Transcript 2011 CLABSI Master Class Monitoring of CVC

2011 CLABSI Master Class
Monitoring of CVC-associated bloodstream infections in
Victorian hospitals
VICNISS Coordinating Centre
Outline
•
•
•
•
VICNISS CLABSI surveillance module
NHSN CLABSI surveillance – revisions
CLABSI rates in Victoria – how do we compare?
Prevention of CLABSI – what does the literature
say?
• CLIP surveillance – VICNISS pilot results
• Ensuring accuracy & reproducibility
• Case studies for discussion
VICNISS & the CLABSI module
VICNISS
• Coordinating Centre
– commenced collecting hospital acquired infection data in
2002
• Quarterly data submission
– large & small acute public hospitals
– private hospitals
• CDC – NHSN (NNIS)
• Collate, analyse & report ‘hospital rates vs. State
rate’; notify CEOs and DoH if significantly high
rates identified
VICNISS surveillance modules
•
•
•
•
•
•
SSI
ICU CLABSI
ICU VAP
Haemodialysis
Surgical prophylactic antibiotics
+ Type 2 process & outcomes
CLABSI – a significant outcome
• Mortality
– attributable mortality 12-25%
• Increased LOS
– 2.4 ICU days
– 6.1-7.5 hospital days
• Healthcare costs
– US $11-25000
Higuera F et al. ICHE 2007
Warren DK et al. Crit Care Med 2006
Posa PJ et al. AACN Adv Crit Care 2006
Siempos II et al. Crit Care Med 2009
Tacconelli E et al. J Hosp Infect 2009
CLABSI case definitions: clinical
• Numerous
• Applications: diagnostic dilemmas, clinical trials
• Specialised laboratory testing methods:
– catheter tip cultures
– quantitative blood and catheter tip cultures
– differential time to positivity
Clinical definitions: heterogeneity
Diagnostic criteria
‘Definite’
•Same organism cultured from catheter tip & blood
(using DTP or quantitative catheter & peripheral cultures)
‘Probable’ •Local infection at insertion site and organism cultured from
blood
•Remission of previously refractory fever within 48 hours of
catheter removal with organism cultured from blood.
‘Possible’
•Pathogen cultured in blood that is typically implicated in
causing catheter-related infections (e.g. S. aureus, Candida)
•Organism cultured from blood and no other focus identified in
a patient with an indwelling CVC
Fatkenheuer G, et al. Ann Hematol. 2003
CLABSI case definition: surveillance
• Uniform & standardised
• Applications:
– public health reporting
– IC monitoring
• Feasible to apply across range of healthcare
facilities
• Laboratory and clinical criteria
NHSN
CLABSI surveillance definition for benchmarking
Edwards JR, et al. Am J Infect Control 2009
Monitoring in infection control
CLABSI surveillance definition to monitor an
intervention
Pronovost PJ, et al. N Engl J Med 2006
NHSN CLABSI surveillance –
revisions
The question of definition*
Case-definition criteria
NNIS NHSN
Recognised pathogen in 1 or more blood
cultures
Y
Y
Skin contaminant in 2 or more blood
cultures drawn on separate occasions
Y
Y
Skin contaminant in 1 blood culture, where
clinician institutes appropriate antimicrobial
therapy
Y
N
*case-definition for CLABSI, adult patients
NNIS/NHSN CLABSI rates*
Surveillance period
ICU type
Jan ‘02-Jun ‘04
Jan ‘06-Dec ‘06
Jan ‘06-Dec ‘07
Cardiothoracic
3.0
1.6
1.4
Medical
5.1
2.9
2.4
- major teaching
3.9
2.4
2.0
- all others
3.3
2.2
1.5
Surgical
Trauma
4.4
2.7
2.3
6.0
4.6
4.0
Medical/surgical
inclusive of criterion 2b & 3b
*published pooled mean rates
2b & 3b removed
NNIS Report, Am J Infect Control 2004
Edwards JA, et al. Am J Infect Control 2007
Edwards JA, et al. Am J Infect Control 2008
CLABSI rates - Victoria
Updated
NHSN
definition:
1 July 2008
pooled mean:
6.05/1000 CVC days
pooled mean:
2.06/1000 CVC days
CLABSI aetiology following definition
change
• VICNISS reporting period 2002-2008
– CNS 36.6%
– MRSA 17.4%
– enterococci 9.6%
• VICNISS reporting period 2008-2011
– CNS 12.3%
– MRSA 11.3%
– enterococci 26.2%
NHSN CLABSI definition
modifications: June 2011
• ‘skin contaminants’ → ‘common commensals’
– revised & expanded organism list
• Relatedness of infecting organisms
– susceptibility profile not required
– genus/species sufficient
Modifying a case-definition
considerations for a surveillance strategy
•
•
•
•
•
Comparison with historical data
Establishing a new baseline for trend analysis
Confidence intervals
Evidence for prevention & treatment strategies
Consider as ‘new’ infection
CLABSI rates in Victoria – how
do we compare?
National trends: CLABSI
Currently available reports:
• WA
– 7 contributing hospitals
– peripherally- and centrally-inserted devices reported
separately
• SA
– 12 contributing hospitals
– all bloodstream infections; denominator ‘bed days’
Healthcare Infection Surveillance WA
(HISWA)
Aggregate ICU
CLABSI rate =
0.77/1000 CVC days
(Q1 2011)
http://www.public.health.wa.gov.au/
SA Healthcare associated BSI report
www.health.sa.gov.au
International data: CLABSI
NHSN rates by ICU type
Edwards JR, et al. Am J Infect Control 2009
Prevention of CLABSI – what
does the literature say?
Prevention of CLABSI
interventions with proven efficacy
• Education
– physicians & nursing staff
Lobo RD, et al. Am J Infect Control 2005
Eggimann P, et al. Ann Intern Med 2005
• Anatomical site
– subclavian < jugular < femoral
Hamilton HC, et al. Cochrane database Syst Rev 2007
• Skin asepsis
– alcoholic chlorhexidine gluconate
Pratt RJ, et al. J Hosp Infect 2007
• Maximal barrier precautions
Raad II, et al. infect Control Hosp Epidemiol 1994
Impregnated & coated devices
• Chlorhexidine-silver sulfadiazine and
minocycline-rifampicin impregnated devices
reduce colonisation & CLABSI
Hockenhul JC, et al. Crit Care Med 2009
Casey AL, et al. Lancet Infect Dis 2008
• CDC guidelines recommend if CLABSI rates are
high
• Threshold CLABSI rates not proposed (cost-benefit
demonstrated for use of chlorhexidine-and-silversulfadiazine–impregnated catheters if CLABSI > 2%).
Maki DG, et al. Ann Intern Med 1997
The ‘beneficial bundle’
• Strategy/intervention consisting of a series of
components
– each component evidence-based & demonstrated
impact
– process measures
• Implementation
– feasible
– achieved by multi-faceted strategy – education,
credentialing, product selection
Bloodstream infections in ICU
US experience with ‘bundle intervention’
• Bloodstream infections associated with CVCs are
preventable
• Bundle comprised of 5 interventions:
–
–
–
–
–
maximal barrier precautions
hand washing
avoidance of femoral site
removal of unnecessary devices
chlorhexidine for skin asepsis
• Significant & sustained impact in reducing rates
of infection at multiple US centres
Pronovost PJ, et al. N Engl J Med 2006
Zero tolerance?
• Proposal for zero tolerance of CLABSI rates –
simple hospital performance indicator
• Modification in case-definition will reduce CLABSI
rates
• Other contributing factors:
– barrier precautions, hand-hygiene, skin preparation,
removal of unnecessary devices, avoidance of femoral site
– education, simulator training, credentialing of HCW
CLIP surveillance – VICNISS
pilot results
ICU ‘bundle intervention’
a lesson for Victorian centres
• Variable uptake of ICU bundle in Australian
centres
• Victorian centres with high rates of infection bundle components used by VICNISS as basis for
recommendations
• VICNISS literature review of evidence-based
bundle components (2009)
• Australian & NZ Intensive Care Society (ANZICS)
collaboration & support for implementation
CLABSI: process monitoring
• Central line insertion practices (CLIP)
– HICPAC CVC insertion guidelines
– Surveillance module: NHSN
– Reporting commenced 2008
• CLABSI prevention bundle
–
–
–
–
hand hygiene
appropriate skin asepsis
dry antiseptic before skin puncture
maximal barrier precautions (cap, sterile gown, gloves,
mask, full drape)
NHSN CLIP data
preliminary findings
• Mar 2008 – Sep 2009
• 72,216 CVC insertions, 744 healthcare facilities
• Majority in ICU (84%), and upper extremity
devices (62%)
• 6,356 (8.8%) did not adhere to bundle:
–
–
–
–
16% did not perform hand hygiene
20% did not use appropriate skin antiseptic
21% did not allow antiseptic to dry
60% did not adhere to maximal barrier precautions
• cap omitted in 63%
• full patient drape omitted in 34%
Allen-Bridson K, et al. SHEA 2010, abstract 686
CLIP data: Victorian experience
• Pilot study, Jan – June 2011
• 4 Victorian centres participating in CLABSI
surveillance
• Audit of CVC insertion practices in ICU
• Minimum 3 month continuous audit period
• Assessment of compliance with NHSN bundle
• Evaluation of feasibility of data collection
CLIP data: Victorian experience
A role for CLABSI process monitoring
in Victoria?
• Following pilot – ongoing participation requested
• Proposed scope for CLABSI process monitoring in
Victoria:
– Optional surveillance module for healthcare facilities
currently participating in CLABSI surveillance
(periodic/continuous)
– If higher than expected CLABSI rates at a single centre
– Monitoring in non-ICU environments, where CLABSI may
be less frequent or more difficult to monitor (interventional
radiology, ward, other)
• CLIP module available 10/2011
Ensuring accuracy &
reproducibility
Validation of CLABSI data (VICNISS)
• Accuracy of data important for benchmarking &
longitudinal analysis, but few validation studies
performed by non-US centres
• Review of hospital medical records comparing
reported surveillance data with gold standard
– 6 Victorian centres, Jan-Dec 2006
– Gold standard = blinded assessment by trained VICNISS
ICC
– NNIS case-definition
McBryde ES, et al. Infect Control Hosp Epidemiol 2009
Outcomes
• Total 398 bacteraemias, 81 reported as CLABSI.
Sample set of 46 reported CLABSIs and 62 not
reported as CLABSIs
• 67% inter-rater agreement with VICNISS review
• PPV 59% (43-73%), NPV 73% (60-83%)
• Sensitivity 35% (23-48%), specificity 87% (82-92%)
• Hypothetical sensitivity 50% [NHSN]
Reproducibility of CLABSI data
VICNISS
• Questionnaire review of Victorian ICCs assessing
reproducibility of case-definition when
compared to international gold standard
– 18/21 VICNISS centres, 2006
– 11-item questionnaire, classification of clinical cases
(CLABSI/not CLABSI)
– NNIS case-definition
– Gold standard = blinded CDC staff specialist
Worth LJ, et al. Am J Infect Control 2009
Assessment tool: an example
A patient with sub-arachnoid haemorrhage is
admitted to hospital directly into ICU and a CVC is
inserted. The patient becomes febrile after 24 hrs,
with no localising symptoms or signs. Blood culture
taken at 24 hrs isolates Staphylococcus aureus, and
treatment with intravenous flucloxacillin is
commenced:
⃞ this is an ICU-acquired CLABSI
⃞ this is not an ICU-acquired CLABSI
Outcomes
• Overall concordance with external comparator
57.1% (range 16.7-94.4%)
• Mean concordance higher for 1A hospitals
compared with non-1A (60.6 vs. 55.3%)
• Proportion of congruently classified cases, by
NNIS criteria: criterion 1, 52.8%; criterion 2a, 83.3%; criterion
2b, 58.3%
• Hypothetical concordance 62.5% [NHSN]
Enhancing CLABSI surveillance
• Credentialing tool for IC staff
– on-line, periodic, rotation of content
• VICNISS website
– FAQs, case studies
• Other
– education opportunities
– multi-disciplinary engagement; collaboration with ANZICS
‘CLAB’ project
Case studies for discussion
Scenario 1
• Trauma patient, day 18 post MVA
• Blood cultures collected at the same time:
– from PICC - Enterobacter gergoviae
– from peripheral site – no growth
Scenario 2
• Patient with 60% burns.
• After prolonged hospital stay, central line in situ,
– blood culture: Enterobacter spp.
• On same day as blood culture - patient had
clinically infected burns with tissue cultures
growing multiple organisms (not Enterobacter).
Scenario 3
• Patient admitted 5 days ago following head
injury.
• Central line in situ.
• Single blood culture from central venous line Pseudomonas spp.
• No peripheral blood culture taken.
• The patient was not febrile or septic at the time
of the culture and was not commenced on
antibiotics.
Scenario 4
28 Apr Admitted to hospital
1 May Admitted to ICU
2
CVC inserted (2200)
3
Blood culture (0600) - Acinetobacter spp
Tracheal aspirate - MSSA
4
Notes: "febrile, ? Source GNB on blood culture”
7
ID documented “Acinetobacter cause of line sepsis”
CXR essentially clear 3 - 7 May
8
CXR increasing consolidation, collapse in the LLL &
increasing consolidation R) lung base
Acinetobacter spp isolated from tracheal aspirate
Scenario 5
• A patient grew an Enterococcus spp from a
single peripheral blood culture.
• Patient in ICU for severe pneumonia but was
clinically improving (extubated the day before,
no longer febrile, white cell count decreasing).
• Medical History - ID physician notes:
“Enterococcus - probable contaminant".
Scenario 6
• A patient is undergoing treatment for acute
myeloid leukaemia
– has chemotherapy-induced mucositis (mouth ulcers, nausea,
vomiting).
– Hickman line in situ
– blood culture taken peripherally - Enterococcus spp
• multiple occasions.
Gut source or CLABSI?
• Gram-negative bacteraemia (or fungaemia) in
ICU patients may occur either because of
translocation of microorganisms from
oedematous, abnormal, or adynamic segments
of bowel or because of microscopic or
macroscopic defects in the bowel wall.
• Absence of proof (of an established infection at
a site other than a central vascular catheter as a
source of bacteraemia) cannot be cited as
proof of absence.
CLABSI due to Enterococci?
• The issue of using a single blood culture positive
for enterococci as evidence of a laboratoryconfirmed case of CLABSI is not a trivial.
– Evidence that Enterococci are frequent contaminants of
blood cultures is compelling.
– Infectious diseases specialists routinely perform a repeat
blood culture as a first step to assess patients who have a
single blood culture positive for Enterococci. If the repeat
culture result is negative, most infectious diseases specialists
would conclude that the single positive blood culture result
represents contamination.
CLABSI surveillance definition
2 proposed changes
• Inclusion of an “indeterminate source” for some
BSIs, and
• Acknowledgement that a single blood culture
positive for Enterococci has little clinical
significance, similar to the interpretation of a
single blood culture positive for CNS.
• CLABSIs could be divided into 3 categories:
– primary
– secondary, or
– indeterminate source.
• Acceptance of an “indeterminate source”
category for some patients with BSI would allow
hospital epidemiologists to acknowledge that
we can not determine the source of every
infection with certainty.
Scenario 7
• Patient with relapsed acute myeloid leukaemia
presented with documented febrile
neutropenia.
• CVC in situ.
• Streptococcus viridians spp grown from two
separate blood draws.
Aerococcus species
Aerococcus urinae
Aerococcus viridans
Bacillus cereus
Bacillus species (not B. anthracis)
Bacillus subtilis
Corynebacterium aquaticum
Corynebacterium bovis
Corynebacterium cystitidis
Corynebacterium glutamicum
Corynebacterium group G-2
Corynebacterium jeikeium
Corynebacterium kutscheri
Corynebacterium matruchotii
Corynebacterium minutissimum
Corynebacterium mycetoides
Corynebacterium pilosum
Staphylococcus auricularis
Staphylococcus capitis ss capitis
Staphylococcus capitis ss unspecified
Staphylococcus capitis ss urealyticus
Staphylococcus coagulase negative
Staphylococcus cohnii
Staphylococcus epidermidis
Staphylococcus gallinarum
Staphylococcus haemolyticus
Staphylococcus hominis
Staphylococcus lentus
Staphylococcus lugdunensis
Staphylococcus saccharolyticus
Staphylococcus saprophyticus
Staphylococcus schleiferi
Staphylococcus sciuri
Staphylococcus simulans
Corynebacterium pseudodiphtheriticum
Staphylococcus species
Corynebacterium pseudotuberculosis
Corynebacterium renale
Corynebacterium species
Corynebacterium striatum
Corynebacterium ulcerans
Corynebacterium urealyticum
Corynebacterium xerosis
Diphtheroids
Gram-positive cocci unspecified
Micrococcus species
Propionibacterium acnes
Propionibacterium avidum
Propionibacterium granulosum
Propionibacterium lymphophilum
Propionibacterium propionicum
Propionibacterium species
Rhodococcus equi
Rhodococcus species
Staphylococcus warneri
Staphylococcus xylosus
Streptococcus anginosus
Streptococcus bovis
Streptococcus mitis
Streptococcus mutans
Streptococcus salivarius
Streptococcus viridans species
Common
commensals,
NHSN, 2011
Scenario 8
• Haematology patient with refractory B-cell
lymphoma.
• Day 3 post allograft - blood cultures from both
Hickman lumens and peripherally - E. coli .
• Patient has an anal fissure. CT scan: no abscess.
• Ongoing abdominal pain,
– Laparotomy 1 week earlier - NAD.
– Abdominal pain still under investigation.
• Hickman was not removed by the treating team,
TPN was ongoing.
Case 9
• A patient with CVC in situ for 9 days becomes
febrile
1/5 - E. coli is isolated in blood culture
2/5 - Klebsiella pneumoniae is isolated in blood culture
• Chest X-ray is clear and no organism is isolated
from urine. No other primary source of infection is
identified.
Case 10
• In the setting of fever, a patient with CVC in situ
isolates Staphylococcus epidermidis from a
single blood culture.
• The treating clinician commences vancomycin
for targeted therapy.