What’s New in the 2011 Guideline What’s New in the 2011 Guideline for Preventing Catheter Related for Preventing Catheter Related
BSI?BSI?
Naomi P. O’Grady, MDNaomi P. O’Grady, MD
Critical Care Medicine DepartmentCritical Care Medicine Department
National Institutes of HealthNational Institutes of Health
I have no disclosures.I have no disclosures.
ObjectivesObjectives
Highlight some areas of controversy, Highlight some areas of controversy, including catheter site selection, including catheter site selection, antimicrobial locks, and chlorhexidine antimicrobial locks, and chlorhexidine impregnated sponge dressings impregnated sponge dressings
Discuss the recommendations in the Discuss the recommendations in the updated guidelineupdated guideline
Outline some of the data to support the Outline some of the data to support the new recommendationsnew recommendations
Clinical Infectious Diseases 2011; 52(9) e162-e193Clinical Infectious Diseases 2011; 52(9) e162-e193
Site SelectionSite Selection
Old RecommendationOld Recommendation
Use a subclavian site (rather than Use a subclavian site (rather than a jugular or a femoral site) in a jugular or a femoral site) in adult patients to minimize adult patients to minimize infection risk for non-tunneled infection risk for non-tunneled CVC placementCVC placement
Site SelectionSite Selection
Rather than focus on one specific site Rather than focus on one specific site to select, we now focus on one specific to select, we now focus on one specific site to avoid.site to avoid.
Avoid the femoral vein for central Avoid the femoral vein for central venous access in adultsvenous access in adults
Femoral site associated with greater Femoral site associated with greater risk of infection and DVTrisk of infection and DVT
Merrer; JAMA, 2001Parienti; JAMA, 2008
JAMA, 2001; 286:700-07
Catheter ComplicationsCatheter Complications
Randomized patients to femoral (145) vs Randomized patients to femoral (145) vs subclavian (144)subclavian (144)
8 ICU’s; 3 years8 ICU’s; 3 years Mechanical complications similar in both Mechanical complications similar in both groupsgroups
Infection and thrombosis higher in Infection and thrombosis higher in femoral groupfemoral group
Catheter ComplicationsCatheter Complications
Catheter ComplicationsCatheter Complications
* Thrombotic complications were 21% in femoral group Thrombotic complications were 21% in femoral group and 1.9% in subclavian group ( p<0.001) with 2 PE’sand 1.9% in subclavian group ( p<0.001) with 2 PE’s
JAMA 2008JAMA 2008
Femoral vs Jugular Femoral vs Jugular CatheterizationCatheterization
375 patients in each arm over a 3 year 375 patients in each arm over a 3 year periodperiod
Primary endpoint was colonization on Primary endpoint was colonization on removalremoval
Insertion complications, CR-BSI, and Insertion complications, CR-BSI, and thrombosis were secondary endpointsthrombosis were secondary endpoints
Mechanical ComplicationsMechanical Complications
Jugular catheters: longer insertion times, Jugular catheters: longer insertion times, more failed attempts and more crossovermore failed attempts and more crossover
Arterial punctures no different (5.1% vs Arterial punctures no different (5.1% vs 3.6%), although hematoma formation higher in 3.6%), although hematoma formation higher in jugularjugular
2 patients required intubation in jugular 2 patients required intubation in jugular groupgroup
1 patient required vascular surgery for 1 patient required vascular surgery for carotid artery insertioncarotid artery insertion
1 patient with acute leg ischemia required 1 patient with acute leg ischemia required limb amputationlimb amputation
Infectious ComplicationsInfectious Complications
JAMA 2008JAMA 2008
Controversy. . .Controversy. . .
JAMA 2008JAMA 2008
Skin AntisepsisSkin Antisepsis
Old RecommendationOld Recommendation
Disinfect clean skin with an Disinfect clean skin with an appropriate antiseptic. A appropriate antiseptic. A chlorhexidine-based preparation chlorhexidine-based preparation with >2% is preferred. with >2% is preferred. Alternatively, tincture of Alternatively, tincture of iodine, an iodophor, or 70% iodine, an iodophor, or 70% alcohol could be used.alcohol could be used.
New RecommendationNew Recommendation
Disinfect clean skin with an Disinfect clean skin with an appropriate antiseptic. A appropriate antiseptic. A chlorhexidine-based preparation chlorhexidine-based preparation with >0.5% is preferred. with >0.5% is preferred. Alternatively, tincture of Alternatively, tincture of iodine, an iodophor, or 70% iodine, an iodophor, or 70% alcohol could be used.alcohol could be used.
Annals of Internal Medicine 2002
Chlorhexidine significantly reduces risk of colonization and BSIChlorhexidine significantly reduces risk of colonization and BSI
Catheter Site Dressing Catheter Site Dressing RegimensRegimens
Old Recommendation: Old Recommendation: No recommendationNo recommendation
Efficacy of Chlorhexidine Efficacy of Chlorhexidine Impregnated Sponges for Impregnated Sponges for
Prevention of Intravascular Prevention of Intravascular Catheter Related InfectionsCatheter Related Infections
Catheter ColonizationCatheter Colonization
Blood Stream InfectionBlood Stream Infection
109 109
(16%)(16%)
8 (1.2%)8 (1.2%)
216 (29%)216 (29%)
24 (3.3%)24 (3.3%)
0.62 (0.49-0.78)0.62 (0.49-0.78)
0.38 (0.16-0.29)0.38 (0.16-0.29)
ChlorhexidineChlorhexidineSpongeSpongeN = 665N = 665
ControlControlN = 736N = 736
RRRR
ICAAC 2000ICAAC 2000
Timsit JF et al. JAMA 2009
Chlorhexidine sponge dressings reduce Chlorhexidine sponge dressings reduce risk of infection and colonizationrisk of infection and colonization
2 x 2 factorial RCT to evaluate chx 2 x 2 factorial RCT to evaluate chx dressing vs standard and to evaluate 3 dressing vs standard and to evaluate 3 day vs 7 day dressing changesday vs 7 day dressing changes
1653 patients1653 patients 3778 catheters3778 catheters 28,931 catheter days28,931 catheter days
Timsit JF et al. JAMA 2009
Chlorhexidine sponge dressings reduce risk of infection and colonizationChlorhexidine sponge dressings reduce risk of infection and colonization
Catheter Site Catheter Site Dressing RegimensDressing Regimens
Use a chlorhexidine sponge Use a chlorhexidine sponge dressing in adult patients with dressing in adult patients with short-term catheters to reduce short-term catheters to reduce the incidence of infection the incidence of infection catheter-related infection.catheter-related infection.
Antimicrobial Lock SolutionsAntimicrobial Lock Solutions
Use prophylactic antimicrobial Use prophylactic antimicrobial lock solution in patients with lock solution in patients with long term catheters who have a long term catheters who have a history of multiple CRBSI despite history of multiple CRBSI despite optimal maximal adherence to optimal maximal adherence to aseptic technique. aseptic technique.
Catheter LocksCatheter Locks
Technique by which an antimicrobial solution is Technique by which an antimicrobial solution is used to fill a catheter lumen and then allowed used to fill a catheter lumen and then allowed to dwell for a period of time while the to dwell for a period of time while the catheter is idle.catheter is idle.
Antibiotics of various concentrations that have Antibiotics of various concentrations that have been used either alone (when directed at a been used either alone (when directed at a specific organism) or in combination (to specific organism) or in combination (to achieve broad empiric coverage)achieve broad empiric coverage)
Formulations made in-houseFormulations made in-house Studies are limited; populations are Studies are limited; populations are hemodialysis, neonates, patients with hemodialysis, neonates, patients with neutropenianeutropenia
Needleless ConnectorsNeedleless Connectors
Mechanical ValveMechanical Valve
Split SeptumSplit Septum
RecommendationRecommendation
When needleless systems are used, a When needleless systems are used, a split septum valve may be preferred over split septum valve may be preferred over a mechanical valve due to increased risk a mechanical valve due to increased risk of infection with some mechanical of infection with some mechanical valves. Category IIvalves. Category II
Bundles and ChecklistsBundles and Checklists
Eliminating Catheter Related Eliminating Catheter Related InfectionsInfections
Crit Care Med; October 2004Crit Care Med; October 2004
Eliminating Catheter Related Eliminating Catheter Related InfectionsInfections
Educational intervention to increase Educational intervention to increase provider awarenessprovider awareness
Created CVC insertion cartCreated CVC insertion cart Asking providers daily if the CVC is Asking providers daily if the CVC is neededneeded
Checklist at bedside for nursesChecklist at bedside for nurses Empowering nurses to stop the procedureEmpowering nurses to stop the procedure Did not include tunneled of PA cathetersDid not include tunneled of PA catheters
Eliminating Catheter Related Eliminating Catheter Related Infections Infections
Implemented simple strategiesImplemented simple strategies No impregnated cathetersNo impregnated catheters Reduced infection rate from 11.3/1000 Reduced infection rate from 11.3/1000 catheter days to 0/1000 catheter days catheter days to 0/1000 catheter days during study periodduring study period
Performance sustainedPerformance sustained Jan-April 2003 only 2 infections Jan-April 2003 only 2 infections (0.54/1000 catheter days)(0.54/1000 catheter days)
Eliminating Catheter Related InfectionsEliminating Catheter Related Infections
Eliminating Catheter Related Eliminating Catheter Related InfectionsInfections
Excluded PICCSExcluded PICCS Implemented teaching programImplemented teaching program CVC cartsCVC carts Checklist for compliance with Checklist for compliance with handwashing and barrier precautionshandwashing and barrier precautions
Eliminating Catheter Related InfectionsEliminating Catheter Related Infections
Antibiotic/Antiseptic CathetersAntibiotic/Antiseptic Catheters
Antibiotic/Antiseptic CathetersAntibiotic/Antiseptic Catheters
Use an antimicrobial or antiseptic-Use an antimicrobial or antiseptic-impregnated CVC in adults whose catheter impregnated CVC in adults whose catheter is expected to remain in place >5 days if, is expected to remain in place >5 days if, after implementing a comprehensive after implementing a comprehensive strategy to reduce rates of CR-BSI, the strategy to reduce rates of CR-BSI, the rate has not sufficiently decreased. The rate has not sufficiently decreased. The comprehensive strategy should include the comprehensive strategy should include the following 3 components: educating persons following 3 components: educating persons who insert and maintain catheters, use of who insert and maintain catheters, use of maximal barrier precautions, and a 0.5% maximal barrier precautions, and a 0.5% chlorhexidine preparation for skin chlorhexidine preparation for skin antisepsis during central venous catheter antisepsis during central venous catheter insertion.insertion.
Efficacy of Chlorhexidine-Silver Efficacy of Chlorhexidine-Silver Sulfadiazine Catheters for Prevention Sulfadiazine Catheters for Prevention
of Catheter Colonizationof Catheter Colonization
Collin, 1999Collin, 1999
George, 1999George, 1999
van Heerden, 1997van Heerden, 1997
Maki, 1997Maki, 1997
Heard, 1998Heard, 1998
Bach, 1996Bach, 1996
-0.2-0.2 00 0.20.2 0.40.4 0.60.6 0.80.8 11 1.21.2
Odds ratio, 95% CIOdds ratio, 95% CI Decreasing risk Increasing riskDecreasing risk Increasing risk
Risk of Bloodstream Infections Risk of Bloodstream Infections Using Two Types of Impregnated Using Two Types of Impregnated
CathetersCatheters
00
1.01.0
0.90.9
0.80.8
0.70.7
0.60.6
0.50.5
0.40.4
0.30.3
0.10.1
0.00.055 1010 1515 2020 2525 3030
Minocycline-rifampin Minocycline-rifampin catheterscatheters
Chlorhexidine-silver Chlorhexidine-silver sulfadiazine catheterssulfadiazine catheters
Proportion of Catheters
Proportion of Catheters
without Infection
without Infection
Duration of Catheterization (Days)Duration of Catheterization (Days)
M/RM/RC/SSC/SS
365365382382
214214246246
93939696
48483939
20201818
9955
4422
No. at RiskNo. at Risk
Darouiche Darouiche NEJM 1999NEJM 1999
CatheterCatheter
Annals of Internal Med 2005Annals of Internal Med 2005
Eliminating Catheter Related InfectionsEliminating Catheter Related Infections
Eliminating Catheter Related InfectionsEliminating Catheter Related Infections
SummarySummary
Educate healthcare workers and provide Educate healthcare workers and provide training for the insertion and training for the insertion and maintenance of cathetersmaintenance of catheters
Use chlorhexidine preferentially for skin Use chlorhexidine preferentially for skin antisepsisantisepsis
Use maximal barrier precautionsUse maximal barrier precautions Use a chlorhexidine sponge dressing in Use a chlorhexidine sponge dressing in adults with short-term cathetersadults with short-term catheters
Use an antibiotic/antiseptic catheters if Use an antibiotic/antiseptic catheters if CRI rates have not sufficiently declinedCRI rates have not sufficiently declined
Use a bundled strategy for simplicityUse a bundled strategy for simplicity
ConclusionsConclusions
Prevention strategies have measurable Prevention strategies have measurable impactimpact
Multiple interventions may be neededMultiple interventions may be needed Performance improvement programs will Performance improvement programs will be focused on moving toward be focused on moving toward elimination of CA-BSIs rather than elimination of CA-BSIs rather than “benchmark goals”“benchmark goals”
Focus of prevention moving away from Focus of prevention moving away from insertion phase and into maintenance insertion phase and into maintenance phasephase
Thank you.Thank you.