2011 Preventing Catheter Related BSI Guidelines
Download
Report
Transcript 2011 Preventing Catheter Related BSI Guidelines
What’s New in the 2011 Guideline for
Preventing Catheter Related BSI?
Naomi P. O’Grady, MD
Critical Care Medicine Department
National Institutes of Health
I have no disclosures.
Objectives
Highlight some areas of controversy, including
catheter site selection, antimicrobial locks, and
chlorhexidine impregnated sponge dressings
Discuss the recommendations in the updated
guideline
Outline some of the data to support the new
recommendations
Clinical Infectious Diseases 2011; 52(9) e162-e193
Site Selection
Old Recommendation
Use a subclavian site (rather than a jugular
or a femoral site) in adult patients to
minimize infection risk for non-tunneled
CVC placement
Site Selection
Rather than focus on one specific site to select,
we now focus on one specific site to avoid.
Avoid the femoral vein for central venous access
in adults
Femoral site associated with greater risk of
infection and DVT
Merrer; JAMA, 2001
Parienti; JAMA, 2008
JAMA, 2001; 286:700-07
Catheter Complications
Randomized patients to femoral (145) vs
subclavian (144)
8 ICU’s; 3 years
Mechanical complications similar in both groups
Infection and thrombosis higher in femoral group
Catheter Complications
Catheter Complications
* Thrombotic complications were 21% in femoral group
and 1.9% in subclavian group ( p<0.001) with 2 PE’s
JAMA 2008
Femoral vs Jugular Catheterization
375 patients in each arm over a 3 year period
Primary endpoint was colonization on removal
Insertion complications, CR-BSI, and thrombosis
were secondary endpoints
Mechanical Complications
Jugular catheters: longer insertion times, more
failed attempts and more crossover
Arterial punctures no different (5.1% vs 3.6%),
although hematoma formation higher in jugular
2 patients required intubation in jugular group
1 patient required vascular surgery for carotid
artery insertion
1 patient with acute leg ischemia required limb
amputation
Infectious Complications
JAMA 2008
Controversy. . .
JAMA 2008
Skin Antisepsis
Old Recommendation
Disinfect clean skin with an appropriate
antiseptic. A chlorhexidine-based
preparation with >2% is preferred.
Alternatively, tincture of iodine, an
iodophor, or 70% alcohol could be
used.
New Recommendation
Disinfect clean skin with an appropriate
antiseptic. A chlorhexidine-based
preparation with >0.5% is preferred.
Alternatively, tincture of iodine, an
iodophor, or 70% alcohol could be
used.
Chlorhexidine significantly reduces risk of colonization and BSI
Annals of Internal Medicine 2002
Catheter Site Dressing Regimens
Old Recommendation:
No recommendation
Efficacy of Chlorhexidine Impregnated
Sponges for Prevention of Intravascular
Catheter Related Infections
Chlorhexidine
Sponge
N = 665
Catheter Colonization
Blood Stream Infection
Control
N = 736
RR
109 (16%)
216 (29%)
0.62 (0.49-0.78)
8 (1.2%)
24 (3.3%)
0.38 (0.16-0.29)
ICAAC 2000
Timsit JF et al. JAMA 2009
Chlorhexidine sponge dressings reduce
risk of infection and colonization
2 x 2 factorial RCT to evaluate chx dressing vs
standard and to evaluate 3 day vs 7 day dressing
changes
1653 patients
3778 catheters
28,931 catheter days
Chlorhexidine sponge dressings reduce risk of infection and colonization
Timsit JF et al. JAMA 2009
Catheter Site
Dressing Regimens
Use a chlorhexidine sponge dressing in
adult patients with short-term catheters
to reduce the incidence of infection
catheter-related infection.
Antimicrobial Lock Solutions
Use prophylactic antimicrobial lock
solution in patients with long term
catheters who have a history of multiple
CRBSI despite optimal maximal adherence
to aseptic technique.
Catheter Locks
Technique by which an antimicrobial solution is
used to fill a catheter lumen and then allowed to
dwell for a period of time while the catheter is idle.
Antibiotics of various concentrations that have
been used either alone (when directed at a specific
organism) or in combination (to achieve broad
empiric coverage)
Formulations made in-house
Studies are limited; populations are hemodialysis,
neonates, patients with neutropenia
Needleless Connectors
Mechanical Valve
Split Septum
Recommendation
When needleless systems are used, a split septum
valve may be preferred over a mechanical valve
due to increased risk of infection with some
mechanical valves. Category II
Bundles and Checklists
Eliminating Catheter Related Infections
Crit Care Med; October 2004
Eliminating Catheter Related Infections
Educational intervention to increase provider
awareness
Created CVC insertion cart
Asking providers daily if the CVC is needed
Checklist at bedside for nurses
Empowering nurses to stop the procedure
Did not include tunneled of PA catheters
Eliminating Catheter Related Infections
Implemented simple strategies
No impregnated catheters
Reduced infection rate from 11.3/1000 catheter
days to 0/1000 catheter days during study period
Performance sustained
Jan-April 2003 only 2 infections (0.54/1000 catheter
days)
Eliminating Catheter Related Infections
Eliminating Catheter Related Infections
Excluded PICCS
Implemented teaching program
CVC carts
Checklist for compliance with handwashing and
barrier precautions
Eliminating Catheter Related Infections
Antibiotic/Antiseptic Catheters
Antibiotic/Antiseptic Catheters
Use an antimicrobial or antiseptic-impregnated CVC
in adults whose catheter is expected to remain in
place >5 days if, after implementing a comprehensive
strategy to reduce rates of CR-BSI, the rate has not
sufficiently decreased. The comprehensive strategy
should include the following 3 components:
educating persons who insert and maintain
catheters, use of maximal barrier precautions, and a
0.5% chlorhexidine preparation for skin antisepsis
during central venous catheter insertion.
Efficacy of Chlorhexidine-Silver Sulfadiazine
Catheters for Prevention of Catheter Colonization
Heard, 1998
Maki, 1997
van Heerden, 1997
George, 1999
Bach, 1996
Collin, 1999
-0.2
0
0.2
Odds ratio, 95% CI
0.4
0.6
0.8
1
Decreasing risk
1.2
Increasing risk
Proportion of Catheters
without Infection
Risk of Bloodstream Infections Using Two
Types of Impregnated Catheters
Catheter
M/R
C/SS
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.1
0.0
0
No. at Risk
365
382
Minocycline-rifampin
catheters
Chlorhexidine-silver
sulfadiazine catheters
5
10
15
20
30
25
Duration of Catheterization (Days)
214
246
93
96
48
39
20
18
9
5
4
2
Darouiche
NEJM 1999
Eliminating Catheter Related Infections
Annals of Internal Med 2005
Eliminating Catheter Related Infections
Summary
Educate healthcare workers and provide training
for the insertion and maintenance of catheters
Use chlorhexidine preferentially for skin
antisepsis
Use maximal barrier precautions
Use a chlorhexidine sponge dressing in adults
with short-term catheters
Use an antibiotic/antiseptic catheters if CRI rates
have not sufficiently declined
Use a bundled strategy for simplicity
Conclusions
Prevention strategies have measurable impact
Multiple interventions may be needed
Performance improvement programs will be
focused on moving toward elimination of CABSIs rather than “benchmark goals”
Focus of prevention moving away from
insertion phase and into maintenance phase
Thank you.