Catheter-Associated Catheter-Associated Bloodstream InfectionsBloodstream Infections

Loreen A. Herwaldt, MD

4JCE Catheter-Associated 4JCE Catheter-Associated Bloodstream Infection RateBloodstream Infection Rate

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Month

This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity &mortality

SICU Catheter-Associated SICU Catheter-Associated Bloodstream Infection RateBloodstream Infection Rate

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Month

This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity &mortality

MICU CVC-Associated BSIMICU CVC-Associated BSI

0

5

10

15

20

25

30

35

Device-related BSI per 1000 Catheter-days

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Month

This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity &mortality

Central Venous CathetersCentral Venous Catheters

• A CVC is an intravenous catheter whose tip ends in the central venous system.

• CVC’s are commonly inserted through the jugular, subclavian, femoral, cephalic, & basilic veins.

• Indications– Administer IV fluids, medications, blood products– Total parenteral nutrition (TPN)– Hemodynamic monitoring

Types of Central Venous Types of Central Venous CathetersCatheters

• Long-term (>4-6 weeks): totally implantable port, tunneled catheters

• Intermediate (>2 weeks, but <6 weeks): peripherally inserted central catheter (PICC)

• Short-term (<2weeks): non-tunneled central catheter (e.g., triple lumen catheter)

• Short-term, non-tunneled CVC Account for 90% of CA-BSI

CVC-associated CVC-associated Bloodstream InfectionsBloodstream Infections

• 200,000 (80,000 ICU) CVC-associated BSI in the hospital per year.

• 10-20% attributable mortality w/ CVC infections in the ICU.

• Costs of $3,700-$28,000 per line infection and total of $2.3 billion per year in US.

Median Catheter-associated BSI Median Catheter-associated BSI Rates by ICU Type in USRates by ICU Type in US

Am J Infect Control 2001; 29: 404-21

0

2

4

6

8

10

12

Coronary

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Medical

Surgical

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days

Sources of Catheter-associated Sources of Catheter-associated Bloodstream InfectionsBloodstream Infections

CONTAMINATION OF DEVICE PRIOR TO INSERTION

Extrinsic >>Manufacturer

SKIN ORGANISMS Endogenous Flora HCW hands Contam Disinfectant Invading Wound

CONTAMINATIONOF

CATHETER HUB

Extrinsic (HCW) Endogenous (Skin)

CONTAMINATED INFUSATE Fluid Medication

Extrinsic Manufacturer

Vein

HEMATOGENOUSFrom Distant Local Infection

Fibrin Sheath, Thrombus

Skin

Prevention of Catheter-Associated Prevention of Catheter-Associated Bloodstream Infections:Bloodstream Infections:

Central venous catheter insertion

Reducing Risk of CVC Reducing Risk of CVC InfectionsInfections

• Do not routinely replace CVC without indication (NEJM 1992;327:1062-8).

• Remove CVC as soon as possible.

• Strict adherence hand hygiene & aseptic technique during CVC insertion.

• Use subclavian vein first, IJ second, and femoral vein last (if possible).

• Replace lines placed under emergency circumstances within 24 hours.

Reducing Risk of CVC InfectionsReducing Risk of CVC Infections

• Always use maximum sterile barrier precautions– Sterile gloves and gown – Nonsterile masks and hats– Large sterile drapes that cover wide area

• Prep site with chlorhexidine gluconate (CHG)– Prep with side to side scrub for 30 seconds– Let dry for 30 seconds

Prevention of Central Venous Prevention of Central Venous Catheter-Related Infection by Using Catheter-Related Infection by Using Maximal Sterile Barrier Precautions Maximal Sterile Barrier Precautions

During InsertionDuring Insertion

Control MSB

N 167 176

% Colonization 7.2% 2.3%*

Colonization per 1000 catheter days

1.0 0.3*

Sepsis per 1000 catheter days

0.5 0.08*

*p<0.05 vs. controlRaad et al, Infect Control Hosp Epidemiol 1994;15:231-238

Prevention of Catheter-Associated Prevention of Catheter-Associated Bloodstream Infections:Bloodstream Infections:

Central venous catheter care

Reducing Risk of CVC Reducing Risk of CVC InfectionsInfections

• Insertion site should be dressed immediately after placing catheter.

• Do not use topical antibiotic ointment or creams at insertion site.

• Transparent dressing should be changed weekly, OR

• Dressing should be changed if becomes damp with fluids of any type, soiled, or is non-occlusive.

Site Care for CVCsSite Care for CVCs

• Change dressing when wet, soiled or bloody

• Change transparent dressings q 7 days

• Change gauze dressings q 2 days

Site Care for CVCsSite Care for CVCs• Perform hand hygiene.• Assemble supplies.• Using clean gloves, remove old dressing

down to the insertion site. • Pull the dressing toward the insertion site of

the catheter (this helps prevent pulling out the line).

• Remove the remainder of the dressing by pulling off the dressing toward the insertion site

Site Care for CVCsSite Care for CVCs• Observe site for erythema, exudate or

other signs of infection; notify MD if present.

• Examine sutures anchoring line to ensure they are intact.

• Put on sterile gloves & palpate the area for tenderness, swelling or fluctuance.

Site Care for CVCsSite Care for CVCs• Clean area around site with CHG in side

to side motion

– Allow CHG to dry for 30 seconds.

– Do not fan or blow on the site.

• Apply appropriate dressing.

• Securely anchor catheter to skin.

• Record date, time and initials on tape or dressing.

Maintaining IV SetsMaintaining IV SetsChange:• IV tubing q 96 hours, except

– Blood tubing q 24 hours– Lipid tubing q 24 hours– Propofol tubing q 12 hours

• IV fluids q 96 hours or when meds outdate

• Transducers, stopcocks, flush devices, and flush solutions q 96 hours

Reducing Risk of CVC Reducing Risk of CVC InfectionsInfections

• Cleanse outside of hubs with alcohol before each use – allow to air dry.

• Use TPN only when appropriate & administer through dedicated port.

Reducing Risk of CVC Reducing Risk of CVC InfectionsInfections

Guidewire exchanges of CVC

A Controlled Trial of Scheduled A Controlled Trial of Scheduled Replacement of Central Venous and Replacement of Central Venous and

Pulmonary-Artery CathetersPulmonary-Artery CathetersCobb et al (NEJM 1992;327:1062-8)Cobb et al (NEJM 1992;327:1062-8)

• Routine CVC change Q 3 day by GWX• Routine CVC change Q 3 day to new site• CVC change by GWX only when CVC

change indicated• CVC change to new site only when CVC

change indicated.

Randomized pts. to one of four study Groups:Randomized pts. to one of four study Groups:

A Controlled Trial of Scheduled A Controlled Trial of Scheduled Replacement of Central Venous and Replacement of Central Venous and

Pulmonary-Artery CathetersPulmonary-Artery CathetersCobb et al (NEJM 1992;327:1062-8)Cobb et al (NEJM 1992;327:1062-8)

• No difference in infection rate in pts. undergoing scheduled change vs. those undergoing line change when indicated.

• Higher rate CR-BSI in patients undergoing GWX (p=0.06).

• High rate of mechanical complications in patients undergoing new stick (p=0.005).

Guidewire ExchangeGuidewire Exchange

• Routine GWX of lines as prophylaxis against CVC infection not supported by literature.

• Acceptable when line infection not suspected.

• Do not use guidewire techniques to replace CVC for which there is strong suspicion of CVC-associated infection.

• Tunneled CVC should never be changed over a guidewire.

Recommended Procedure for Recommended Procedure for Guidewire Exchange of CVCGuidewire Exchange of CVC

• Wide skin prep as with all CVC placements.

• Double glove and use MSB technique.

• Once old line removed, remove outer gloves prior to handling new line.

• Use new sterile caps on ports & new IV tubing.

Blood Cultures and Central Blood Cultures and Central Venous Catheter InfectionsVenous Catheter Infections

• Diagnosis of catheter-associated bloodstream infection depends on a positive blood cx

• Contamination of cultures can result in unnecessary use of antibiotics and possible CVC removal

Blood Cultures and Central Blood Cultures and Central Venous Catheter InfectionsVenous Catheter Infections

• Peripheral sites are preferable to CVC hubs for obtaining blood cx.

• Antiseptic should be applied to both skin or catheter hub, and blood cx bottle/ tube (air dry – no blowing or fanning).

• Drawing less than the correct amount (8-10 mls) into a blood cx bottle reduces culture sensitivity.