A quality improvement imperative: Achieving command over hospital acquired infections in intensive care units

Device related infections in the form of catheter-related blood stream infections, ventilator-associated pneumonias and catheter-associated urinary tract infections cause significant morbidity and mortality in intensive care units (ICUs). In addition, they impart heavy economic burden on healthcare. These infections can be detrimental to patients especially when they are caused by multidrug resistant organisms (MDRO) such as carbapenemase resistant Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii which have very limited to no options for treatment. MDRO have been a long standing problem for ICUs. Interaction between community and the healthcare environment has been an important factor in controlling the development and spread of these MDRO. More recently several studies have addressed different factors that play a role in the occurrence of infections including patient risk factors, bioburden on the patient and the environment and processes that involve healthcare personnel and systematic issues. Lately, there has been heightened awareness among clinicians and administrators that curtailing these infections is important to ensure superior quality care in an ICU and to avoid potential financial penalties. Whether achieving a "zero" infection rate is possible, striving towards "zero" with a goal towards achieving a "near zero" rate is essential. To this end, we will review the national trends and the impact of device related infections and MDRO on ICUs and focus on the evidence behind various techniques of infection prevention that include incorporation of evidence-based process improvement initiatives that require multidisciplinary involvement such as aseptic insertion of devices, prompt removal of devices when no longer indicated and their optimal maintenance. We will review the science of process improvement that focused on decreasing bioburden on patient and ICU environment via universal and targeted decolonization by comparing and contrasting the two modalities, utility of active surveillance for MDRO and ways to limit transmission within ICUs and wider medical community. Finally, we will review the management of device related infections and the treatment options for MDRO that are available and in development including those in pipeline. To our knowledge, such a comprehensive review has not been performed and this manuscript will provide a great depth of insight into the issue at hand and provide guidance in tackling the problem.