Catheter-related bloodstream infections

Wanida PaoinThammasat University

Catheter-related bloodstream infections Incidence in PICU: 7.3-13.8 central lin

- e associated bloodstreaminfections/1000 cath days

Risk factors premature < 1000 g low immunity multiple CVC long term CVC insertion r educed ICU Nurse:Patient Ratio - - using Non ICU Trained Nurses in ICUs

From: Mermel L , Rhode Island Hospital

POTENTIAL ROUTES OF INFECTION

Strategies for Prevention of Catheter-Related Infections Quality Assurance and Continuing Education Surveillance

Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis,

Manifestations suggesting local or BSI, the dressing should be removed to allow thorough examination of the site

Hand Hygiene and Aseptic Technique Maximal sterile barrier precautions (e.g., cap, mask,

sterile gown, sterile gloves, and large sterile drape) d uring the insertion of CVCs

Hand hygiene before and after inserting, replacing, accessing, or dressing an intravascular catheter .

Washing hands with conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams .

Catheter Insertion

Efficacy of Barrier Precautions During CVC Insertion

Barrier precautionsMinimal Maximal

Cath colonization 7.2% 2.3%*

Cath sepsis 3.6% 0.6%*

* p<0.05

1994Raadetal,ICHE

Strategies for Prevention of CR Infections Site of Catheter Insertion

Femoral catheters: relatively high colonization rates, higher risk for deep venous thrombosis

Internal jugular cath: higher risk for infection than those inserted into a subclavian or femoral vein

Catheter Placement

Prospective, Randomized, Multicenter Stud y of Fem oral vs Subclavian CVC Insertion

Femoral cath Subclavian cath Cat h col oni zat i on 14.2%

2.2% Cat h sepsi s 4.4%

1.5%Cath t hrombosi s 6% 0%

M MMMMM MM MM MM M M 2001

Strategies for Prevention of CR Infections Skin Antisepsis

2% aqueous chlorhexidine gluconate lowered BSI rates compared with site preparation with 10% povidone-iodine or 70% alcohol

Cutaneous Antisepsis

CR Infection Prevention w/ Chlorhexidine

Cath colonization CRBSI CHX Control CHX Control

23. % 7%*† 0.5% 26 91. % (Maki ` )2% 7 *% 06. %

06 93. % (Sheehan` )4.7% 9.3%* 0 05 95. % (Garland ` )12/103 3110/ 3* 0110. / 3 0910. / 3 (`96)34% 27 *%3510. / 3 4110. / 3 (`97)

red values = <0.05 *= povidone iodine † = alcohol

Strategies for Prevention of CR Infections Catheter Site Dressing Regimens

Transparent, semipermeable polyurethane dressings: R eliably secure the device, P ermit continuous visual inspection of the catheter

site, P ermit patients to bathe R equire less frequent changes than do standard ga

uze A meta-analysis: The risk for CRBSIs did not differ

between the groups using transparent dressings versus groups using gauze dressing.

If blood is oozing from the catheter insertion site, gauze dressing might be preferred .

Strategies for Prevention of CR Infections Catheter Site Dressing Regimens

Chlorhexidine-impregnated sponge (Biopatch ™) placed over the site A multi-center study: reduced the risk

for catheter colonization and CRBSI . No adverse systemic effects resulted

from use of this device.

- Chlorhexidine Impregnated Sponge

- Chlorhexidine Impregnated Sponge (Biopatch)at C ath InsertionSite

- CI sponge Control 665 736

Cathcolonization 16% 2 9 %* CRBSI 12. % 33*

-* 062 049078RR . ( . . ) † -038016089RR . ( . .

Maki, Mermel, et al ICAAC 2000

Strategies for Prevention of CR Infections Antimicrobial/Antiseptic

Impregnated Catheters and Cuffs Chlorhexidine/Silver sulfadiazine. Minocycline/Rifampin. Platinum/Silver Silver cuffs

- Chlorhexidine Impregnated Sponge - -Chlorhexidine SilverSulfadiazine Impregna

ted 2 ndGenerationCatheters

CHSSControl#CVCs 368 374MMMM MMMMMMMM 7d 7dCath col oni z 64 12.8%

910( / 3CD) 1910( / 3CD)†

†p=0.006 2001Ruppetal,ICAAC

- -Minocycline Rifampin Impre gnated Catheters

- -Minocycline Rifampin Impregnated vs 1stGen - -Chlorhexidine Silver Sulfadiazine Impr

egnated CVCs*

-M R CHSSDuration 6 d 7dCRBSI 03. % 3 4. % -01 006(RR . , CI . )

- *M R impregnation intraluminal &extralumi nal, CHSS impregnation only extraluminal 1999Darouicheet al, NEM J

Silver Iontophoretic Catheter

-Silver Iontophoretic Control

CRBSI 31. % 8%*CRBSI 1% 39. %†

Combined OR -0.23 (0.07 0.66)

* 2001Bong et al, ICAAC†- 2001IbanezNollaetal,I CAAC

Silver Iontophoretic Catheter

Catheter type Caths w/ significant growth

Control 100%Chlorhexidine/silver

sulfadiazine 6 7 % Silver iontophoretic 20%

insertion site of lab animals inoculated w/ S. aureus, caths quantitatively cultur ed at 7 d

1996

Strategies for Prevention of CR Infections Antibiotic/Antiseptic Ointments

Povidone-iodine ointment Mupirocin ointment

Antibiotic Lock Prophylaxis Flushing and filling the lumen of the catheter

with an antibiotic solution and leaving the solution to dwell in the lumen of the catheter .

Heparin plus 25 micrograms/ml of vancomycin Vancomycin/ciprofloxacin/heparin combination Minocycline and ethylenediaminetetraraacetic

acid (EDTA )

Strategies for Prevention of CR Infections Anticoagulants

Prevent catheter thrombosis Heparin flush Heparin-bonded coating Warfarin

Strategies for Prevention of CR Infections Replacement of intravascular

catheters Replace CVCs if purulence is observed

at the insertion site Replace CVCs if the patient is

hemodynamically unstable and CRBSI is suspected

Do not use guidewire techniques to replace catheters in patients suspected of having catheter-related infection

Strategies for Prevention of CR Infections Replacement of administration sets

Replace administration sets, and add-on devices, no more frequently than at 72-hour intervals, unless catheter-related infection is suspected

Replace tubing used to administer blood, blood products, or lipid emulsions within 24 hours

If the solution contains only dextrose and amino acids, the administration set does not need to be replaced more frequently than every 72 hours

Strategies for Prevention of CR InfectionsQuality Assurance and Continuing Education

+++

A subclavian site instead of a jugular or femoral site

++

Hands hygiene, m aximal barrier precaution s f or CVCi nsert i on

+++

Changing administration sets at appropriate intervals

+++

Remove caths after intended use +++

- Chlorhexidine containing cutaneous antiseptics

+

Transparent, semipermeable polyurethan e dressings

+

Antimicrobial/Antiseptic Impregnated Catheters and Cuffs

+,+

Anticoagulants +

Antibiotic/Antiseptic Ointments -