The ideal management of the exit site: antisepsis, dressing,

securement

Giancarlo Scoppettuolo Catholic University, Rome

Targeting Zero

Targeting Zero is the philosophy that every

healthcare institution should be working toward a

goal of zero healthcare-associated infections

(HAIs). While HAI prevention is challenging and

complex, APIC believes that all organizations

should set the aspirational goal of elimination and

strive for zero infections. Every HAI impacts the

life of

VAD SELECTION

AND HEALTHCARE WORKERS

EDUCATION AND TRAINING

INSERTION

CARE OF EXITE SITE DISINFECTION OF CATHETER HUBS,

CONNECTORS AND INJECTION PORTS

CRBSI Prevention

Prevention of extra and intraluminal colonization

CHG Eluting Disk (applied after catheter insertion and with every dressing change)

CHG Skin Preparation (applied before catheter insertion and with every dressing change)

Swabable Needleless Connector

Intraluminal

colonization

Extraluminal

colonization

Modified, Courtesy of R. Garcia, MD

Why Proper CL Maintenance is Critical

Average Central Line Days

0 1 2 3 4 5 6 7

Insertion

Period

= 30 min

= 0.3%

Maintenance Period = 167.5h = 99.7%

Modified, courtesy of J. LeDonne, MD

Manteinance of Exit Site

• Which antiseptic?

• Which Dressing?

• When to change?

• Is there any indication for chlorhexidine impregnated dressing?

• Which securement?

Guidelines for CRBSI Prevention

• CDC Atlanta 2002

• RCN 2005

• INS 2006

• BCSH 2006

• EPIC 2007

• SHEA/IDSA 2008

• ESPEN 2009

• RCN 2010

• INS 2011

• CDC 2011

WHICH ANTISEPTIC?

Advantages of chlorhexidine

• Bactericidal

• Broad activity against Gram positive and Gram negative bacteria, facultative anaerobes, yeasts and some lipid-enveloped viruses, including HIV (but not sporicidal)

• Rapid onset of activity

• Prolonged antimicrobial effect

• Synergistic effect with alcohol

• Lack of inactivation when exposed to blood and serum

© Wil liams & Wilkins 1996. All Rights Reserved. Published by Lippincott Williams & Wi lkins, Inc. 5

Figure 1

Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Mimoz, Ol ivier; Pieroni, Laurence; Lawrence, Christine; Edouard, Alain; Costa,

Yannick; Samii, Kamran; Brun-Buisson, Christian Cri tica l Care Medicine. 24(11):1818-1823, November 1996.

Figure 1 . Time to occurrence of catheter colonization in

the chlorhexidine group (closed squares) and the povidone iodine group (open squares). The risk of catheter colonization was significantly greater in the

povidone iodine group than in the chlorhexidine group (p < .01, Log-rank test).

Premature Infant Skin

“Shaping the Future of Pediatric Vascular Access 2012”

• Stratum corneum poorly developed or absent

• Thin epidermis

• Dermis not fully

formed and deficient of structural proteins

Full Term Infant Skin

“Shaping the Future of Pediatric Vascular Access 2012”

Healthy infants

• Well-formed stratum corneum…..note multiple layers

• Thick epidermis

• Structural proteins present in the dermis

CHG Safety in Premature Infants

• Issues: systemic absorption, skin toxicity • Concern: hexachlorophene caused neurotoxicity • Hexachlorophene: – Bacteriostatic – disrupts bacterial cell wall – slow onset efficacy

• CHG: –

–

–

–

Bacteriocidal increases cell membrane permeability rapid onset binds to SC proteins

Chapman A, et al. J Perinatol (2012); 32(1):4-9 “Shaping the Future of Pediatric Vascular Access 2012”

CHG versus PI in Neonates

• Pilot parallel comparison: 2% CHG (alcohol) vs. 10% Povidone Iodine

• 48 neonates ≥ 1500 g (~ 30wks GA) and ≥ 7 days

• No catheter related BSIs in either group

• No dermatitis - CHG or PI (i.e., ≥ 2,no pink-red all area)

• CHG absorption occurred:

• 7 of 10 had blood CHG between 13 – 100 ng/ml • No neurotoxicity

Studies needed in younger preterms

“Shaping the Future of Pediatric Vascular Access 2012”

Garland J, et al. J Perinatol (2009); 29:808-813

CHG Use in NICUs

• A survey of 90 NICU training units found:

55

27

28

28 55

Used CHG, central venous catheter care

No restrictions

Restrictions: GA, actual age or birth weight

Reported adverse reactions, all skin related 17 burns, 2 erosions, 9 erythema Had concerns: Off label use, Immature skin, Limited

safety data Tamma P, et al. Infect Control Hosp

Epidemiol (2010);31(3):846-849 “Shaping the Future of Pediatric Vascular Access 2012”

2010

WHICH DRESSING? AND WHEN TO CHANGE?

Advantages of Semipermeable Transparent Dressing

• Visibility of insertion site

• Better stabilization of catheter, avoiding “in and out” movements

• Better protection against secretions, mostly if catheter’sexit site is near tracheostomy or oral and nose secretions

• Longer time between dressing changes (7 days vs 2 days)

Is there any indication for chlorhexidine impregnated

dressing?

WHICH SECUREMENT?

Disadvantages of sutures

• Sutures disrupt the skin around the catheter exit site, causing inflammation and heavy colonization

• Bad securement of catheter, with movement of “in and out” and increased risk of thrombosis and infection

• Patient discomfort

• Risk of sharps injury to healthcare workers from inadvertent needlestick injury

RCN 2005

RCN 2010

INS 2006

INS 2011

BCSH 2006

CDC 2011

Conclusions

• A proper care of the catheter exit site is critical for CRBSI prevention

• The preferred antiseptic for skin during the dressing change is 2% chlorhexidine (preferably in isopropyl alcohol)

• To cover and protect the exit site , you can use gauze and tapes or semipermeable transparent dressing, taking into account the differences in terms of replacing (2 vs 7 days)

• To secure the catheter, use sutureless devices instead of sutures.

Last Conclusion…

• All this works and is really effective not as an isolate strategy, but only if it is part of a bundle of recommendations…

• Hands hygiene and maximal barrier precautions

• Ultrasound guided insertion

• Use of 2% chlorhexidine, for skin antisepsis before insertion and for continous or discontinous antisespis of exit site

• Use of sutureless devices for catheter securement, whenever possible

• Use of transparent dressings, whenever possible

• Prompt removal of unnecessary lines

Targeting zero CLABSI in patients with

PICC lines: a case-control study

G. Scoppettuolo§, L. Dolcetti§, C. Taraschi§, C. Chiarini§,

C. Donato§, S. Lardo§, A. La Greca*, M. Pittiruti* § Clinic of Infectious Diseases, * Dpt. of Surgey, Catholic

University, Rome

AVA 2011

Results CASES

( I nfect ious

Diseases)

CONTROLS

( Other w ards)

P

CRBSI 0 14 < 0.001

CLABSI / 1 0 0 0 catheter days 0 2.66 < 0.001

Diagnosis

· DTP · Blood culture + t ip

culture

10 4

Median t im e for CLABSI

onset

NA 21+12

Et iology of CLABSI · Candida albicans

· Candida parapsilosis

· CONS · S. aureus

· E. coli

· K. pneum oniae

NA 3

2

3 1

3

2

CLABSI related deaths 0 0 NS

Thank you for your attention!

Giancarlo Scoppettuolo, MD

Catholic University

“A. Gemelli” Hospital, Rome

E-mail: g.scoppettuolo@rm.unicatt.it

Web: www.gavecelt.info

www.evanetwork.info

www.policlinicogemelli.it