Transcript Slide 1

SURVEILLANCE AND
PREVENTION AND
CONTROLOF CENTRAL
INTRAVENOUS CATHETERASSOCIATED INFECTIONS
C. Glen Mayhall, M.D.
Healthcare Epidemiologist
Department of Healthcare Epidemiology
Professor, Department of Internal Medicine
Division of Infectious Diseases
CIVC – ASSOCIATED INFECTIONS
OUTLINE
• Types of Central IV Catheters
• Pathogenesis of CIVC-associated infections
• Etiologies of CIVC-associated infections
• Definitions of CIVC-associated infections
• Clinical signs of infection
• Epidemiology
• Prevention and Control
CIVC – ASSOCIATED INFECTIONS
The Problem
• Noncuffed, percutaneously inserted central
venous catheters for short-term use
– 7 million sold each year in the U.S.
– 80,000 catheter-related bloodstream infections
per year
– 28,000 deaths per year
– $45,000 in healthcare cost per infection
– $2.3 billion annually
Safdar N, Fine JP, Maki DG. Ann Intern Med 2005; 142:451-466
Pronovost, P, Needham D, Berenholtz S, et al. N Engl J Med 2006; 355:27252732
CIVC - ASSOCIATED INFECTIONS
Types of Central Venous Catheters
Courtesy Issam Raad, M.D. University of Texas M.D. Anderson Cancer Center, 2007
CIVC – ASSOCIATED INFECTIONS
Pathogenesis
•Source of microorganisms
•Routes for colonization of the catheter
•Local catheter tract colonization/infection
•Bacteremia
•Hematogenous seeding of the catheter
Safdar N, Maki DG. Intens Care Med 2004; 30:62-67
CIVC – ASSOCIATED INFECTIONS
PATHOGENESIS
Intralumenal infection
Raad II, University of Texas M.D. Anderson Cancer Center, 2007.
CIVC – ASSOCIATED INFECTIONS
PATHOGENESIS
Intralumenal infections
Raad II, University of Texas M.D. Anderson Cancer Center, 2007.
CIVC – ASSOCIATED INFECTIONS
PATHOGENESIS
Intralumenal infection
Raad II, University of Texas M.D. Anderson Cancer Center, 2007.
CIVC – ASSOCIATED INFECTIONS
• ETIOLOGIES OF INFECTIONS
1992 – 1999
– Coagulase – negative staphylococci – 37%
– Staphylococcus aureus – 13%
– Enterococcus species – 13%
– Escherichia coli – 2%
– Enterobacter species – 5%
– Pseudomonas aeruginosa – 4%
– Klebsiella pneumoniae – 3%
– Candida species – 8%
Centers for Disease Control and Prevention, 2002
CIVC – ASSOCIATED INFECTIONS
DEFINITIONS OF INTRAVENOUS
CATHETER-ASSOCIATED BLOODSTREAM
INFECTIONS
• CENTERS FOR DISEASE CONTROL NAD
PREVENTION (CDC)
– Laboratory-confirmed bloodstream infection (LCBI)
• Recognized pathogen cultured from one or more blood cultures
• Organism cultured from blood not related to infection at another
site
CIVC – ASSOCIATED INFECTIONS
DEFINITIONS (cont.)
• CDC (cont.)
– LCBI (cont.)
• Fever (>38C), chills, hypotension ( > 1)
– Skin contaminant cultured from two or more blood
cultures
– Skin contaminant cultured from one blood culture and
physician initiates treatment
– Positive antigen test for microorganism in blood
CIVC – ASSOCIATED INFECTIONS
•
DEFINITIONS (cont.)
CLINICAL DEFINITIONS
– Catheter colonization
• No signs of inflammation at the catheter insertion site
• Positive semiquantitative (roll plate) culture - >15 colonies
• May be complicated by bacteremia
CIVC – ASSOCIATED INFECTIONS
DEFINITIONS (cont.)
• CLINICAL DEFINITIONS (cont.)
– Catheter – associated infection
• Signs of inflammation at catheter insertion site
–
–
–
–
–
Erythema
Warmth
Swelling
Tenderness
Purulent drainage
• Positive semiquantitative catheter culture
CIVC – ASSOCIATED INFECTIONS
CLINICAL SIGNS OF INFECTION AT CIVC
INSERTION SITES
• Subclavian insertion site infection
Maki DG, University of Wisconsin, 2007.
CIVC – ASSOCIATED INFECTIONS
CLINICAL SIGNS OF INFECTION AT CIVC INSERTION
SITES
• Implantable Port
Port Pocket Infections
Chest Port (top) Arm Port (bottom)
• Warm, red, tender port site
• Elevated WBC, fever
• Prevent by sterile technique
•
to access ports
Treat with IV antibiotics, port
removal
Maki DG, University of Wisconsin, 2007.
CIVC – ASSOCIATED INFECTIONS
CLINICAL SIGNS OF INFECTION
AT CIVC INSERTION SITES
Hickman catheter
Patient with AML
Septic, severely
neutropenic
Hickman removed,
antibiotics started
PICC line placed
Maki DG, University of Wisconsin, 2007.
CIVC – ASSOCIATED INFECTIONS
CLINICAL SIGNS OF INFECTION AT CIVC
INSERTION SITES
• PICC line
• Another example of the
importance of patient
education
• Patient would take showers
with dressing off and then
do site care after
• Patient thought cleaning
site in shower was a good
idea
• Exposure to tap water has
been shown to cause
CRBSIs with GNR water
organisms
Maki DG, University of Wisconsin, 2007.
CIVC – ASSOCIATED INFECTIONS
CLINICAL SIGNS OF INFECTION AT CIVC
INSERTION SITES
• PICC line
• Bleeding into arm after
PICC placed
• Patient with
thrombocytopenia, did not
receive platelets before
procedure
• Bleeding into tissue
resulted in infection
• PICC removed
Maki DG, University of Wisconsin, 2007.
CIVC – ASSOCIATED INFECTIONS
CLINICAL SIGNS OF INFECTION AT CIVC
INSERTION SITES
• PICC line
• Diabetic with PICC, doing
•
•
•
•
own dressings at home
Purulent drainage, cultured
positive for yeast
Blood cultures positive
Line pulled and replaced
other arm
Importance of patient and
family education and reeducation
Maki DG, University of Wisconsin, 2007.
CIVC – ASSOCIATED INFECTIONS
CLINICAL SIGNS OF INFECTION AT CIVC
INSERTION SITES
• Septic thrombophlebitis
• Failure to remove PIVC
placed in field by EMTs
• New fever and no
identified source, after 3
days S. aureus
bacteremia
• Patient’s vein was
removed, “full of pus”
Maki DG, University of Wisconsin, 2007.
CIVC – ASSOCIATED INFECTIONS
EPIDEMIOLOGY
•CIVC – ASSOCIATED INFECTION RATES
National Nosocomial Infection Surveillance System, January 1992-June 2001
(issued August 2001)
No.
Catheter days
Pool mean/1,000
catheter - days
Coronary
102
252,325
4.5
Cardiothoracic
Medical
Medical/surgical
Major teaching
All others
64
135
419,674
671,632
2.9
5.9
123
180
579,704
863,757
5.3
3.8
Neurosurgical
47
123,780
4.7
Type of intensive care unit
CDC, 2007
CIVC – ASSOCIATED INFECTIONS
EPIDMIOLOGY
• RISK FACTORS FOR INFECTION
– Site of insertion
• Subclavian vein
– Lowest infection rate
– Highest risk for mechanical complications
• Internal jugular vein
– Intermediate risk of infection
– Lower risk for mechanical complications
• Femoral vein
– Highest risk for infection
– Lower risk for mechanical complications
Goetz AM, Wagener MM, Miller JM, Muder RR. Infect Cont Hosp Epidemiol 1998;
19:842-845
Lorente L, Henry C, Martin MM, et al. Crit Care 2005; 9:R631-R635
CVIC – ASSOCIATE INFECTIONS
EPIDEMIOLOGY
• RISK FACTORS FOR INFECTION
– Site of insertion
• PICC line
–
–
–
–
–
Considered low risk insertion site
Outpatient PICC lines – 0.4 per 1000 catheter days
Rates of infection in high risk patients rising
Safdar and Maki – 2.1 per 1000 catheter days
PICC lines more vulnerable to thrombosis, dislodgement
Safdar N, Maki DG. Chest 2005; 128:489-495
CIVC – ASSOCIATED INFECTIONS
EPIDEMIOLOGY
• RISK FACTORS FOR INFECTION
– Duration of catheterization
– Inexperience of the operator
Physician’s experience
(no. of insertions)
No. of
catheters
No. of
infections (%)
< 10
56
11 (20)
10 – 25
44
8 (18)
26 – 50
25
3 (12)
51 – 100
25
2 (8)
> 100
19
0 (0)
Armstrong CW, Mayhall CG, Miller KB, et al. J Infect Dis 1986; 154:808-816
CIVC – ASSOCIATED INFECTIONS
EPIDEMIOLOGY
• RISK FACTORS FOR INFECTION
– Ineffective insertion site antisepsis
• Chlorhexidine the agent of choice
– 2% aqueous or 2% tincture
– More effect than povidone-iodine or alcohol
– 0.5% tincture of chlorhexidine is no more effective than
alcohol
Maki DG, Ringer M, Alvarado CJ. Lancet 1991; 338:339-343.
Humar A, Ostromecki A, Direnfeld J, et al. Clin Infect Dis 2000; 31:1001-1007.
CIVC – ASSOCIATED INFECTIONS
EPIDEMIOLOGY
• RISK FACTORS FOR INFECTION
– Failure to use appropriate insertion technique
– Appropriate technique is maximal sterile
barrier precautions
– Use of a topical antibiotic ointment or cream
may result in fungemia
Raad II, Hohn DC, Gilbreath BJ, et al. Infect Control Hosp Epidemiol 1994; 15:231-238.
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Surveillance
– Clinical – check insertion sites for signs of
inflammation, ask patients about pain
• Encourage patients to report pain, discomfort at
•
•
insertion site to healthcare providers
Record operator, date and time of catheter
insertion and dressing changes on a standard form
Do not routinely culture catheter tips
CDC. MMWR 2002; 51 (No. RR-10): 1-36.
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Surveillance
– Epidemiologic
• Count catheter days
• Calculate cases of primary bacteremia per 1000
•
catheter days
This is how rates for public reporting of bacteremia
will be reported
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Hand hygiene is necessary before sterile
gloves are donned and after they are
doffed
• Choose CIVC with least ports needed for
care of the patient
CDC. MMWR 2002; 51 (No.RR-10): 1-36.
McGee DC, Gould MK. N Engl J Med 2003; 348:1123-1133.
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Insertion site selection
– Subclavian
– Internal jugular
– Femoral
– Site selection based on the relative risks for
infectious vs mechanical complications
Lorente L, Henry C, Martin MM, et al. Crit Care 2005; 9:R631-R635
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Type of catheter – Coated with
antimicrobial agents or not
• Types of coated catheters
– Chlorhexidine – silver – sulfadiazine – 4
studies
• All showed decreased rate of catheter colonization
• Only one showed a significant decrease in catheter
–associated bacteremia
Maki DG, Stolz SM, Wheeler S, Mermel LA. Ann Intern Med 1997; 127:257-266.
Rupp ME, Lisco SJ, Lipsett PA, et al. Ann Intern Med 2005; 143:570-580.
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Types of coated catheters
– Minocycline – rifampin coated catheters
• Significant reduction in catheter colonization and
bacteremia compared to uncoated catheters
• Significantly greater reduction in catheter
colonization and bacteremia when compared with
a chlorhexidine – silver sulfadiazine coated
catheter
Raad I, Darouiche R, Dupuis J, et al. Ann Intern Med 1997; 127:267-274.
Darouiche RO, Raad II, Heard SO, et al. N Engl J Med 1999; 340:1-8.
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Should catheters coated with antimicrobials
be used?
– More expensive than uncoated catheters
– May select for antimicrobial resistance
– May be used to cover up poor aseptic
technique
– May have limited effect on reducing
bacteremias
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Catheter insertion
– Maximal sterile barrier precautions
• Cap
• Mask
• Sterile Gown
• Sterile gloves
• Large sterile drape
– Skin asepsis – 2% chlorhexidine
– Sterile sleeve to protect pulmonary artery
catheters
Raad II, Hohn DC, Gilbreath J, Infect Control Hosp Epidemiol 1994; 15:231-238
CDC. MMWR 2002; 51(No. RR-10): 1-36
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Maximal sterile barrier precautions
– PICC lines
– Guidewire exchanges
• Trainees must be supervised by personnel
who have been trained and exhibit
competency in the insertion of CIVCs
• REMOVE CIVCs AS SOON AS POSSIBLE
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Catheter insertion site care
– Replace catheter site dressings
• Damp
• Loosened
• Soiled
• When dressing removed for site inspection
– Dressing changes
• Gauze and tape – every 2 days
• Transparent – every 7 days
CDC. MMWR 2002; 51(No. RR-10): 1-36
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Should CIVCs be changed to a new site or
be changed over a guidewire at routine
intervals to prevent CIVC – associated
infections?
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
– No
• Four randomized clinical trials indicated that
•
•
routine rotation of CIVCs does not significantly
reduce infection rates
Includes guidewire exchanges
Also applies to hemodialysis catheters
Uldall PR, Merchant N, Woods F, et al. Lancet 1981; 1:1373
Powell C, Kudsk KA, Kulich PA, et al. J Parenter Enteral Nurt 1988; 12:4621-464
Eyer S, Brummitt C, Crossley K, et al. Crit Care Med 1990; 18:1073-1079
Cobb DK, High KP, Sawyer RG, et al. N Engl J Med 1992; 327:1062-1068
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Guidewire exchanges
– May be used to replace a malfunctioning
catheter when no evidence of infection
– Must never be used to replace an infected
catheter
– Use a new set of sterile gloves before
handling the new catheter
CIVC - ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Infection control bundle for the prevention
of catheter-associated bloodstream
infection
– Prospective observational study
– Multicenter study - 103 ICUs
– 1981 ICU months
– 375,757 catheter-days
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med 2006; 355:2725-2732
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Infection control bundle
– First step
• Implement use of daily goals sheet to improve
•
•
clinician-to-clinician communication*
Instituted program to control ventilator-associated
pneumonia†
Comprehensive unit-based safety program‡§
*Pronovost P, Berenholtz S, Dorman T, et al. J Crit Care Med 2003; 18:71-75
†Berenholtz
SM, Milanovich S, Faircloth A, et al. Jt Comm J Qual Saf 2004; 30:195-204
‡Pronovost
P, Weast B, Rosenstein B, et al. J Patient Saf 2005; 1:33-40
§Pronovost
PJ, Weast B, Bishop K, et al. Jt Comm J Qual Saf 2004; 30:59-68
CIVC – ASSOCIATED INFECTIONS
PREVENTION AND CONTROL
• Interventions – evidence based
– Hand washing
– Maximal sterile barrier precautions
– Chlorhexidine preparation of the skin
– Avoiding femoral site, if possible
– Removing unnecessary catheters
CIVC – ASSOCIATED INFECTIONS
•
PREVENTION AND CONTROL
Promoters of the interventions
–
–
–
–
Clinician education
Central line cart
Infection control procedures checklist
Providers stopped if not following infection control
procedures
– Feedback of rates to teams
– Letters to CEOs of hospitals to stock chlorhexidine
CIVC – ASSOCIATED INFECTIONS
Table 3. Rates of Catheter-Related Bloodstream Infection from Baseline (before
Implementation of the Study Intervention) to 18 months of Follow-up.*
Study Period
No. of
ICUs
No. of Bloodstream Infections per 1000 Catheter-Days
Overall
Teaching
Hospital
Nonteaching
Hospital
<200 Beds
>200 Beds
median (interquartile range)
Baseline
55
2.7 (0.6-4.78)
2.7 (1.3-4.7)
2.6 (0-4.9)
2.1 (0-3.0)
2.7 (1.3-4.8)
During
implementation
96
1.6 (0-4.4)†
1.7 (0-4.5)
0 (0-3.5)
0 (0-5.8)
1.7 (0-4.3)†
0-3 mo
96
0 (0-3.0)‡
1.3 (0-3.1)†
0 (0-1.6)†
0 (0-2.7)
1.1 (0-3.1)‡
4-6 mo
96
0 (0-2.7)‡
1.1 (0-3.6)†
0 (0-0)‡
0 (0-0)†
0 (0-3.2)‡
7-9 mo
95
0 (0-2.1)‡
0.8 (0-2.4)‡
0 (0-0)‡
0 (0-0)†
0 (0-2.2)‡
10-12 mo
90
0 (0-1.9)‡
0 (0-2.3)‡
0 (0-1.5)‡
0 (0-0)†
0.2 (0-2.3)‡
13-15 mo
85
0 (0-1.6)‡
0 (0-2.2)‡
0 (0-0)‡
0 (0-0)†
0 (0-2.0)‡
16-18 mo
70
0 (0-2.4)‡
0 (0-2.7) ‡
0 (0-1.2)†
0 (0.0)†
0 (0-2.6)‡
After implementation
*Because the ICUs implemented the study intervention at different times, the total number of ICUs contributing data for each period varies.
Of the 103 participating ICUs, 48 did not contribute baseline data. P values were calculated by the two-sample Wilcoxon rank-sum test.
†P<0.05
for the comparison with the baseline (preimplementation) period.
‡P<0.002
for the comparison with the baseline (preimplementation) period.
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med 2006; 355:27252732