Emerging Infections — Relevance in the ICU

It is impossible to destroy the micro-organisms. We have to learn to live with them smartly

"It takes about 8-10 years to develop an antibiotic. But in no time organisms acquire resistance to it" - Dr MN Sivakumar Anaeshthiologist and Fellowship Critical Care Kovai Medical Centre and Hospital Coimbatore

Emerging multi drug resistance infection in ICU a global pandemic and India is no exception to it. This problem is increasing despite our better understanding on patho-physiology of sepsis, newer diagnostic tools and antimicrobial agents. Infection is the second leading cause of mortality in non-coronary ICUs. In the United States annually there are 80,000 new infections, 28,000 deaths related to this and 2.3 billion dollars are spent on treat them. Economic burden of these infections are so huge, that insurance companies are not willing to pay for infections acquired in ICU. In an epidemiological study conducted in the US from 1979 to 2000, overall mortality of sepsis is decreasing despite increasing incidence of sepsis.

Why this pandemic?

Indiscriminate usage of antibiotics and poor infection control practices are the common cause for the rise of multi-drug resistant micro-organisms in the ICU. Antibiotics are used at places where it is not needed and at improper dosages, which has led bacteria to acquire resistance. Poor infection control practices cause infections spread from one patient to other in ICU. Most of Indian ICUs lack good infection control programme and infection surveillance systems. Lack of adequate microbiological support make physicians more handicapped to treat multi-drug resistant infections. More use of immuno suppressive drugs, chemotherapeutic agents and HIV patients are other cause for rise of infections. This has led to emergence of fungal infections and it contributes to 20 per cent of all blood stream infections in the ICU.

Relevance

This multi-drug resistance infection is going to have huge impact on mortality, morbidity and cost of therapy. Even with the best of care, mortality in multi drug resistant infection is around 50 per cent. Attribute mortality due to ventilator associated pneumonia is 25 per cent to 40 per cent.

Excessive duration of hospitalisation related to nosocomial infection amounts to:

• One to four days: Urinary Tract Infection (UTI).
• One week: Surgical site infection.
• One to four weeks: Blood stream infection and pneumonia.

This imposes huge economical burden for the patient families. In an Indian ICU, the cost of treating a severe pneumonia with broad spectrum antibiotics is around two lakh. Infections due to ESBL, MRSA, MDR pseudomonas and acinetobacter, which were thought to be western floras, are very common in all parts of our country now.

Several million compounds are screened, several millions are spent and it takes about 8- 10 years to develop an antibiotic. But in no time organisms acquire resistance to it. Very few antibiotics are released in the last couple of years. Future generations are going to have scarcity of drugs, as rightly said by Infectious Disease Society of America, 'Bad Bugs and No Drugs!'

Prevention Is Better

These infections are lethal and treating them is going to cost lakhs, so it is better if you can prevent them. Simple measures like hand washing, head end of bed elevation to prevent pneumonia and isolation of infected patients can help cut down the infection. Judicious use of antibiotics is needed to prevent further emergence of resistance.

Prompt detection and treatment of outbreaks due to multi-drug resistant organism is very vital. All ICUs should have infection control programme and infection control nurse. Surveillance systems are necessary to evaluate effectiveness of infection control programme.

A study was conducted in Michigan to reduce Catheter Related Blood stream Infections (CRBSI), which has five interventions.

• Hand washing.
• Cleaning skin with chlorhexidine.
• Using full barrier precautions during insertion.
• Avoiding femoral site if possible.
• Removing line when not needed.

These interventions reduced CRBSI by 66 per cent.

Centre for Disease Control (CDC) in the United States has issued guidelines to prevent resistant infections. It has four vital components:

• Prevent infection.
• Prevent transmission.
• Diagnose and treat infection.
• Use antibiotics wisely.

Micro-organisms are ubiquitous and indispensable. Number of E.coli in human gut is much more than number of human being who have lived on earth. It is impossible to destroy them. We have to learn to live with them smartly. Prevention strategies and strategies and responsible use of antibiotics are the key.

drsiva74@yahoo.com