catheter-related bloodstream infections wanida paoin thammasat university
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Catheter-related bloodstream infections
Wanida PaoinThammasat University
Catheter-related bloodstream infections Incidence in PICU: 7.3-13.8 central lin
- e associated bloodstreaminfections/1000 cath days
Risk factors premature < 1000 g low immunity multiple CVC long term CVC insertion r educed ICU Nurse:Patient Ratio - - using Non ICU Trained Nurses in ICUs
From: Mermel L , Rhode Island Hospital
POTENTIAL ROUTES OF INFECTION
Strategies for Prevention of Catheter-Related Infections Quality Assurance and Continuing Education Surveillance
Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis,
Manifestations suggesting local or BSI, the dressing should be removed to allow thorough examination of the site
Hand Hygiene and Aseptic Technique Maximal sterile barrier precautions (e.g., cap, mask,
sterile gown, sterile gloves, and large sterile drape) d uring the insertion of CVCs
Hand hygiene before and after inserting, replacing, accessing, or dressing an intravascular catheter .
Washing hands with conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams .
Catheter Insertion
Efficacy of Barrier Precautions During CVC Insertion
Barrier precautionsMinimal Maximal
Cath colonization 7.2% 2.3%*
Cath sepsis 3.6% 0.6%*
* p<0.05
1994Raadetal,ICHE
Strategies for Prevention of CR Infections Site of Catheter Insertion
Femoral catheters: relatively high colonization rates, higher risk for deep venous thrombosis
Internal jugular cath: higher risk for infection than those inserted into a subclavian or femoral vein
Catheter Placement
Prospective, Randomized, Multicenter Stud y of Fem oral vs Subclavian CVC Insertion
Femoral cath Subclavian cath Cat h col oni zat i on 14.2%
2.2% Cat h sepsi s 4.4%
1.5%Cath t hrombosi s 6% 0%
M MMMMM MM MM MM M M 2001
Strategies for Prevention of CR Infections Skin Antisepsis
2% aqueous chlorhexidine gluconate lowered BSI rates compared with site preparation with 10% povidone-iodine or 70% alcohol
Cutaneous Antisepsis
CR Infection Prevention w/ Chlorhexidine
Cath colonization CRBSI CHX Control CHX Control
23. % 7%*† 0.5% 26 91. % (Maki ` )2% 7 *% 06. %
06 93. % (Sheehan` )4.7% 9.3%* 0 05 95. % (Garland ` )12/103 3110/ 3* 0110. / 3 0910. / 3 (`96)34% 27 *%3510. / 3 4110. / 3 (`97)
red values = <0.05 *= povidone iodine † = alcohol
Strategies for Prevention of CR Infections Catheter Site Dressing Regimens
Transparent, semipermeable polyurethane dressings: R eliably secure the device, P ermit continuous visual inspection of the catheter
site, P ermit patients to bathe R equire less frequent changes than do standard ga
uze A meta-analysis: The risk for CRBSIs did not differ
between the groups using transparent dressings versus groups using gauze dressing.
If blood is oozing from the catheter insertion site, gauze dressing might be preferred .
Strategies for Prevention of CR Infections Catheter Site Dressing Regimens
Chlorhexidine-impregnated sponge (Biopatch ™) placed over the site A multi-center study: reduced the risk
for catheter colonization and CRBSI . No adverse systemic effects resulted
from use of this device.
- Chlorhexidine Impregnated Sponge
- Chlorhexidine Impregnated Sponge (Biopatch)at C ath InsertionSite
- CI sponge Control 665 736
Cathcolonization 16% 2 9 %* CRBSI 12. % 33*
-* 062 049078RR . ( . . ) † -038016089RR . ( . .
Maki, Mermel, et al ICAAC 2000
Strategies for Prevention of CR Infections Antimicrobial/Antiseptic
Impregnated Catheters and Cuffs Chlorhexidine/Silver sulfadiazine. Minocycline/Rifampin. Platinum/Silver Silver cuffs
- Chlorhexidine Impregnated Sponge - -Chlorhexidine SilverSulfadiazine Impregna
ted 2 ndGenerationCatheters
CHSSControl#CVCs 368 374MMMM MMMMMMMM 7d 7dCath col oni z 64 12.8%
910( / 3CD) 1910( / 3CD)†
†p=0.006 2001Ruppetal,ICAAC
- -Minocycline Rifampin Impre gnated Catheters
- -Minocycline Rifampin Impregnated vs 1stGen - -Chlorhexidine Silver Sulfadiazine Impr
egnated CVCs*
-M R CHSSDuration 6 d 7dCRBSI 03. % 3 4. % -01 006(RR . , CI . )
- *M R impregnation intraluminal &extralumi nal, CHSS impregnation only extraluminal 1999Darouicheet al, NEM J
Silver Iontophoretic Catheter
-Silver Iontophoretic Control
CRBSI 31. % 8%*CRBSI 1% 39. %†
Combined OR -0.23 (0.07 0.66)
* 2001Bong et al, ICAAC†- 2001IbanezNollaetal,I CAAC
Silver Iontophoretic Catheter
Catheter type Caths w/ significant growth
Control 100%Chlorhexidine/silver
sulfadiazine 6 7 % Silver iontophoretic 20%
insertion site of lab animals inoculated w/ S. aureus, caths quantitatively cultur ed at 7 d
1996
Strategies for Prevention of CR Infections Antibiotic/Antiseptic Ointments
Povidone-iodine ointment Mupirocin ointment
Antibiotic Lock Prophylaxis Flushing and filling the lumen of the catheter
with an antibiotic solution and leaving the solution to dwell in the lumen of the catheter .
Heparin plus 25 micrograms/ml of vancomycin Vancomycin/ciprofloxacin/heparin combination Minocycline and ethylenediaminetetraraacetic
acid (EDTA )
Strategies for Prevention of CR Infections Anticoagulants
Prevent catheter thrombosis Heparin flush Heparin-bonded coating Warfarin
Strategies for Prevention of CR Infections Replacement of intravascular
catheters Replace CVCs if purulence is observed
at the insertion site Replace CVCs if the patient is
hemodynamically unstable and CRBSI is suspected
Do not use guidewire techniques to replace catheters in patients suspected of having catheter-related infection
Strategies for Prevention of CR Infections Replacement of administration sets
Replace administration sets, and add-on devices, no more frequently than at 72-hour intervals, unless catheter-related infection is suspected
Replace tubing used to administer blood, blood products, or lipid emulsions within 24 hours
If the solution contains only dextrose and amino acids, the administration set does not need to be replaced more frequently than every 72 hours
Strategies for Prevention of CR InfectionsQuality Assurance and Continuing Education
+++
A subclavian site instead of a jugular or femoral site
++
Hands hygiene, m aximal barrier precaution s f or CVCi nsert i on
+++
Changing administration sets at appropriate intervals
+++
Remove caths after intended use +++
- Chlorhexidine containing cutaneous antiseptics
+
Transparent, semipermeable polyurethan e dressings
+
Antimicrobial/Antiseptic Impregnated Catheters and Cuffs
+,+
Anticoagulants +
Antibiotic/Antiseptic Ointments -