity in detecting carriage in patients as shown by a study from a hospital in Northern India.[2] Another study also showed similar results of multiple anatomic site sampling to achieve a sensitivity ≥90% for MRSA detection.[3] A study conducted in hospitals across the United States taking specific measures of effective programs, which included conducting organized surveillance and control activities resulted in effectual infection control, which reduced their hospital's infection rates by 32%.[4]

Acinetobacter, Pseudomonas and MRSA have been associated with infections in patients hospitalized for prolonged periods. Developments of multidrug resistance in these organisms pose a serious therapeutic challenge for the clinicians.[5] Prolonged ICU stay, particularly amidst patients who are colonized with these multidrug resistant strains is one of the most important predisposing factors to get colonized with these organisms, thereby causing a threat.[6] Screening of critically ill patients at admission and monitoring for early detection of infection during the length of stay in the ICU, may establish a causal relationship. So, this study was designed to document evidence that screening of patients for organisms associated with hospital acquired infections and correlating the results with isolates from active infections in the ICUs will help in establishing a causal relationship. This will in turn help in planning infection control measures.


  Methodology Top


The study was conducted in Pondicherry Institute of Medical Sciences during March 2014 and April 2014 following the approval by the Institute Ethics Committee. Patients admitted to ICU during the 2 months period were recruited into the study after obtaining a written informed consent. All patients admitted for 48 h or more in the ICU were inducted into the study. Those with pre-existing infections with MRSA, Acinetobacter, or Pseudomonas prior to admission in the ICU, patients who had been admitted in other hospitals prior to admission to the present ICU and those who had been transferred to the ICU from other wards in the hospital for critical care and were found to be infected were excluded from the study. Details of the clinical diagnosis, general condition of the patient, indication for admission to ICU, indwelling devices if any, and other co-morbid conditions such as diabetes, multi-organ dysfunction, or surgeries done were considered.

Sterile moist swabs were collected on the day of admission from the following sites, anterior nares, throat, both axilla and groin. Each patient was sampled only once. The swabs were processed by standard microbiological techniques and susceptibility was done for these isolates, according to, the Clinical and Laboratory Standards Institute guidelines [7] with recommended antibiotic panels for specific organisms.

Patients were monitored every day for the full length of their stay for detecting any signs of infection. In case of infection, routine cultures were done and reports were reviewed. The results were correlated with the screening results and analyzed. Similarity of antibiotic susceptibility pattern was taken as a crude method of typing to see if the organisms were of the same strain.


  Results Top


The organisms cultured were mainly Acinetobacter baumannii and Klebsiella pneumoniae [Table 1]. Of the 100 patients who were screened, 10 patients had clinical infection caused by A. baumannii. Among these 10 patients, 7 of them had their antibiotic sensitivity pattern similar to that of colonizers [Figure 1]. The colonizers were predominantly from the throat swabs. The details of the patient's stay, clinical diagnosis, and type of antibiotic susceptibility pattern seen in colonizers and clinical samples are described in [Table 2].
Table 1: Colonizers isolated from patients admitted to ICU during the study period

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Figure 1: Acinetobacter baumannii colonization and culture outcomes in patients with infection admitted to Intensive Care Unit during the study period

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Table 2: Characteristics of patients with both Acinetobacter baumannii infection and colonization

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  Discussion Top


Patients admitted to the ICU are at a higher risk to acquire an infection. Several factors attribute to the increased rate of infection. Moribund condition of the patient, environmental factors of the ICU, several life support systems and devices contribute to the increased risk of infection. Several studies have shown that patients' own endogenous flora is a major source of infection.[2] Of the 100 patients, who were screened immediately on arrival in the ICU and correlating with isolates from wound swabs, endotracheal tube aspirates, and bronchoalveolar lavages, there were 7 that truly matched i.e. 7 of the 100 individuals contracted an infection with the same organism initially found on their body surface as part of the screening process.

The main organisms isolated were A. baumannii and K. pneumoniae. Anterior nares and throat were found to be the most frequently colonized sites. This could be due to endotracheal devices or nasogastric intubation thus exposing the patient to an array of respiratory tract infections. The study also reveals that though 7 out of these 100 patients studied had a positive correlation between colonization and infection, these figures were statistically significant.

Other studies have documented patient to patient transmission, or improper barrier nursing methods contributing to nosocomial infections.[8] However, endogenous flora leading to infection is a major cause, which may be due to improper maintenance of patient hygiene or contamination of the immediate surroundings of the patient resulting in nonimplementation of standard precautions for patient care in the ICU.

Another area this study has highlighted is the emerging importance of the offending organism. It was initially assumed that Pseudomonas was the primary organism of importance.[9] However, in the present study, A. baumannii proved to be the most frequently isolated organism thus highlighting its growing importance in nosocomial infections. Another forerunner was K. pneumoniae, with most cultures being positive from the respiratory tract.

This study shows that probably these organisms were responsible for the infections acquired later on during the patients' stay in the ICU. Hence measures must be taken to reduce colonization in patients admitted to the ICU. Reducing colonization by use of chlorhexidine bath have shown promising results.[10] This study shows the extent to which endogenous organisms are responsible for infections in critically ill patients admitted in the ICU. Based on the statistical analysis, the association in seven cases among the 100 screened was significant (P < 0.001). It shows that the endogenous flora are a potential source for causing hospital acquired infections, and hence, specific protocols can be implemented by the Hospital Infection Control Committee for advocating skin and mouth care measures to decrease colonization in critically ill patients admitted to ICU of the hospital. A larger study needs to be done to reflect the actual relationship between colonization and risk for developing infections in critical care units.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sydnor ER, Perl TM. Hospital epidemiology and infection control in acute-care settings. Clin Microbiol Rev 2011;24:141-73.  Back to cited text no. 1
    
2.
Datta P, Vasdeva HR, Chander J. Optimization of multiple muco-cutaneous site sampling method for screening MRSA colonization in ICU. Indian J Crit Care Med 2013;17:243-5.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Lautenbach E, Nachamkin I, Hu B, Fishman NO, Tolomeo P, Prasad P, et al. Surveillance cultures for detection of methicillin-resistant Staphylococcus aureus: Diagnostic yield of anatomic sites and comparison of provider- and patient-collected samples. Infect Control Hosp Epidemiol 2009;30:380-2.  Back to cited text no. 3
    
4.
Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; 2008. p. 10-20.  Back to cited text no. 4
    
5.
Manchanda V, Sanchaita S, Singh N. Multidrug resistant Acinetobacter. J Glob Infect Dis 2010;2:291-304.  Back to cited text no. 5
    
6.
Vahdani P, Yaghoubi T, Aminzadeh Z. Hospital acquired antibiotic-resistant Acinetobacter baumannii infections in a 400-bed hospital in Tehran, Iran. Int J Prev Med 2011;2:127-30.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Clinical And Laboratory Standards Institute. Performance Standards For Antimicrobial Susceptibility Testing; Twenty Second Informational Supplement. CLSI Document, M100-S22, Pennsylvania, USA: Clinical And Laboratory Standards Institute; 2012.  Back to cited text no. 7
    
8.
Weber DJ, Rutala WA, Miller MB, Huslage K, Sickbert-Bennett E. Role of hospital surfaces in the transmission of emerging health care-associated pathogens: Norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control 2010;38 5 Suppl 1:S25-33.  Back to cited text no. 8
    
9.
Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA, et al. NHSN annual update: Antimicrobial-resistant pathogens associated with healthcare-associated infections: Annual summary of data reported to the national healthcare safety network at the centers for disease control and prevention, 2006-2007. Infect Control Hosp Epidemiol 2008;29:996-1011.  Back to cited text no. 9
    
10.
Martínez-Reséndez MF, Garza-González E, Mendoza-Olazaran S, Herrera-Guerra A, Rodríguez-López JM, Pérez-Rodriguez E, et al. Impact of daily chlorhexidine baths and hand hygiene compliance on nosocomial infection rates in critically ill patients. Am J Infect Control 2014;42:713-7.  Back to cited text no. 10
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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