Almost every item of equipment encountered in the intensive care unit (ICU), ranging from ventilators and dialysis machines, to intravenous and urinary catheters, to such mundane items as ECG electrodes, has been shown to be a source of nosocomial infection. By far the most important vehicle of transmission remains the hands of attendants.

The risk elements can be considered under four headings: the environment, the equipment, the attendant, and the technique. The environment

The ICU will develop its own resident flora of bacteria, which will reflect the predominant case mix and antibiotic usage within the unit. The organisms causing nosocomial infection are constantly changing; hence surveillance noting both global and local trends is important. The staphylococcal infections of the late 1950s and 1960s yield first to coliforms and then Pseudomonas, only to return to the staphylococci, both coagulase-negative staphylococci and methicillin-resistant Staphylococcus aureus (MRSA). In addition, there has been the emergence of an Enterobacter species able to express extended b-lactamases, the inherent penem resistance of Stenotrophomonas maltophilia, and the spread of vancomycin-resistant (glycopeptide-resistant) enterococci. The effects of local practice are superimposed on these global problems. Thus heavy use of third-generation cephalosporins is likely to encourage the emergence of vancomycin-resistant enterococci, and the use of imipenem or meropenem may lead to problems with S. maltophilia. The antibiotic policy of the ICU must be kept under continuous review so that there is no indiscriminant use of antibiotics.

There are no requirements for special ventilation or air filtration systems other than those required for specific isolation purposes ( Baueref al 1990). However, the environment must be kept clean. Special cleaning procedures are not required, other than to ensure that frequencies are optimal and that staff are trained in the technique of damp-dusting using detergent-containing water that is changed frequently and clean mops. All surfaces must be damp-wiped at least daily. Cleaning of clinical equipment, particularly that attached to patients, should be assigned to a specific attendant. The routine use of disinfectants for cleaning is unnecessary. Cleaning of isolation rooms when vacated may require disinfection with a general-purpose phenolic as recommended by the local infection control officer.

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