NOSOCOMIAL BLOODSTREAM INFECTIONS AND SEPSIS: SPICE, 2014

David Jay Weber, M.D., M.P.H.Professor of Medicine, Pediatrics, & Epidemiology

Associate Chief Medical OfficerUniversity Of North Carolina at Chapel Hill

TOPICS

Epidemiology Impact of healthcare-associated infections Definitions NHSN surveillance definitions Incidence and prevalence of CLA-BSI

Pathogenesis Mechanisms of CLA-BSI Microbiology Risk factors Diagnosis Sepsis

Prevention

LECTURE GOALS

Understand the impact of bloodstream infections Understand the incidence and causative pathogens of

bloodstream infection Understand the risk factors for healthcare-associated

bloodstream infections Understand the prevention and control of bloodstream

infections Understand the pathophysiology and risk factors for

sepsis and septic shock

IMPACT OF BLOODSTREAM INFECTIONS

Approximately 250,000 nosocomial BSIs per year Accounts for ~14% of healthcare-associated infections Increases length of stay by 7-21 days Attributable cost = $3,700 - $39,000 per episode

Major risk = use of an intravascular device Rate of BSIs varies by:

Hospital size, unit, and service Population served (elderly/infants, acute/chronic) Use and type of intravascular access device Time-trends Endemic/Epidemic

Weber DJ, Rutala WA. Infect Dis Clin NA 2011;25:77-102

Magill SS, et al. New Engl J Med 2014;370:1198

MORTALITY OF NOSOCOMIAL BSI,SCOPE, 1995-98

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Viridans streptococci

Serratia sp.

Pseudomonas sp.

Enterobacter sp.

Klebsiella sp.

E. coli

Candida sp.

Enterococcus sp.

S. aureus

CoNS

BSI Pathogens

Crude mortality

Edmond M, et al. CID 1999;29:239

IMPACT OF CLA-BSIs Prevalence

ICUs: ~80,000 CLA-BSIs/year1

Hospital-wide: ~248,000 CLA-BSI/year1

Cost/year $7,288 to $29,156 per infection (total ~670 million to $2.7 billion)3

1Mermel L, et al. CID 2009;49:1 – 2http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf - Eggimann P, Pitter D. CLin Microbiol Infect 2002;8:295

DEFINITIONS

Primary bacteremia: Culture-documented bacteremia occurring in the absence of recognized infection with the same pathogen at another site

Secondary bacteremia: Culture-documented bacteremia originating from an identifiable infection at a specific site

Pseudo-bacteremia: Positive blood cultures resulting from contamination during the collection procedure or during laboratory processing

Septicemia: A systemic disease caused by the presence of microorganisms or their toxins circulating in the blood

Sepsis: A clinical picture that is consistent with the presence of microorganisms or their toxic by-products in circulating blood

Septic shock: A syndrome of circulating insufficiency with hypoperfusion of body tissues resulting from an inadequate cardiac output relative to metabolic demands

Mermel L, et al. CID 2009;49:1-45

CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLA-BSI) EVENT

HAI All NHSN site specific infections must first meet the NHSN definition

before a site specific infection (e.g., CLA-BSI) can be reported to NHSN {An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were not present during admission time period but were all present on or after the 3rd calendar day of admission to the facility. All elements of the site specific definition mujst occur within a time frame that does not exceed a gap of 1 calendar day between any two adjacent elements}

Primary bloodstream infection (BSI) Primary BSI are laboratory-confirmed bloodstream (LCBI) that are NOT

secondary to an infection at another body site

NHSN DEFINITIONS: CLA-BSI

Central line Catheter must terminate in aorta, pulmonary artery, superior or inferior

vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac or common iliac veins, femoral veins, umbilical artery/vein (neonates)

Excludes femoral arterial catheters, intraaortic balloon pump, ECMO The following are NOT considered central lines:

Extracorporeal membrane oxygenation (ECMO) Femoral arterial catheters Intra-aortic balloon pump (IABP) devices Hemodialysis reliable outflow (HeRO) dialysis catheters

Infusion: Introduction of a solution through a blood vessel via a catheter lumen

NHSN DEFINITIONS: CLA-BSI

Temporary central line: A non-tunneled, non-implanted catheter Permanent central line:

Tunneled catheters, including certain dialysis catheters Implanted catheters (including ports)

CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLA-BSI) EVENT

A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days when all elements of the LCBI were first present, with day of device placement being Day 1 AND

A CL or UC was in place on the day of the event or the day before. If a patient is admitted or transferred into a facility with a central line in place, day of first access is considered Day 1

http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html

LABORATORY CONFIRMED BLOODSTREAM INFECTION (LCBI)

LCBI 1: Patient has a recognized pathogen cultured from one or more blood cultures AND organism cultured from blood is not related to an infection at another site

LCBI 2: Patient has at least one of the following signs or symptoms: fever (>38oC), chills or hypotension AND positive laboratory results are not related to an infection at another site AND common commensal (see list) is cultured from 2 or more blood cultures drawn on separate occasions. Criterion elements must occur within a time frame that does not exceed a gap of 1 calendar day.

LABORATORY CONFIRMED BLOODSTREAM INFECTION (LCBI)

LCBI 3: Patient <1 year of age has at least one of the following signs or symptoms: fever (>38oC core), hypothermia (<36oC core), apnea, or bradycardia AND positive laboratory results are not related to an infection at another site AND common commensal (see list) is cultured from 2 or more blood cultures drawn on separate occasions. Criterion elements must occur within a time frame that does not exceed a gap of 1 calendar day.

MUCOSAL BARRIER INJURY LABORATORY-CONFIRMED BLOODSTREAM INFECITON (MBI-

LCBI)

MBI-LCBI 1: Patient of any age meets criterion 1 for LCBI with at least one blood culture growing one of the intestinal organisms (see list) with no other organism isolated AND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within the

past year with one of the following documented during the same hospitalization as positive blood culture

Grade III or IV gastrointestinal graft versus host disease (GI GVHD) >1 liter diarrhea in a 24-hour period (or >20 mL/kg in a 24 hour period for

patients <18 years of age) with onset on or within 7 calendar days before the date the first positive blood culture was collected

Is neutropenic, defined as at least 2 separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC <500 cells/mm3 on or within 3 calendar days before the positive blood culture was collected

MUCOSAL BARRIER INJURY LABORATORY-CONFIRMED BLOODSTREAM INFECITON (MBI-

LCBI)

MBI-LCBI 2: Patient of any age meets criterion 2 for LCBI when the blood cultures are growing only viridans group streptococci with no other organisms isolated AND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within the

past year with one of the following documented during the same hospitalization as positive blood culture

Grade III or IV gastrointestinal graft versus host disease (GI GVHD) >1 liter diarrhea in a 24-hour period (or >20 mL/kg in a 24 hour period for

patients <18 years of age) with onset on or within 7 calendar days before the date the first positive blood culture was collected

Is neutropenic, defined as at least 2 separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC <500 cells/mm3 on or within 3 calendar days before the positive blood culture was collected

MUCOSAL BARRIER INJURY LABORATORY-CONFIRMED BLOODSTREAM INFECITON (MBI-

LCBI)

MBI-LCBI 3: Patient <1year of age meets criterion 3 for LCBI when the blood cultures are growing only viridans group streptococci with no other organisms isolated AND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within the

past year with one of the following documented during the same hospitalization as positive blood culture

Grade III or IV gastrointestinal graft versus host disease (GI GVHD) >1 mL/kg diarrhea in a 24-hour period in a 24 hour period with onset on or

within 7 calendar days before the date the first blood culture is collected Is neutropenic, defined as at least 2 separate days with values of

absolute neutrophil count (ANC) or total white blood cell count (WBC <500 cells/mm3 on or within 3 calendar days before the positive blood culture was collected

COMMENSAL ORGANISMS (i.e., skin flora)

Corynebacterium spp. (not C. diphtheriae) Bacillus spp. (not B. anthracis) Propionibacterium spp. Coagulase-negative stahylococci (including S. epidermidis) Aerococcus spp. Micrococcus spp. For full list see: http://www.cdc.gov/nhsn/XLS/master-organism-

Com-Commensals-Lists.xls

INTESTINAL ORGANISMS

Bacteroides spp. Candida spp. Clostridium spp. Enterococcus spp. Fusobacterium spp. Peptostreptococcus spp. Prevotella spp. Veillonella spp. Enterobacteriaceae*

Enterobacteriaceae* Citrobacter Enterobacter Escherichia (e.g., E. coli) Klebsiella Providencia Salmonella Serratia Shigella Yersinia

* Partial list

http://www.cdc.gov/nhsn/TOC_PSCManual.html, 2012

http://www.sciencedirect.com/science/article/pii/S019665531301153X#

BLOODSTREAM INFECTION RATES IN ICUs, STEP DOWN UNITS (SDUs), and WARDS

# Admissions # Patient-days

BSI:

# Cases

BSI: Cases per 100 admissions

BSI: Cases per 1,000 device days

Medical ICU 2,196 10,643 78 3.55 7.33

Medical SDU 2,505 7,750 30 1.20 3.87

Medical Ward 16,656 72,781 150 0.90 2.06

Surgical ICU 1,063 5,531 52 4.89 9.40

Surgical SDU 3,117 6,587 12 0.38 1.82

Surgical Ward 14,829 73,999 85 0.57 1.15

Weber DJ, et al. ICHE 2007;28:1361-1366

CLA-BSI MRSA RATES, US ICUs, 1997-2007

Burton DC, et al. JAMA 2009;301:727

CHANGES IN INCIDENCE OF CLA-BSI OVER TIME, UNC HOSPITALS

Weber DJ, et al. ICHE 2010;31:875 DiBiase LM, et al. ICHE 2014;35:200

PATHOGENESIS CLA-BSI

Multifactorial and complex Most catheter-related infections appear to result form migration of

skin organisms at insertion site into the cutaneous tract with eventual colonization of the catheter tip

Catheter hub also important contributor to intralumenal colonization (especially in long-term catheters)

Less important = hematogenous seeding of catheter tip from distant focus of infection or contaminated infusate

BIOFILM

SOURCE OF CLA-BSI WITH NONCUFFED SHORT-TERM VENOUS CATHETERS

Safdar N, Maki D. Intensive Care Med 2004;30:62

SOURCE OF CLA-BSI WITH SHORT-TERM VENOUS CATHETERS FOR TPN

Segura M, et al. Clin Nutrition 1993;12:102

TOP 10 PATHOGENS ASSOCIATED WITH CLA-BSIs: NHSN, 2009-2010

0% 5% 10% 15% 20% 25%

P. aeruginosa

E. coli

Enterbacter spp.

C. albicans

E. faecium

K. pneumoniae/oxytoca

Other Candida

E. faecalis

S. aureus

CoNS

Sievert DM, et al. ICHE 2013;34:1-14

COMPLICATIONS OF CLA-BSIs

Local infection Tunnel infection, pocket infection

Sepsis Remote site infection

Osteomyelitis Meningitis

Endovascular infection Endocarditis Mycotic aneurysms (septic thrombophlebitis)

INDEPENDENT RISK FACTORSFOR CLA-BSIs

Prolonged hospitalization before catheterization Prolonged duration of catheterization Heavy microbial colonization at the insertion site Heavy microbial colonization of the catheter hub Internal jugular catheterization Femoral catheterization Neutropenia Prematurity Reduced nurse-to-patient ratio in the ICU Total parenteral nutrition Substandard catheter care e.g., excessive manipulation) Transfusion of blood products (in children)

Marschall J, et al. ICHE 2009;29(suppl 1):S22

FACTORS ASSOCIATED WITH REDUCED RISK OF CLA-BSI

Female gender Antibiotic administration Minocycline-rifampin impregnated catheters

EVALUATION OF FEVER IN CRITICALLY ILL ADULT PATIENTS

Definition of temperature >38.3 oC → trigger for clinical assessment (not necessarily a lab

or radiographic evaluation for infection) <36.0 oC → in absence of known cause of hypothermia Most accurate: Pulmonary artery thermistor, urinary bladder

catheter thermistor, esophageal probe, rectal probe Other acceptable methods: Oral probe, infrared ear thermometry Less desirable: Temporal artery thermometer, axillary

thermometer, chemical dot

O’Grady NP, et al. Clin Infect Dis 2008;36:1330-1349

EVALUATION OF FEVER IN CRITICALLY ILL ADULT PATIENTS

Blood cultures Obtain 3-4 blood cultures within first 24 hours (obtain before

antibiotics if at all possible) For patients without a CVC, obtain at least 2 blood cultures from

peripheral sites by separate venipunctures For patients with a CVC, 1 blood culture should be drawn by

venipuncture and at least 1 should be drawn through the CVC Draw 20-30 mL of blood per blood culture; disinfect the skin with

2% chlorhexidine/70% isopropyl alcohol (ChloraPrep)

BSI INFECTIONS: SYMPTOMS/SIGNS

Constitutional: Fever, rigors, hypotension, shock Respiratory: Hyperventilation, respiratory failure Gastrointestinal: Abdominal pain, vomiting, diarrhea Neurologic: Confusion, seizures

CLUES TO CVC INFECTIONS

CVC: Exit site infection (erythema, tenderness, purulence) or tunnel infection (erythema, tenderness, purulence, induration)

High grade bacteremia/fungemia (multiple positive cultures) Abrupt onset, associated with shock Symptoms/signs of sepsis (i.e., fever/ hypotension) without obvious

source (no identifiable local infection) Evidence of septic thrombophlebitis of great vein Continued bacteremia/fungemia despite appropriate therapy Symptoms/signs of sepsis plus catheter malfunction Bacteremia with CoNS, Candida, Bacillus, Corynebacterium

CVC INFECTION: EVALUATION

Examine area around catheter exit for redness, tenderness, pus Examine tunnel tract (implantable catheter) for redness,

tenderness Blood cultures x 2-3 (always obtain at least one peripheral

culture) Consider catheter removal with semiquatitative of catheter tip

(not subcutaneous segment). Catheter colonization defined by: >15 cfu from a 5-cm catheter tip by roll plate method >102 cfu from a catheter by quantitative (sonication)

broth culture

CELLULITIS OVERLYING CATHETER

SEPSIS: PERIPHERAL EMBOLI TO SKIN

SEPSIS: EMBOLI TO RETINA

GANGRENE

SEPTIC EMBOLI

CVC INFECTION: DIAGNOSIS

A definitive diagnosis of CLA-BSI requires that the same organism grow from at least 1 percutaneous blood culture and from a culture of the catheter tip (A-I), OR

Two sets of blood samples (one from the catheter hub and the other from a peripheral vein) that, when cultured, meet CLA-BSI criteria for quantitative blood cultures or differential time to positivity (A-II)

For quantitative blood cultures, a colony count of microbes grown from blood obtained through the catheter hub that is at least 3x greater than the colony count from blood obtained from a peripheral vein (A-II)

For deferential time to positivity; growth of microbes from a blood sample drawn from a catheter hub at least 2 hours before microbial growth is detected in a blood sample obtained from a peripheral vein (A-II)

LABORATORY METHODSFOR DIAGNOSIS CLA-BIS

REMOVAL OF CVC: INDICATIONS

Long-term catheters Severe sepsis Suppurative thrombophlebitis Endocarditis Bloodstream infection that

continues despite >72 hours of antimicrobial therapy to which the microbes are susceptible

Infections due to fungi, S. aureus, P. aeruginosa, or mycobacteria

Short term catheters Infections due to Gram negative

bacill, S. aureus, fungi, and mycobacteria

Mermel L,et al.CID2009;49:1

CVC INFECTION: EMPIRIC THERAPY Gram-positive cocci (S. aureus, Coag neg staph)

Vancomycin (alternative: daptomycin); avoid linezolid Gram-negative bacilli (E. coli, Klebsiella, Enterobacter)

4o cephalosporin, carbapenem, -lactam/ -lactamase combination +/- aminoglycosie

Neutropenic patients Cover for MDR GNRs including P. aeruginosa

Femoral catheters In critically ill patients cover for GNRs and Candida

Suspected Candida TPN, prolonged uss of broad spectrum antibiotics, hematologic

malignancy, stem cell or solid organ transplant, femoral catheterization, Candida colonization at multiple sites

Choice of drug = echinocandin (selected patients fluconazole)

ANTIBIOTIC LOCK THERAPY

Antibiotic lock therapy is indicated for patients with CLA-BSI involving long-term catheters without signs of exit site or tunnel infection for whom catheter salvage is the goal (B-II)

For CLA-BSI, antibiotic lock should not be used alone; instead, it should be used in conjunction with systemic antimicrobial therapy, with both regimens administered for 7-14 days (B-II)

Dwell times for antibiotic lock solutions should generally not exceed 48 h before reinstallation of lock solution; preferably, reinstallation should take place every 24 h for ambulatory patients with femoral catheters (B-II). For dialysis patients, the lock solution can be renewed every dialysis session (B-II)

Cather removal is recommended for CLA-BSI due to S. aureus, Candida sp. For patients with multiple positive catheter drawn blood cultures that grow CoNS

or GNRs and concurrent negative peripheral blood cultures, antibiotic lock therapy can be given without systemic therapy for 10-14 days (B-III)

There is insufficient data to recommend an ethanol lock for treatment (C-III)

The Sepsis Continuum

SIRS Sepsis Severe Sepsis

> 2 of the following:

• T >38.5oC or <35oC

• HR >90

• RR >20 or PaCO2 <32 mmHg

• WBC >12, 000 or <4, 000

or >10% Bands

Sepsis + Organ Failure:• Shock / hypotension

• Acute lung Injury

• Renal

• Hepatic

• Hematologic

• CNS

• Metabolic acidosis

SIRS due to infection

NONINFECTIOUS MIMICS OF SEPSIS

Acute MI Acute PE Acute pancreatitis Fat emboli syndrome Acute adrenal insufficiency Acute GI hemorrhage

Overzealous diuresis Transfusion reactions Adverse drug reactions Procedure-related transient

bacteremia Amniotic fluid embolism

MANAGEMENT OF SEPSIS

Initial resuscitation with fluid replacement Use dobutamine to maintain blood pressure Assure adequate ventilation Obtain appropriate cultures before antibiotics Perform imaging studies to confirm source of infection, if possible Begin IV antibiotics within first hour of recognizing sepsis Use broad spectrum antibiotics Attempt to identify and control source of infection

Dellinger RP, et al. Crit Care Med 2008;36:296

OUTCOME DEPENDING AN ADEQUECY OF EMPIRIC THERAPY

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MacArthur R, et al.CID 2004;38:284

IHI: PREVENTION OFCENTRAL LINE INFECTIONS

Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis (now CHG-alcohol) Optimal catheter site selection, with subclavian vein as the

preferred site for nontunneled catheters Daily review of line necessity, with prompt removal of

unnecessary lines

PREVENTION OF CLA-BSI:EDUCATION

Educate HCP regarding indications for intravascular catheter use, proper procedures for insertion and maintenance of IV catheters (IA)

Periodically assess knowledge of and adherence to guidelines for all HCP involved in catheter insertion and maintenance (IA)

Designate only trained HCP who demonstrate competency for intersertion and maintenance of peripheral and central venous catheters (IA)

Ensure appropriate nursing staff levels in ICUs (IB)

O’Grady NP, et al. Clin Infect Dis 2011;52:e1

PREVENTION OF CLA-BSI:SELECTION OF CVC CATHETERS AND SITES

Weigh the risks and benefits of placing a CVC at a recommended site to reduce infectious complications against the risk for complications (lA)

Avoid using the femoral vein for central venous access in adult patients (lA) Use a subclavian site, rather that jugular or femoral site, in adults (lB) Avoid the subclavian site in hemodialysis & ESRD patients (lA) Use ultrasound guidance to place CVC (lB) Use a CVC with the minimum number of ports or lumens essential for the

management of the patient (lB) Promptly remove any CVC catheter that is no longer essential (lA) When adherence to aseptic technique cannot be ensured (e.g., ED

placement), replace the catheter as soon as possible (lB)

PREVENTION OF CLA-BSI:HAND HYGIENE AND ASEPTIC TECHNIQUE

Perform hand hygiene before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an IV catheter (lB)

Maintain aseptic technique for the insertion and care of IV catheters (lB) Wear clean vs sterile gloves for the insertion of peripheral IV catheters (lC) Sterile gloves should be worn for the insertion of arterial, central, or midline

catheters (lA) Wear either clean or sterile gloves when changing the dressing on IV

catheters (lC) Use maximal sterile barrier precautions (cap, mask, sterile gown, sterile

gloves, sterile full body drape) for the insertion of CVCs, PICCs, or guidewire exchange (lB)

PREVENTION OF CLA-BSI:SKIN PREPARATION

Prepare skin with an antiseptic (70% alcohol, tincture of iodine, an iodophor or chlorhexidine) before peripheral IV catheter insertion (lB)

Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before a CVC or arterial catheter insertion or dressing (lA)

Antiseptics should be allowed to dry according to the manufacturer’s recommendation prior to placing the catheter (lB)

PREVENTION OF CLA-BSI:CATHETER SITE DRESSING REGIMENS

Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site (lA)

If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved (ll)

Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled (lB)

Do not use topical antibiotics ointment or creams on insertion sites, except for dialysis catheter (lB)

Do not submerge the catheter or catheter site in water (lB) Replace dressings on CVC sites at least every 7 days for transparent

dressings, except in pediatrics (lB)

PREVENTION OF CLA-BSI:CATHETER SITE DRESSING REGIMENS

Replace transparent dressings used on tunneled or implanted CVC sites no more than 1x/week until the insertion site has healed (ll)

Ensure that catheter site care is compatible with the catheter material (lB) Use a chlorhexidine-impregnated sponge dressing for temporary short-term

catheters in patients older than 2 mo of age if CLA-BSI rates are not decreasing (lB)

Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis. If patients have tenderness at the insertion site, fever with a source, or other manifestations of local or bloodstream infections, remove the dressing and exam the site (lB)

PREVENTION OF CLA-BSI:OTHER

Use a 2% chlorhexidine wash for daily skin cleansing to reduce CLA-BSI (II) Use a sutureless securement device (ll) Use a chlorhexidine/silver sulfadiazene or minocycline/rifampin

impregnated CVC in patients whose catheter will remain in place >5d (lA) Do not administer system antimicrobial prophylaxis (lB0 Use prophylactic antimicrobial lock solution in patients with long-term

catheters who have a history of multiple CLA-BSI despite optimal maximal adherence to aseptic technique (ll)

Do not routinely use anticoagulant therapy to reduce the risk of catheter-associated infection in general patient populations (ll)

Do not routinely replace CVCs, PICCs, hemodialysis catheters (lB)

CDC EDUCATIONAL MATERIAL

http://www.cdc.gov/HAI/bsi/bsi.html

BATHE ICU PATIENTS >2 MONTHS OF AGE WITH A CHG PREPARATION DAILY

Intervention = Daily bathing with 2% CHG impregnated washcloth Design & setting : Cross-over study in MICU Result: CHG associated with decreased

rate (per 1,000 patient days) of CLA-BSI

(4.1 vs 10.4)

Bleasdale S, et al. Arch Intern Med 2007;167:2073

IMPREGNATED CATHETERS:META-ANALYSIS, 1985-2006

Meta-analysis, 1985-2006 Site: ICU 34 studies included in the review Outcome: Catheter colonization (RR, 95% CI), CLA-BSI (RR, 95% CI)

Coated catheter vs uncoated catheter Catheter colonization CLA-BSI CH-SS (external) 0.59 (0.50-0.71) 0.66 (0.47-0.93)CH-SS (internal and external) 0.44 (0.23-0.85) 0.70 (0.30-1.62)Minocycline/rifampcin 0.40 (0.23-0.67) 0.39 (0.17-0.92)Silver, platinum, carbon 0.76 (0.57-1.01) 0.54 (0.16-1.85)Silver ion-alloy 1.09 (0.68-1.74) 0.95 (0.29-3.16)Chlorhexidine 1.11 (0.80-1.55) 2.37 (0.63-8.96)

CH-SS, chlorhexidine/silver sulfadiazene Ramritu P, et al. AJIC 2008;36:104

IMPREGNATED CATHETERS:META-ANALYSIS , 1985-2006

Ramritu P, et al. Am J Infect Control 2008;36:104-17

IMPREGNATED CATHETERS:META-ANALYSIS, 1985-2006

CHG/Ag-Sulphadiazene vs Noncoated catheters Minocycline/Fig vs noncoated catheters

IMPREGNATED CATHETERS:META-ANALYSIS

Meta-analysis, 1950-2006 34 studies included in the review Outcome: Catheter colonization (RR, 95% CI), CLA-BSI (RR, 95% CI)

Coated catheter vs uncoated catheter Catheter colonization CLA-BSICH-SS (external) 0.51 (0.42-0.61) 0.68 (0.47-0.98)CH-SS (internal and external) 0.39 (0.25-0.60) 0.47 (0.20-1.10)Minocycline/rifampcin 0.39 (0.27-0.55) 0.29 (0.16-0.52)Silver alloy 1.21 (0.84-1.77) 0.58 (0.29-1.17)Silver iontophoretic 0.84 (0.60-1.16) 1.98 (0.40-9.95)Silver 1.07 (0.71-1.62) 0.93 (0.34-2.50)

CH-SS, chlorhexidine/silver sulfadiazene Casey A, et al. Lancet ID 2008;8:763

INFECTION CONTROL INTERVENTIONS

2000: Addition of 2% chlorhexadine/70% isopropyl alcohol (ChoraPrep®) to the central line dressing kit

2001: Mandatory training for nurses on IV line site care and maintenance. 2003: Full body drape added to central line kit. MD could choose kit

containing a catheter impregnated with antiseptic or antibiotic 2005: 2nd generation impregnated catheter included in all central line kits

(except for Neonatal ICU) 2006: Pilot in MICU of IHI bundle to prevent CLA-BSI. 2007: Implementation of the IHI bundle in all ICUs. 2008: Implementation of Infection Control Liaison Program 2009: Implementation of Biopatch

CONCLUSIONS

Healthcare-associated bloodstream (BSI) cause significant morbidity and mortality

The most important risk factor for BSI is a central venous catheter

A near 0 rate of CLA-BSI is possible using existing technology and appropriate process measures

Current guidelines should be followed for the diagnosis and management of CLA-BSI