nosocomial bloodstream infections and sepsis: spice, 2014 david jay weber, m.d., m.p.h. professor of...
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NOSOCOMIAL BLOODSTREAM INFECTIONS AND SEPSIS: SPICE, 2014
David Jay Weber, M.D., M.P.H.Professor of Medicine, Pediatrics, & Epidemiology
Associate Chief Medical OfficerUniversity Of North Carolina at Chapel Hill
TOPICS
Epidemiology Impact of healthcare-associated infections Definitions NHSN surveillance definitions Incidence and prevalence of CLA-BSI
Pathogenesis Mechanisms of CLA-BSI Microbiology Risk factors Diagnosis Sepsis
Prevention
LECTURE GOALS
Understand the impact of bloodstream infections Understand the incidence and causative pathogens of
bloodstream infection Understand the risk factors for healthcare-associated
bloodstream infections Understand the prevention and control of bloodstream
infections Understand the pathophysiology and risk factors for
sepsis and septic shock
IMPACT OF BLOODSTREAM INFECTIONS
Approximately 250,000 nosocomial BSIs per year Accounts for ~14% of healthcare-associated infections Increases length of stay by 7-21 days Attributable cost = $3,700 - $39,000 per episode
Major risk = use of an intravascular device Rate of BSIs varies by:
Hospital size, unit, and service Population served (elderly/infants, acute/chronic) Use and type of intravascular access device Time-trends Endemic/Epidemic
Weber DJ, Rutala WA. Infect Dis Clin NA 2011;25:77-102
Magill SS, et al. New Engl J Med 2014;370:1198
MORTALITY OF NOSOCOMIAL BSI,SCOPE, 1995-98
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
Viridans streptococci
Serratia sp.
Pseudomonas sp.
Enterobacter sp.
Klebsiella sp.
E. coli
Candida sp.
Enterococcus sp.
S. aureus
CoNS
BSI Pathogens
Crude mortality
Edmond M, et al. CID 1999;29:239
IMPACT OF CLA-BSIs Prevalence
ICUs: ~80,000 CLA-BSIs/year1
Hospital-wide: ~248,000 CLA-BSI/year1
Cost/year $7,288 to $29,156 per infection (total ~670 million to $2.7 billion)3
1Mermel L, et al. CID 2009;49:1 – 2http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf - Eggimann P, Pitter D. CLin Microbiol Infect 2002;8:295
DEFINITIONS
Primary bacteremia: Culture-documented bacteremia occurring in the absence of recognized infection with the same pathogen at another site
Secondary bacteremia: Culture-documented bacteremia originating from an identifiable infection at a specific site
Pseudo-bacteremia: Positive blood cultures resulting from contamination during the collection procedure or during laboratory processing
Septicemia: A systemic disease caused by the presence of microorganisms or their toxins circulating in the blood
Sepsis: A clinical picture that is consistent with the presence of microorganisms or their toxic by-products in circulating blood
Septic shock: A syndrome of circulating insufficiency with hypoperfusion of body tissues resulting from an inadequate cardiac output relative to metabolic demands
Mermel L, et al. CID 2009;49:1-45
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLA-BSI) EVENT
HAI All NHSN site specific infections must first meet the NHSN definition
before a site specific infection (e.g., CLA-BSI) can be reported to NHSN {An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were not present during admission time period but were all present on or after the 3rd calendar day of admission to the facility. All elements of the site specific definition mujst occur within a time frame that does not exceed a gap of 1 calendar day between any two adjacent elements}
Primary bloodstream infection (BSI) Primary BSI are laboratory-confirmed bloodstream (LCBI) that are NOT
secondary to an infection at another body site
NHSN DEFINITIONS: CLA-BSI
Central line Catheter must terminate in aorta, pulmonary artery, superior or inferior
vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac or common iliac veins, femoral veins, umbilical artery/vein (neonates)
Excludes femoral arterial catheters, intraaortic balloon pump, ECMO The following are NOT considered central lines:
Extracorporeal membrane oxygenation (ECMO) Femoral arterial catheters Intra-aortic balloon pump (IABP) devices Hemodialysis reliable outflow (HeRO) dialysis catheters
Infusion: Introduction of a solution through a blood vessel via a catheter lumen
NHSN DEFINITIONS: CLA-BSI
Temporary central line: A non-tunneled, non-implanted catheter Permanent central line:
Tunneled catheters, including certain dialysis catheters Implanted catheters (including ports)
CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLA-BSI) EVENT
A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days when all elements of the LCBI were first present, with day of device placement being Day 1 AND
A CL or UC was in place on the day of the event or the day before. If a patient is admitted or transferred into a facility with a central line in place, day of first access is considered Day 1
http://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html
LABORATORY CONFIRMED BLOODSTREAM INFECTION (LCBI)
LCBI 1: Patient has a recognized pathogen cultured from one or more blood cultures AND organism cultured from blood is not related to an infection at another site
LCBI 2: Patient has at least one of the following signs or symptoms: fever (>38oC), chills or hypotension AND positive laboratory results are not related to an infection at another site AND common commensal (see list) is cultured from 2 or more blood cultures drawn on separate occasions. Criterion elements must occur within a time frame that does not exceed a gap of 1 calendar day.
LABORATORY CONFIRMED BLOODSTREAM INFECTION (LCBI)
LCBI 3: Patient <1 year of age has at least one of the following signs or symptoms: fever (>38oC core), hypothermia (<36oC core), apnea, or bradycardia AND positive laboratory results are not related to an infection at another site AND common commensal (see list) is cultured from 2 or more blood cultures drawn on separate occasions. Criterion elements must occur within a time frame that does not exceed a gap of 1 calendar day.
MUCOSAL BARRIER INJURY LABORATORY-CONFIRMED BLOODSTREAM INFECITON (MBI-
LCBI)
MBI-LCBI 1: Patient of any age meets criterion 1 for LCBI with at least one blood culture growing one of the intestinal organisms (see list) with no other organism isolated AND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within the
past year with one of the following documented during the same hospitalization as positive blood culture
Grade III or IV gastrointestinal graft versus host disease (GI GVHD) >1 liter diarrhea in a 24-hour period (or >20 mL/kg in a 24 hour period for
patients <18 years of age) with onset on or within 7 calendar days before the date the first positive blood culture was collected
Is neutropenic, defined as at least 2 separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC <500 cells/mm3 on or within 3 calendar days before the positive blood culture was collected
MUCOSAL BARRIER INJURY LABORATORY-CONFIRMED BLOODSTREAM INFECITON (MBI-
LCBI)
MBI-LCBI 2: Patient of any age meets criterion 2 for LCBI when the blood cultures are growing only viridans group streptococci with no other organisms isolated AND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within the
past year with one of the following documented during the same hospitalization as positive blood culture
Grade III or IV gastrointestinal graft versus host disease (GI GVHD) >1 liter diarrhea in a 24-hour period (or >20 mL/kg in a 24 hour period for
patients <18 years of age) with onset on or within 7 calendar days before the date the first positive blood culture was collected
Is neutropenic, defined as at least 2 separate days with values of absolute neutrophil count (ANC) or total white blood cell count (WBC <500 cells/mm3 on or within 3 calendar days before the positive blood culture was collected
MUCOSAL BARRIER INJURY LABORATORY-CONFIRMED BLOODSTREAM INFECITON (MBI-
LCBI)
MBI-LCBI 3: Patient <1year of age meets criterion 3 for LCBI when the blood cultures are growing only viridans group streptococci with no other organisms isolated AND patient meets at least one of the following: Is an allogeneic hematopoietic stem cell transplant recipient within the
past year with one of the following documented during the same hospitalization as positive blood culture
Grade III or IV gastrointestinal graft versus host disease (GI GVHD) >1 mL/kg diarrhea in a 24-hour period in a 24 hour period with onset on or
within 7 calendar days before the date the first blood culture is collected Is neutropenic, defined as at least 2 separate days with values of
absolute neutrophil count (ANC) or total white blood cell count (WBC <500 cells/mm3 on or within 3 calendar days before the positive blood culture was collected
COMMENSAL ORGANISMS (i.e., skin flora)
Corynebacterium spp. (not C. diphtheriae) Bacillus spp. (not B. anthracis) Propionibacterium spp. Coagulase-negative stahylococci (including S. epidermidis) Aerococcus spp. Micrococcus spp. For full list see: http://www.cdc.gov/nhsn/XLS/master-organism-
Com-Commensals-Lists.xls
INTESTINAL ORGANISMS
Bacteroides spp. Candida spp. Clostridium spp. Enterococcus spp. Fusobacterium spp. Peptostreptococcus spp. Prevotella spp. Veillonella spp. Enterobacteriaceae*
Enterobacteriaceae* Citrobacter Enterobacter Escherichia (e.g., E. coli) Klebsiella Providencia Salmonella Serratia Shigella Yersinia
* Partial list
http://www.cdc.gov/nhsn/TOC_PSCManual.html, 2012
http://www.sciencedirect.com/science/article/pii/S019665531301153X#
BLOODSTREAM INFECTION RATES IN ICUs, STEP DOWN UNITS (SDUs), and WARDS
# Admissions # Patient-days
BSI:
# Cases
BSI: Cases per 100 admissions
BSI: Cases per 1,000 device days
Medical ICU 2,196 10,643 78 3.55 7.33
Medical SDU 2,505 7,750 30 1.20 3.87
Medical Ward 16,656 72,781 150 0.90 2.06
Surgical ICU 1,063 5,531 52 4.89 9.40
Surgical SDU 3,117 6,587 12 0.38 1.82
Surgical Ward 14,829 73,999 85 0.57 1.15
Weber DJ, et al. ICHE 2007;28:1361-1366
CLA-BSI MRSA RATES, US ICUs, 1997-2007
Burton DC, et al. JAMA 2009;301:727
CHANGES IN INCIDENCE OF CLA-BSI OVER TIME, UNC HOSPITALS
Weber DJ, et al. ICHE 2010;31:875 DiBiase LM, et al. ICHE 2014;35:200
PATHOGENESIS CLA-BSI
Multifactorial and complex Most catheter-related infections appear to result form migration of
skin organisms at insertion site into the cutaneous tract with eventual colonization of the catheter tip
Catheter hub also important contributor to intralumenal colonization (especially in long-term catheters)
Less important = hematogenous seeding of catheter tip from distant focus of infection or contaminated infusate
BIOFILM
SOURCE OF CLA-BSI WITH NONCUFFED SHORT-TERM VENOUS CATHETERS
Safdar N, Maki D. Intensive Care Med 2004;30:62
SOURCE OF CLA-BSI WITH SHORT-TERM VENOUS CATHETERS FOR TPN
Segura M, et al. Clin Nutrition 1993;12:102
TOP 10 PATHOGENS ASSOCIATED WITH CLA-BSIs: NHSN, 2009-2010
0% 5% 10% 15% 20% 25%
P. aeruginosa
E. coli
Enterbacter spp.
C. albicans
E. faecium
K. pneumoniae/oxytoca
Other Candida
E. faecalis
S. aureus
CoNS
Sievert DM, et al. ICHE 2013;34:1-14
COMPLICATIONS OF CLA-BSIs
Local infection Tunnel infection, pocket infection
Sepsis Remote site infection
Osteomyelitis Meningitis
Endovascular infection Endocarditis Mycotic aneurysms (septic thrombophlebitis)
INDEPENDENT RISK FACTORSFOR CLA-BSIs
Prolonged hospitalization before catheterization Prolonged duration of catheterization Heavy microbial colonization at the insertion site Heavy microbial colonization of the catheter hub Internal jugular catheterization Femoral catheterization Neutropenia Prematurity Reduced nurse-to-patient ratio in the ICU Total parenteral nutrition Substandard catheter care e.g., excessive manipulation) Transfusion of blood products (in children)
Marschall J, et al. ICHE 2009;29(suppl 1):S22
FACTORS ASSOCIATED WITH REDUCED RISK OF CLA-BSI
Female gender Antibiotic administration Minocycline-rifampin impregnated catheters
EVALUATION OF FEVER IN CRITICALLY ILL ADULT PATIENTS
Definition of temperature >38.3 oC → trigger for clinical assessment (not necessarily a lab
or radiographic evaluation for infection) <36.0 oC → in absence of known cause of hypothermia Most accurate: Pulmonary artery thermistor, urinary bladder
catheter thermistor, esophageal probe, rectal probe Other acceptable methods: Oral probe, infrared ear thermometry Less desirable: Temporal artery thermometer, axillary
thermometer, chemical dot
O’Grady NP, et al. Clin Infect Dis 2008;36:1330-1349
EVALUATION OF FEVER IN CRITICALLY ILL ADULT PATIENTS
Blood cultures Obtain 3-4 blood cultures within first 24 hours (obtain before
antibiotics if at all possible) For patients without a CVC, obtain at least 2 blood cultures from
peripheral sites by separate venipunctures For patients with a CVC, 1 blood culture should be drawn by
venipuncture and at least 1 should be drawn through the CVC Draw 20-30 mL of blood per blood culture; disinfect the skin with
2% chlorhexidine/70% isopropyl alcohol (ChloraPrep)
BSI INFECTIONS: SYMPTOMS/SIGNS
Constitutional: Fever, rigors, hypotension, shock Respiratory: Hyperventilation, respiratory failure Gastrointestinal: Abdominal pain, vomiting, diarrhea Neurologic: Confusion, seizures
CLUES TO CVC INFECTIONS
CVC: Exit site infection (erythema, tenderness, purulence) or tunnel infection (erythema, tenderness, purulence, induration)
High grade bacteremia/fungemia (multiple positive cultures) Abrupt onset, associated with shock Symptoms/signs of sepsis (i.e., fever/ hypotension) without obvious
source (no identifiable local infection) Evidence of septic thrombophlebitis of great vein Continued bacteremia/fungemia despite appropriate therapy Symptoms/signs of sepsis plus catheter malfunction Bacteremia with CoNS, Candida, Bacillus, Corynebacterium
CVC INFECTION: EVALUATION
Examine area around catheter exit for redness, tenderness, pus Examine tunnel tract (implantable catheter) for redness,
tenderness Blood cultures x 2-3 (always obtain at least one peripheral
culture) Consider catheter removal with semiquatitative of catheter tip
(not subcutaneous segment). Catheter colonization defined by: >15 cfu from a 5-cm catheter tip by roll plate method >102 cfu from a catheter by quantitative (sonication)
broth culture
CELLULITIS OVERLYING CATHETER
SEPSIS: PERIPHERAL EMBOLI TO SKIN
SEPSIS: EMBOLI TO RETINA
GANGRENE
SEPTIC EMBOLI
CVC INFECTION: DIAGNOSIS
A definitive diagnosis of CLA-BSI requires that the same organism grow from at least 1 percutaneous blood culture and from a culture of the catheter tip (A-I), OR
Two sets of blood samples (one from the catheter hub and the other from a peripheral vein) that, when cultured, meet CLA-BSI criteria for quantitative blood cultures or differential time to positivity (A-II)
For quantitative blood cultures, a colony count of microbes grown from blood obtained through the catheter hub that is at least 3x greater than the colony count from blood obtained from a peripheral vein (A-II)
For deferential time to positivity; growth of microbes from a blood sample drawn from a catheter hub at least 2 hours before microbial growth is detected in a blood sample obtained from a peripheral vein (A-II)
LABORATORY METHODSFOR DIAGNOSIS CLA-BIS
REMOVAL OF CVC: INDICATIONS
Long-term catheters Severe sepsis Suppurative thrombophlebitis Endocarditis Bloodstream infection that
continues despite >72 hours of antimicrobial therapy to which the microbes are susceptible
Infections due to fungi, S. aureus, P. aeruginosa, or mycobacteria
Short term catheters Infections due to Gram negative
bacill, S. aureus, fungi, and mycobacteria
Mermel L,et al.CID2009;49:1
CVC INFECTION: EMPIRIC THERAPY Gram-positive cocci (S. aureus, Coag neg staph)
Vancomycin (alternative: daptomycin); avoid linezolid Gram-negative bacilli (E. coli, Klebsiella, Enterobacter)
4o cephalosporin, carbapenem, -lactam/ -lactamase combination +/- aminoglycosie
Neutropenic patients Cover for MDR GNRs including P. aeruginosa
Femoral catheters In critically ill patients cover for GNRs and Candida
Suspected Candida TPN, prolonged uss of broad spectrum antibiotics, hematologic
malignancy, stem cell or solid organ transplant, femoral catheterization, Candida colonization at multiple sites
Choice of drug = echinocandin (selected patients fluconazole)
ANTIBIOTIC LOCK THERAPY
Antibiotic lock therapy is indicated for patients with CLA-BSI involving long-term catheters without signs of exit site or tunnel infection for whom catheter salvage is the goal (B-II)
For CLA-BSI, antibiotic lock should not be used alone; instead, it should be used in conjunction with systemic antimicrobial therapy, with both regimens administered for 7-14 days (B-II)
Dwell times for antibiotic lock solutions should generally not exceed 48 h before reinstallation of lock solution; preferably, reinstallation should take place every 24 h for ambulatory patients with femoral catheters (B-II). For dialysis patients, the lock solution can be renewed every dialysis session (B-II)
Cather removal is recommended for CLA-BSI due to S. aureus, Candida sp. For patients with multiple positive catheter drawn blood cultures that grow CoNS
or GNRs and concurrent negative peripheral blood cultures, antibiotic lock therapy can be given without systemic therapy for 10-14 days (B-III)
There is insufficient data to recommend an ethanol lock for treatment (C-III)
The Sepsis Continuum
SIRS Sepsis Severe Sepsis
> 2 of the following:
• T >38.5oC or <35oC
• HR >90
• RR >20 or PaCO2 <32 mmHg
• WBC >12, 000 or <4, 000
or >10% Bands
Sepsis + Organ Failure:• Shock / hypotension
• Acute lung Injury
• Renal
• Hepatic
• Hematologic
• CNS
• Metabolic acidosis
SIRS due to infection
NONINFECTIOUS MIMICS OF SEPSIS
Acute MI Acute PE Acute pancreatitis Fat emboli syndrome Acute adrenal insufficiency Acute GI hemorrhage
Overzealous diuresis Transfusion reactions Adverse drug reactions Procedure-related transient
bacteremia Amniotic fluid embolism
MANAGEMENT OF SEPSIS
Initial resuscitation with fluid replacement Use dobutamine to maintain blood pressure Assure adequate ventilation Obtain appropriate cultures before antibiotics Perform imaging studies to confirm source of infection, if possible Begin IV antibiotics within first hour of recognizing sepsis Use broad spectrum antibiotics Attempt to identify and control source of infection
Dellinger RP, et al. Crit Care Med 2008;36:296
OUTCOME DEPENDING AN ADEQUECY OF EMPIRIC THERAPY
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Inadequate therapy
MacArthur R, et al.CID 2004;38:284
IHI: PREVENTION OFCENTRAL LINE INFECTIONS
Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis (now CHG-alcohol) Optimal catheter site selection, with subclavian vein as the
preferred site for nontunneled catheters Daily review of line necessity, with prompt removal of
unnecessary lines
PREVENTION OF CLA-BSI:EDUCATION
Educate HCP regarding indications for intravascular catheter use, proper procedures for insertion and maintenance of IV catheters (IA)
Periodically assess knowledge of and adherence to guidelines for all HCP involved in catheter insertion and maintenance (IA)
Designate only trained HCP who demonstrate competency for intersertion and maintenance of peripheral and central venous catheters (IA)
Ensure appropriate nursing staff levels in ICUs (IB)
O’Grady NP, et al. Clin Infect Dis 2011;52:e1
PREVENTION OF CLA-BSI:SELECTION OF CVC CATHETERS AND SITES
Weigh the risks and benefits of placing a CVC at a recommended site to reduce infectious complications against the risk for complications (lA)
Avoid using the femoral vein for central venous access in adult patients (lA) Use a subclavian site, rather that jugular or femoral site, in adults (lB) Avoid the subclavian site in hemodialysis & ESRD patients (lA) Use ultrasound guidance to place CVC (lB) Use a CVC with the minimum number of ports or lumens essential for the
management of the patient (lB) Promptly remove any CVC catheter that is no longer essential (lA) When adherence to aseptic technique cannot be ensured (e.g., ED
placement), replace the catheter as soon as possible (lB)
PREVENTION OF CLA-BSI:HAND HYGIENE AND ASEPTIC TECHNIQUE
Perform hand hygiene before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an IV catheter (lB)
Maintain aseptic technique for the insertion and care of IV catheters (lB) Wear clean vs sterile gloves for the insertion of peripheral IV catheters (lC) Sterile gloves should be worn for the insertion of arterial, central, or midline
catheters (lA) Wear either clean or sterile gloves when changing the dressing on IV
catheters (lC) Use maximal sterile barrier precautions (cap, mask, sterile gown, sterile
gloves, sterile full body drape) for the insertion of CVCs, PICCs, or guidewire exchange (lB)
PREVENTION OF CLA-BSI:SKIN PREPARATION
Prepare skin with an antiseptic (70% alcohol, tincture of iodine, an iodophor or chlorhexidine) before peripheral IV catheter insertion (lB)
Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before a CVC or arterial catheter insertion or dressing (lA)
Antiseptics should be allowed to dry according to the manufacturer’s recommendation prior to placing the catheter (lB)
PREVENTION OF CLA-BSI:CATHETER SITE DRESSING REGIMENS
Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site (lA)
If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved (ll)
Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled (lB)
Do not use topical antibiotics ointment or creams on insertion sites, except for dialysis catheter (lB)
Do not submerge the catheter or catheter site in water (lB) Replace dressings on CVC sites at least every 7 days for transparent
dressings, except in pediatrics (lB)
PREVENTION OF CLA-BSI:CATHETER SITE DRESSING REGIMENS
Replace transparent dressings used on tunneled or implanted CVC sites no more than 1x/week until the insertion site has healed (ll)
Ensure that catheter site care is compatible with the catheter material (lB) Use a chlorhexidine-impregnated sponge dressing for temporary short-term
catheters in patients older than 2 mo of age if CLA-BSI rates are not decreasing (lB)
Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis. If patients have tenderness at the insertion site, fever with a source, or other manifestations of local or bloodstream infections, remove the dressing and exam the site (lB)
PREVENTION OF CLA-BSI:OTHER
Use a 2% chlorhexidine wash for daily skin cleansing to reduce CLA-BSI (II) Use a sutureless securement device (ll) Use a chlorhexidine/silver sulfadiazene or minocycline/rifampin
impregnated CVC in patients whose catheter will remain in place >5d (lA) Do not administer system antimicrobial prophylaxis (lB0 Use prophylactic antimicrobial lock solution in patients with long-term
catheters who have a history of multiple CLA-BSI despite optimal maximal adherence to aseptic technique (ll)
Do not routinely use anticoagulant therapy to reduce the risk of catheter-associated infection in general patient populations (ll)
Do not routinely replace CVCs, PICCs, hemodialysis catheters (lB)
CDC EDUCATIONAL MATERIAL
http://www.cdc.gov/HAI/bsi/bsi.html
BATHE ICU PATIENTS >2 MONTHS OF AGE WITH A CHG PREPARATION DAILY
Intervention = Daily bathing with 2% CHG impregnated washcloth Design & setting : Cross-over study in MICU Result: CHG associated with decreased
rate (per 1,000 patient days) of CLA-BSI
(4.1 vs 10.4)
Bleasdale S, et al. Arch Intern Med 2007;167:2073
IMPREGNATED CATHETERS:META-ANALYSIS, 1985-2006
Meta-analysis, 1985-2006 Site: ICU 34 studies included in the review Outcome: Catheter colonization (RR, 95% CI), CLA-BSI (RR, 95% CI)
Coated catheter vs uncoated catheter Catheter colonization CLA-BSI CH-SS (external) 0.59 (0.50-0.71) 0.66 (0.47-0.93)CH-SS (internal and external) 0.44 (0.23-0.85) 0.70 (0.30-1.62)Minocycline/rifampcin 0.40 (0.23-0.67) 0.39 (0.17-0.92)Silver, platinum, carbon 0.76 (0.57-1.01) 0.54 (0.16-1.85)Silver ion-alloy 1.09 (0.68-1.74) 0.95 (0.29-3.16)Chlorhexidine 1.11 (0.80-1.55) 2.37 (0.63-8.96)
CH-SS, chlorhexidine/silver sulfadiazene Ramritu P, et al. AJIC 2008;36:104
IMPREGNATED CATHETERS:META-ANALYSIS , 1985-2006
Ramritu P, et al. Am J Infect Control 2008;36:104-17
IMPREGNATED CATHETERS:META-ANALYSIS, 1985-2006
CHG/Ag-Sulphadiazene vs Noncoated catheters Minocycline/Fig vs noncoated catheters
IMPREGNATED CATHETERS:META-ANALYSIS
Meta-analysis, 1950-2006 34 studies included in the review Outcome: Catheter colonization (RR, 95% CI), CLA-BSI (RR, 95% CI)
Coated catheter vs uncoated catheter Catheter colonization CLA-BSICH-SS (external) 0.51 (0.42-0.61) 0.68 (0.47-0.98)CH-SS (internal and external) 0.39 (0.25-0.60) 0.47 (0.20-1.10)Minocycline/rifampcin 0.39 (0.27-0.55) 0.29 (0.16-0.52)Silver alloy 1.21 (0.84-1.77) 0.58 (0.29-1.17)Silver iontophoretic 0.84 (0.60-1.16) 1.98 (0.40-9.95)Silver 1.07 (0.71-1.62) 0.93 (0.34-2.50)
CH-SS, chlorhexidine/silver sulfadiazene Casey A, et al. Lancet ID 2008;8:763
INFECTION CONTROL INTERVENTIONS
2000: Addition of 2% chlorhexadine/70% isopropyl alcohol (ChoraPrep®) to the central line dressing kit
2001: Mandatory training for nurses on IV line site care and maintenance. 2003: Full body drape added to central line kit. MD could choose kit
containing a catheter impregnated with antiseptic or antibiotic 2005: 2nd generation impregnated catheter included in all central line kits
(except for Neonatal ICU) 2006: Pilot in MICU of IHI bundle to prevent CLA-BSI. 2007: Implementation of the IHI bundle in all ICUs. 2008: Implementation of Infection Control Liaison Program 2009: Implementation of Biopatch
CONCLUSIONS
Healthcare-associated bloodstream (BSI) cause significant morbidity and mortality
The most important risk factor for BSI is a central venous catheter
A near 0 rate of CLA-BSI is possible using existing technology and appropriate process measures
Current guidelines should be followed for the diagnosis and management of CLA-BSI