Transcript PowerPoint slides

On the CUSP: STOP BSI
The Role of Technology in CLABSI Prevention
© 2009
Learning Objectives
• To review considerations for picking new technology
to reduce CLABSI
• To review currently available data regarding the
efficacy of several technologies in reducing CLABSI
– Chlorhexidine bathing
– Chlorhexidine impregnated sponges
– Antiseptic-coated catheters
© 2009
Considerations When Picking
New Technology
• Is technology needed to reduce CLABSI in your units?
– Has best practice been fully adopted?
• CDC guidelines recommend consideration if rates
remain high after implementation of basic prevention
strategies
• Risk of overreliance on technology
– Exercise caution in implementing new technology if rates
rise after implementing best practice
• First go back and make sure they are doing what they
are supposed to be doing
© 2009
Considerations When Picking
New Technology
• When are CLA-BSIs occurring?
– < ~10 days often associated with extraluminal
contamination of the exit site
– > ~10 days often associated with intraluminal
contamination via hub or connector
– Best approach is prevention of both extraluminal and
intraluminal contamination
• What are central line use patterns in the unit?
– Removed within 24-72 hours or in for long periods of time?
• May need patient-level protocol to direct technology to
those at higher risk for CLABSI
© 2009
Chlorhexidine Bathing
• Theory: decolonization of skin decreases organisms
that might contaminate the insertion site at the time
of placement and while the line is in situ
– May also reduce hub colonization if reduce overall
microbial burden
– May offer the additional advantages of
• Decreasing rate of blood culture contamination
• Decreasing rates of other organisms (MRSA, VRE, etc.)
Moro ML et al. Infect Control Hosp Epidemiol. 1994;15:253-64.
Vernon MO et al. Arch Intern Med. 2006;166:306-12.
© 2009
Chlorhexidine Bathing: Evidence
• 52 week crossover study in 2
MICUs in one center
• Chlorhexidine (CHG)
washcloths vs. soap & water
bath daily
• Primary BSI rate
– CHG: 4.1 infections/1000
patient days
– Soap & water: 10.4
infections/1000 patient
days
– Incidence difference 6.3
(95% CI 1.2-11.0)
Bleasdale SC et al. Arch Intern Med. 2007;167:2073.
© 2009
CHG Impregnated Sponge
(Biopatch)
• Theory: decolonization of the catheter insertion site
decreases chance of extraluminal catheter infection
• Considerations
– Learning curve for optimal application—may initially have
extra manipulation of insertion site; incorrect application, etc.
– Insertion site not visible
– No affect on hub
© 2009
CHG Impregnated Sponge
• RCT comparing Biopatch to standard dressings
• Lines included: arterial catheters and central venous
catheters; none antiseptic or antimicrobial coated
• Outcome: Catheter-related infection
– Catheter-related bloodstream infection
• ≥ 1 positive peripheral blood culture, a quantitative catheter
tip culture growing the same organism or differential time to
positivity of blood cultures ≥ 2 hours, and no other source
– Catheter-related clinical sepsis without bloodstream
infection
• Fever, positive cath tip, pus at line site, and no other source
Timsit JF et al. JAMA. 2009;301:1231-41.
© 2009
CHG Impregnated Sponge
• 1636 catheters
• Median duration of insertion:
6 days
• Major catheter-related
infection rate
– CHG sponge: 0.6
infections/1000 catheter
days
– Standard dressing: 1.4
infections/1000 catheter
days
– Hazard ratio 0.39 (95% CI
0.16-0.93)
• 8 episodes of contact
dermatitis in sponge group
© 2009
Coated Catheters
• Theory: decrease extraluminal catheter colonization
and intraluminal colonization if interior surface of
catheter also coated
• Types
– Heparin + benzalkonium bonded
(activity on inner and outer surface)
– Silver + platinum coating on inner & outer surface
– Chlorhexidine and silver sulphadiazine
• Outer ± inner coating
– Antibiotic coating on outer & inner surface:
minocycline and rifampin
Casey AL et al. Lancet Infect Dis. 2008;8:763-76
Gilbert RE and Harden M. Curr Opin Infect Dis. 2008;21:235
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1st Generation Chlorhexidine and Silver
Sulphadiazine vs. Standard
RR 0.68 (0.47-0.98)
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2nd Generation Chlorhexidine and Silver
Sulphadiazine vs. Standard
OR 0.47 (0.20-1.10)
• No additional benefit of outer and inner coating
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Minocycline/Rifampin vs. Standard
RR 0.29 (0.16-0.52)
Minocycline/Rifampin vs. Chlorhexidine
RR 0.12 (0.02-0.67)
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Coated Catheters: Considerations
• Heparin and Minocycline/Rifampin coatings
appear to be more effective than other coatings
• Limited data regarding:
– Risk of development of minocycline or rifampin
resistance
– Risk of selection of fungal organisms
• In a different pooled analysis:
– Treatment effect seen with catheters in place for 5-12
days but not 13-20 days
– Treatment effect seen for femoral and internal jugular
insertion sites but not in studies using exclusively
subclavian insertion sites
Hockenhull JC et al. Health Technol Assess. 2008;12(12).
© 2009
Coated Catheters: Considerations
• Decision to use coated catheters depends on
local factors
– Extent of adoption of best practice
– Duration of catheterization
• May need to make protocol based on expectations
of duration of catheterization at individual patient
level rather than unit level
– Usual sites of catheters
– Concerns about rifampin resistance
• May choose not to use catheters with rifampin
coating in patients with endovascular hardware
© 2009
Other Technologies
• Antiseptic hubs
– No published clinical data supporting efficacy
• Dressings containing chlorhexidine (e.g.
Tegaderm™ CHG dressing)
– No published clinical data supporting efficacy
• Antimicrobial lock solutions
– Not recommended for routine use
– Could be considered in individual patients with limited
venous access & history of recurrent CLABSI or in patients
at risk for severe sequelae of CLABSI (e.g. new prosthetic
heart valve)
© 2009
Needleless Intravenous
Access Devices
• “Do not routinely use positive-pressure needleless
connectors with mechanical valves before a
thorough assessment of risk, benefits, and
education regarding proper use (B-II)
– Routine use of the currently marketed devices that are
associated with an increased risk of CLABSI is not
recommended”
Marschall J et al, Infect Control Hosp Epidemiol 2008;29:S22-S30
© 2009
Action Items
• Assess compliance with best practice for CLABSI
prevention in your institution
• If new technologies are desired, evaluate which
ones are most appropriate for your patients
• Monitor for any unexpected effects associated
with adoption of new technologies
© 2009