A 48-year-old patient with Guillain Barre Syndrome who has been hospitalised for 30 days was recently re-admitted to your ICU with septic shock. He required mechanical ventilation via his tracheostomy, vasopressor treatment, and is now recovering.

a)    What factors in this patient contribute to an increased risk for nosocomial infections?
(30% marks)

b)    How would you reduce the risk of him acquiring another nosocomial infection while in the ICU?
(70% marks)
 

[Click here to toggle visibility of the answers]

College answer

This question had several aspects to it that required structure to cover those elements. Candidates were expected to cover elements related to the specific patient care of the individual patient but also to cover general ICU aspects in regard to infection prevention management. Detailed descriptions were not required, as long as the general elements were covered with some relevant examples. Especially important points are underlined.

A)

Recognition that long stay patient in hospital who has a tracheostomy is a high risk patient for exposure to and/or colonisation with potential resistant flora and is therefore at risk for development of nosocomial infections (3 marks)

        1. Increased risk if higher severity of illness, significant comorbidities ,diabetes, malnutrition or immunosuppressed (all critically unwell patients at risk)
        2. Previous or ongoing antibiotic treatment, specifically when complex regimens and/or prolonged duration
        3. Open wounds, pressure sores
        4. Invasive devices – consider timely removal if not required or change when concern of colonisation

B)

  1. Prevention of specific infections in the intensive care unit (3 marks)
    1. Ventilator association pneumonia care bundle
 
      1. Prevention colonisation oral cavity (oral hygiene,
      2. Prevention aspiration (Nursing 30-45 degrees, subglottic aspiration, cuff pressure maintenance)
      3. Minimize duration of ventilation (minimise sedation, early mobilisation)
      4. Endotracheal and circuit care (HME, avoid routine ventilator circuit change, suction when required for secretions).
    1. CLABSI (central line associated blood stream infection) prevention bundle
      1. Insertion: Equipment (including PPE and catheter selection, dressing), preparation (including site selection) and sterile technique;
      2. Care: daily check insertion sites for signs of inflammation, daily review need (and remove when not required), check for lumen patency, hand hygiene and swab hub when handling. Consider timely removal if not required or change when concern of colonisation/infection/inflammation
      3. Documentation
      4. Education (staff experience)
    2. Infective diarrhea
      1. Vigilance/high index of suspicion for symptoms consistent with infective diarrhea, specifically for Clostridioides difficile
      2. Contact precautions/isolation (including hand washing) when C difficile suspected/confirmed
    3. Urinary tract infection
      1. consider timely removal of catheter if not required or change when concern of colonisation

NG tube/sinusitis- consider PEG.

  1. Environmental and personal aspects (2 marks)
    1. Hand hygiene
    2. Aseptic or sterile technique for procedures
    3. Personal protective equipment as per unit/hospital protocol, specifically in case of multi resistant organisms (ESBL, VRE, MRSA)
    4. Environmental hygiene (bench top cleaning, disposable versus non disposable curtains)
    5. Visitor education in regard to hand hygiene
  1. Antimicrobial stewardship – (some mention of appropriate antibiotic choice and de- escalation) multidisciplinary approach to provide correct treatment to patients with infections, improve outcome and to reduce risk of resistance development (2 marks)
    1. Regular screening for colonisation with
      1. Surveillance cultures (tracheal aspirate, urine if catheterised)
      2. Nasal/rectal swabs if concern for multi resistant organisms (VRE, MRSA)
    2. Knowledge of local microbiological data and resistance patterns
    3. Therapeutic guidelines on empiric antibiotic treatment
    4. De-escalation, change from parenteral to enteral antibiotics, avoid long duration when possible

Discussion

Increased risk in GBS patients is hard to discuss, not because the topic is entirely unfamiliar to senior ICU trainees, but rather because the answer requires a structured approach, and with so much to discuss, it is difficult to know how best to structure such a vast amount of information. A certain discipline is also going to be required. A well-informed exam candidate will squander many minutes writing everything they know about this.

Let us consider this in terms of predisposing factors and the possible infection they cause. One way is to organise the factors is according to the infections they promote, and the process which  has caused them. The ideas used to populate this table came from this article by Henderson et al (2003).  

Factors which Contribute to the Increased Risk of Nosocomial Infection among Patients with Guillain-Barre Syndrome
Infectious consequences Contributing factors
VAP
  • Prolonged intubation
  • Gram-negative colonisation of the lower airway
  • Poor oral hygiene (with intubation)
  • Weak cough
Sinusitis
  • Prolonged NGT dwell-time
Hospital-acquired pneumonia
  • Weak cough
  • Impaired airway defence reflexes
  • Prostration and basal atelectasis
Pressure area infections
  • Prolonged immobility
Line-related sepsis
  • Prolonged need for parenteral medications
Urinary tract infection
  • Long term IDC
Increased predisposition to infection
  • Immunosuppressant therapies
  • Malnutrition
Resistant organisms
  • Multiple courses of antibiotics
  • Prolonged hospital stay, and therefore increased risk of cross-contamination

With this exercise behind us, we can easily recombine the contributing factors into a structured list of interventions designed to address them:

Strategies fpr the Prevention of Nosocomial Infection in Patients with Guillain-Barre
Factor Intervention
Prolonged intubation
  • If expecting prolonged ventilation, think about an early tracheostomy
Gram-negative colonisation of the lower airway
  • Consider SDD
  • Upright (30 degrees head up) position
  • Discontinue PPI to maintain lower GI tract acidity
  • Promote gastro-oesophageal sphincter competence by removing NGT when able
Poor oral hygiene
  • Extubate early to give the nurses access
  • Educate nursing staff re. importance of oral hygiene, and promote internal audits of compliance
Weak cough
  • Chest physiotherapy to assist cough
  • Postural drainage
  • Longer suction catheters
Prolonged NGT dwell-time
  • If prolonged swallowing dysfunction is anticipated, a PEG may be a better option
Impaired airway defence reflexes
  • Prevent aspiration by the methods recommended in the VAP prevention section above (eg. head up position, etc)
  • If feeding orally, ensure the fluids are thickened and the diet is puree.
Prostration and basal atelectasis
  • Ensure daily physiotherapy engagement and encourage early passive mobilisation (eg. placing the patient into a chair-like position i bed)
Prolonged immobility
  • Realistically, this is GBS and you can't do much about this. Anecdotally, it appears that larger and earlier doses of IVIG tend to produce a more rapid improvement, but this is really not the topic of discussion here.
Prolonged need for parenteral medications
  • Rationalise IV medications (eg. can't that paracetamol be oral?)
  • Rationalise IV antibiotics
  • Rationalise central access (if it has to be parenteral, can it be peripherally parentral?)
  • If central access is imperative, transition to PICCs
Long term IDC
  • Unless the patient has specific urinary retention problems, the IDC may be superfluous in the later stages of disease
Immunosuppressant therapies
  • Corticosteroids have no role to play and so you shouldn't be using them anyway
Malnutrition
  • Optimal nutrition (including protein intake) may require specialist dietitian consultation and a means of delivering the nutrients safely (eg. PEG)
Resistant organisms
  • Antibiotic stewardship should be practiced
Cross-contamination with MROs
  • Single room with handwashing basin and alcohol handrub for staff
  • Standard contact precautions for all visitors

References

Henderson, R. D., et al. "The morbidity of Guillain-Barré syndrome admitted to the intensive care unit." Neurology 60.1 (2003): 17-21.