Transcript Catheter-related bloodstream infections

Catheter-related
bloodstream infections
Wanida Paoin
Thammasat University
Catheter-related bloodstream infections

Incidence in PICU: 7.3-13.8 central line-associated
bloodstream infections/1000 cath days

Risk factors

premature < 1000 g
low immunity
multiple CVC
long term CVC insertion
reduced ICU Nurse:Patient Ratio

using Non-ICU-Trained Nurses in ICUs




POTENTIAL ROUTES OF INFECTION
From: Mermel L, Rhode Island Hospital
Strategies for Prevention of CatheterRelated 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) during 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
Cath colonization
Cath sepsis
*p<0.05
Raadet al, ICHE 1994
Barrier precautions
Minimal
Maximal
7.2%
2.3%*
3.6%
0.6%*
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 Study of
Femoral vs Subclavian CVC Insertion
Femoral cath Subclavian cath
Cath colonization
14.2%
2.2%
Cath sepsis
Cath thrombosis
4.4%
6%
1.5%
0%
Merrer et al JAMA 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
CHX
Control
2.3%
7%*†
2%
7%*
4.7%
9.3%*
12/103 31/103*
34%
27%*
CRBSI
CHX
Control
0.5% 2.6% (Maki `91)
0.6% 0.6% (Sheehan`93)
0
0.5% (Garland `95)
0.1/103 0.9/103 (Minoz`96)
3.5/103 4.1/103 (Humar`97)
red values = p<0.05
*= povidone iodine † = alcohol
Strategies for Prevention of CR
Infections

Catheter Site Dressing Regimens

Transparent, semipermeable polyurethane
dressings:






Reliably secure the device,
Permit continuous visual inspection of the catheter site,
Permit patients to bathe
Require less frequent changes than do standard gauze
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
Cath Insertion Site
C-I sponge
Control
665
736
Cath colonization
16%
29%*
CRBSI
1.2%
3.3%*†
*RR 0.62 (0.49-0.78)
†RR 0.38 (0.16-0.89
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-Silver Sulfadiazine-Impregnated
2ndGeneration Catheters
#CVCs
Cath duration
Cath coloniz
†p=0.006
Rupp et al, ICAAC 2001
CHSS
Control
368
374
7d
7d
6.4%
12.8%
(9/103CD) (19/103CD)†
Minocycline-Rifampin-Impregnated
Catheters
Minocycline-Rifampin-Impregnated vs 1stGen
Chlorhexidine-Silver Sulfadiazine-Impregnated CVCs*
Duration
CRBSI
M-R
6d
0.3%
(RR 0.1, CI 0-0.6)
CHSS
7d
3. 4%
*M-R impregnation intraluminal &extraluminal, CHSS
impregnation only extraluminal
Darouicheet al, NEMJ 1999
Silver Iontophoretic Catheter
CRBSI
CRBSI
Silver-Iontophoretic
3.1%
1%
Combined OR
0.23 (0.07-0.66)
*Bong et al, ICAAC 2001
†Ibanez-Nolla et al, ICAAC 2001
Control
8%*
3.9%†
Silver Iontophoretic Catheter
Catheter type
Caths w/ significant growth
Control
Chlorhexidine/silver
sulfadiazine
Silver iontophoretic
100%
67%
20%
insertion site of lab animals inoculated w/ S.
aureus, caths quantitatively cultured at 7 d
Raadet al, JID 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 catheterrelated 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
Infections
Quality
Assurance and Continuing Education
A subclavian site instead of a jugular or femoral site
+++
++
Hands hygiene, maximal barrier precautions for CVC
insertion
Changing administration sets at appropriate intervals
Remove caths after intended use
+++
Chlorhexidine-containing cutaneous antiseptics
Transparent, semipermeable polyurethane dressings
Antimicrobial/Antiseptic Impregnated Catheters and
Cuffs
+
+
+,+
Anticoagulants
Antibiotic/Antiseptic Ointments
+
-
+++
+++