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Zerotoleranceforcatheterrelatedinfections:is
itadreamfordevelopingcountries?
Update 1.Juli 2009 IDSA Guideline on Treatment
CDC-Guideline (2002)
Clin Infect Dis 2009 July
http://www.cdc.gov/mmwr/PDF/rr/rr5110.pdf
Chair: Len Mermel, Providence, RI
ry
Andreas F. WIDMER, MD,MS
CDC Guidelines for the Prevention of
Intravascular Catheter-Related Infections, 2011
ib
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Member Task Force „Patient Safety“ WHO
ICPIC core member WHO
Specialist in Internal Medicine,Infectious Diseases, and Infection Control
Deputy Head Division of Infectious Diseases & Hospital Epidemiology
University Hospital, Basel, Switzerland
Update 200IDSA Guideline on Treatment
Chair: Len Mermel, Providence, RI
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DREAM?
Low cost – close to zero CLABSI?
ID
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Mermel LA et al, IDSA Guidelines. Clin Infect Dis 2009
15Mio CVCdays peryear inthe US
5.3CABSIs/1000catheter days
250,000Episodes of CABSIsinICUs/year
Estimated 9‘60020‘000deaths/year dueto CABSIs
Attributable mortality:1225%
Attributable cost perepisode:3‘70029‘000US$
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•
•
•
•
•
•
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Magnitudeof the Problem
Annual Patient Stays in the 6`000 Acute Care Hospitals and
Associated ICUs in the United States
USA
Estimated Motorvehicle deaths
CH; 350 (2010)
CH
Turkey 4’000 (2010)
Atrributable
mortality
333
1‘000 deaths
2‘000 CR-BSIs
400‘000 cath days
800‘000 ICU days
1‘000‘000 Patients/ 8‘000‘000 pat-days/ year
CDC Guidelines for the Prevention of Intravascular CatheterRelated Infections, 2011
CDC Guidelines for the Prevention of Intravascular
Catheter-Related Infections. MMWR 2002;51:# RR-10
Wenzel R and Edmond M. N Engl J Med 2006;355:2781-2783
4
Source: https://www.cia.gov/library/publications/the-world-factbook/geos/tu.html Accessed Oct 1, 2011
Catheter use:Expected Rateof CRBSIs
mean (CI95)
per 1000 cath days
Peripheral venous catheter
Arterial catheter
13
6
0.2
1.5
(0.1–0.3)
(0.9–2.4)
0.6 (0.3–1.2)
2.9 (1.8–4.5)
Short-term, nonmedicated CVC 61
Pulmonary-artery catheter
12
3.3
1.9
(3.3–4.0)
(1.1–2.5)
2.3 (2.0–2.4)
5.5 (3.2–12.4)
(13.5–18.3)
(4.2–9.2)
2.8
1.1
PICC
Long-term tunneled
and cuffed CVC
Port a cath
15
6
16.2
6.3
8
1.2
18
13
20.9
5.1
Hands of
Health Care Workers
Remote Infection
Skin Colonization
(2.3–3.1)
(0.7–1.6)
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Hemodialysis catheter
Noncuffed
Cuffed
Contaminated
Infusate
(0.5–2.2)
0.4
(18.2–21.9)
(4.0–6.3)
1.2 (1.0–1.3)
0.2 (0.1–0.2)
ry
prospective mean (CI95)
studies per 100 catheters
Contaminated
Disinfectants
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Device
Hub
Colonization
(0.2–0.7)
Fibrin
sheath
Hematogenous Seeding
Widmer AF. In: Wenzel RP: Prevention and Control of Nosocomial Infections, 1997
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C
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ID
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Crnich CJ & Maki DG. CID 2002; 34:1232–42
BiofilmFormationonCatheters
1 day
Widmer AF. J Infect Dis 1990;162:96-100
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10 days
PBS
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MHB
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Coagulase-negative staphylococci oxa R
Definitions and Epidemiology
Surveillance Definition CABSI
Catheter-associated bloodstream infection (CA-BSI):
Defined by the following:
A CLABSI is a primary BSI in a patient that had a central line
within the 48-hour period before the development of the BSI
and is not bloodstream related to an infection at another site.
Bloodstream infection is considered to be associated with a
central line „if the line was in use during the 48-hour
period before development of the bloodstream infection“
and other sources have been ruled out
CDC Guidelines for the Prevention of Intravascular
Catheter-Related Infections. MMWR 2002;51:# RR-10
Clinical Definition CRBSI
Signs and Symptoms of CR BSIs
Noncolonized and
CVC-related BSI, Colonized CVCs,
n = 35
n = 333
Uninfected CVCs,
n =894
Pain
Erythema
Swelling
Purulence
(0, 1)
(0–2)
(0, 1)
(0, 1)
25 (2%)
25 (2%)
126 (10%)
10 (0.8%)
0.0
0.0
0.2 ±0.4
0
0.2 ±0.4
0.1 ±0.3
0.1 ±0.4
0.0 ±0.1
0.2 ±0.4
0.1 ±0.2
0.1 ±0.4
0
Overall
(0–5)
126 (10.0%)
0.2 ±0.4
0.1 ±0.1
0.1 ±0.1
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Parameters
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isolation of the same organism (i.e., identical species, antibiogram)
from a semiquantitative or quantitative culture of a catheter segment
and from the blood (preferably drawn from a peripheral vein) of a
patient with accompanying clinical symptoms of BSI and no other
apparent source of infection. In the absence of laboratory
confirmation, defervescence after removal of an implicated catheter
from a patient with BSI may be considered indirect evidence of CRBSI.
- positive semiquantitative culture 15 CFU) (tip OR sc segment)
- > 103 CFU/catheter segment culture (Sonication)
- 2 simulataneous quantitative blood cultures with a 5:1 Ratio
- Differential time period to positivity of CVC culture vs peripheral
blood culture (automated BC system) > 2 hrs
ry
No. (%) of CVCs
n=1263
Catheter-related bloodstream infection (CR-BSI):
Safdar N & Maki D. Crit Care Med 2002; 30:2632–2635
ID
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CDC Guidelines for the Prevention of Intravascular
Catheter-Related Infections. MMWR 2002;51:# RR-10
C
M
Accuracy of Diagnosisof Catheterassociated Infection
by „DifferentialTimeto Positivity“:2hrs
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Blotetal
Cathtype
Sensitivity
Specifity
PPV
NPV
96%
100%
100%
93%
LT/ST
94%
91%
94%
91%
DifferentialTimetoPositivity(DTP)amongPatientswith
SuspectedCatheterRelatedCandidemia.
Candida BSI
Definite other source of Infection
J.Clin Microbiol 1998;36:105
109,
Blotetal
1999
Candida BSI
Definite other source of Infection
SeifertH.2003
ST
82%
88%
75%
92%
Raad II
ST
LT
81%
93%
92%
75%
94%
86%
84%
87%
ST
96%
90%
61%
99%
AnnInternMed 2004
Bouza E.
2007
30h cut-off
Candida BSI
Definite other source of Infection
Ronen Ben-Ami, J Clin Microbiol 2008;46: 2222–2226
CVCsimpregnatedwithminocyclineandrifampinvs
chlorhexidenegluconateandsilversulfadiazine
ry
Arandomized,multicenterclinicaltrial
Darouiche and Raad II. NEJM 1999;340:1-8.)
ID
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Infection Control Activity
Coating of Catheters
InVivoAntiinfective Efficacy of the NewCoated
CHX/SDDCatheter
In-vitro
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C
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CRBSIs:MetaanalysisrifampicinandminocyclineCVCs
versusuncoatedCVCs
In-vivo (rabbit model)
Falagas ME. Journal of Antimicrobial Chemotherapy (2007) 59, 359–369
Bassetti S. AAC 2001;45:1535–1538
SecondGenerationC/SSCoatedvs.UncoatedShortTermCentral
VenousCatheters
3xhigherconcentrationofchlorhexidineonexternalsurface,andchlorhexidineincorporatedontoluminalsurface
ofcatheter,hub,andextensionlines
Catheter Colonization
Catheter-related BSI
BSI/1000 catheter-days
32/345
(9%)
1/345
(0.3%)
59/362
(16%)
3/362
(0.8%)
0.42
1.24
P
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Coated Control
<0.01
Teaching
NS
NS
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Outcome
ry
Infection Control Activity
ID
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Rupp M. et al. Ann Intern Med 2006;143:570-80
M
CRBSIs Rates in the SICU and Control ICU (1998–2002)
TheIntervention:MichiganInterventionICU
study
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Berenholtz SM & Perl Tl. Crit Care Med 2004;32:2014-20
1.
2.
3.
4.
5.
Handwashing
fullbarrier precautions during the insertion of CVCs
cleaning the skin with chlorhexidine
avoiding the femoral site,if possible,
removing unnecessary catheters
Pronovost P et al. N Engl J Med 2006;355:2725-2732
24
TheIntervention
USA
Europe
1. Handwashing
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2. fullbarrierprecautions
duringtheinsertionof
CVCs
3. cleaningtheskinwith
chlorhexidine
4. avoidingthefemoralsite,if
possible,
5. removingunnecessary
catheters
1. Handhygiene with alcoholic
compound
2. fullbarrier precautions during
the insertion of CVCs
3. cleaning the skin with
chlorhexidine,(alternative:
octenidin,polihexanide
4. avoiding the femoral site,if
possible,
5. removing unnecessary
catheters
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Characteristics of 103 Participating ICUs, According to the Period of
Implementation of the Intervention to Reduce the Rate of CatheterRelated Bloodstream Infections
Study sample: >25‘000 catheter days
Pronovost P et al. N Engl J Med 2006;355:2725-2732
Pronovost P et al. N Engl J Med 2006;355:2725-2732
26
ID
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TheIntervention
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Technique of Alcoholic Hand Antisepsis WHO
1.
2.
3.
4.
5.
Chair: Didier Pittet
http://www.who.int/patientsafety/en/
Widmer AF.
Surgical Hand Hygiene in:
WHO Guideline for Hand Hygiene 2009
Widmer AF. Infect Control Hosp Epidemiol 2004
Widmer AF. Infect Control Hosp Epidemiol 2007
Widmer AF. J Hosp Infect 2009
Tschudin & Widmer. Crit Care Med 2010
Widmer AF. Manuel of Clinical Microbiology 2011
WHO Update Juni 07
Handwashing
fullbarrierprecautionsduringtheinsertionofCVCs
cleaningtheskinwithchlorhexidine
avoidingthefemoralsite,ifpossible,
removingunnecessarycatheters
Pronovost P et al. N Engl J Med 2006;355:2725-2732
28
Baseline Data
Rate of CR-BSIs before Intervention
Pronovost P et al. N Engl J Med 2006;355:2725-2732
30
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Rates of Catheter-Related Bloodstream Infection from Baseline
(before Implementation of the Study Intervention) to 18 Months of
Follow-up
Rates of Catheter-Related Bloodstream Infection from Baseline
(before Implementation of the Study Intervention) to 18 Months of
Follow-up
median/1’000
CVC days
ID
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Maximal barrier precautions:
Raad II. Infect Control Hosp Epidemiol 1994;15:231
mean/1’000 CVC days: 7.7
mean/1’000 CVC days: 1.4
•An evidence-based intervention resulted in a large and sustained reduction (up to 66%)
in rates of catheter-related bloodstream infection that was maintained throughout the
18-month study period
Pronovost P et al. N Engl J Med 2006;355:2725-2732 31
•An evidence-based intervention resulted in a large and sustained reduction (up to 66%)
Pronovost.
New Engl J Med 2006;355:2725
in rates
of catheter-related
bloodstream infection that was maintained throughout the
18-month study period
CharacteristicsoftheParticipatingICUs
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PublishedresultsofuseofInstituteforHealthcare
Improvementcentralcatheterbundle
a
By type of hospital, 46% academic teaching hospitals, 28% private community hospitals, 26% public hospitals.
Paul Chittick, MD; Robert J. Sherertz Crit Care Med 2010 Vol. 38, No. 8 (Suppl.)
Rosenthal VD et al, Infect Control Hosp Epidemiol 2010; 31(12):1264-1272
DeathsinPatientswithCentralLineAssociatedBloodstreamInfection
(CLABSI)duringBaselineandInterventionPeriods
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ID
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Infection_Control_11
Rosenthal VD et al, Infect Control Hosp Epidemiol 2010; 31(12):1264-1272
Rosenthal V. Ann Intern Med. 2006 Oct 17;145(8):582-91.
Infection_Control_11
RepresentativeInfectionControlPracticesandthe
ResultsofProcessSurveillance
ry
CharacteristicsofPatientsatBaselineand
DuringtheInterventionPeriod
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Note. Data are % of opportunities,
unless otherwise indicated. CHG,
chlorhexidine gluconate; CI, confidence
interval; IQR, interquartile range; IV,
intravenous; RR, relative risk.
a No. of times hand hygiene performed
/ no. of opportunities where indicated,
during random periods of process
surveillance.
b 7,831/15,728.
c 48,574/80,557.
d No. of central line–days /
no. of patient-days.
e 30,889/58,742.
f 160,016/306,340.
Rosenthal VD et al, Infect Control Hosp Epidemiol 2010; 31(12):1264-1272
Infection_Control_11
Chlorhexidine vs PVP Iodine for catheter site care
M
ID
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Infection_Control_11
Rosenthal VD et al, Infect Control Hosp
Epidemiol 2010; 31(12):1264-1272
ES
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Infection Control Activity
Catheter SiteCare
8 RTCs (4143 catheters):
Chaiyakunapruk N. Ann Intern Med. 2002;136:792-801.
Risk Ratio for BSI = 0,49 (95%-CI 0,28-0,88)
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Forest plot : Effect of chlorhexidine-impregnated dressing on
bacterial colonization of the catheter or exit-site on skin
Timsit JF JAMA 2009;301:1231-1241
ID
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Ho KM & Letton E, J Antimicrob Chemother 2006 Jun
Sensitivityanalysisofkeyinputparametersinthemodel.
CRBSI,catheterrelatedbloodstreaminfection
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CumulativeRiskofCatheterRelated
InfectionandCatheterColonization
Median duration of catheterization was
6 days
(interquartile range, 4-10 days)
for all curves
Standard dressing
y-Axis in blue indicates values in the
range of 0-0.05
CHGIS indicates Chlorhexidine
gluconate-impregnated sponge
CHX
CI, confidence interval
HR, hazard ratio
Timsit JF JAMA 2009;301:1231-1241
Xin Ye Am J Infect Control 2011;39:647-54
Antiseptic dressings
3.5
4.5
5.5
6.5
$6,000
$71,959
$181,200
$290,441
$399,682
$508,923
$618,164
$727,405
$11,000
$117,476
$317,751
$518,026
$718,302
$918,577
$1,118,852
$1,319,127
$16,000
$162,993
$454,302
$745,612
$1,036,921
$1,328,231
$1,619,540
$1,910,849
$21,000
$208,510
$590,854
$973,197
$1,355,541
$1,737,884
$2,120,228
$2,502,572
$26,000
$254,027
$727,405
$1,200,783
$1,674,160
$2,147,538
$2,620,916
$3,094,294
$31,000
$299,544
$863,956
$1,428,368
$1,992,780
$2,557,192
$3,121,604
$3,686,016
$36,000
$345,061
$1,000,508
$1,655,954
$2,311,400
$2,966,846
$3,622,292
$4,277,738
$41,000
$390,579
$1,137,059
$1,883,539
$2,630,019
$3,376,500
$4,122,980
$4,869,460
$46,000
$436,096
$1,273,610
$2,111,125
$2,948,639
$3,786,154
$4,623,668
$5,461,182
type of
device
in vitro
studies
clinical
studies
chlorhexidinesponge
positives
positives
chlorhexidinegel
positives
ry
CRBSIsper1,000CVCdays
0.5
1.5
2.5
BIOPATCH®
Tegaderm™ CHG
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Cost per
CRBSI
ib
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Sensitivityanalysisofkeyinputparametersin
themodelonCRBSI
positives
ongoing
ID
O
silver
ongoing
M
Chlorhexidineimpregnatedsponge
Randomized Controlled Clinical Trial
• Fewer laboratory-confirmed BSIs
(analysis of 387 patients with information about BSI)
C
Control
Sponge
n/1’000 CVC-days
ES
n/1’000 CVC-days
7.2
Effect of Octenidin on the Incidence of CR-BSIs
Treatment
3.8
Group A vs. Group B
n=8 (4.1%) vs. n=16 (8.3%)
*
Odds Ratio
95%-CI
p-value
0.44
[0.18 , 1.09]
0.075
p=0.02
Dwell-times: 15.8 (control), 16.6. (sponge)
*
CNS: 39%; E. coli: 25%; species matched between blood and catheter culture in 4
cases (‘catheter related’)
**
Ruschulte. Ann Hematol 2008;88:267
No laboratory-confirmed BSI in surgical patients (Basel)
• No relevant difference in side effects (i.e. skin irritation)
between the groups
48
Dettenkofer & Widmer AF. Clin Microbiol Infect 2009
1 week
ib
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ry
AmulticenterRCTcomparingsilvercoated
orCHXbiopatch tostandardCVCsinGreekICUs
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1 week
ID
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Arvaniti K Crit Care Med 2012 Vol. 40, No. 1
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Education,Trainingand Staffing
ES
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1. Educate healthcare personnel regarding the indications for intravascular catheter
use, proper procedures for the insertion and maintenance of intravascular catheters,
and appropriate infection control measures to prevent intravascular catheter-related
infections [7–15]. Category IA
2. Periodically assess knowledge of and adherence to guidelines for all personnel
involved in the insertion and maintenance of intravascular catheters [7–15]. Category
IA
Guidelines for the Prevention of Intravascular Catheter-Related Infections 10
3. Designate only trained personnel who demonstrate competence for the insertion
and maintenance of peripheral and central intravascular catheters. [14–28]. Category
IA
4. Ensure appropriate nursing staff levels in ICUs. Observational studies suggest that
a higher proportion of "pool nurses" or an elevated patient–to-nurse ratio is
associated with CRBSI in ICUs where nurses are managing patients with CVCs [29–
31]. Category IB
Catheter Site Dressing Regimens
1.
Use either sterile gauze or sterile, (semi)-transparent dressing to cover the catheter site .
IA
2. If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved .
II
3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled
IB
4. Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential
to promote fungal infections and antimicrobial resistance
IB
5. Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to
reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected
with an impermeable cover during the shower)
IB
6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings.
II
7. Replace dressings used on short-term CVC sites <every 7 days for transparent dressings,
IB
8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the
dressing is soiled or loose), until the insertion site has healed.
II
9. No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed
and tunneled CVCs.
UI
10. Ensure that catheter site care is compatible with the catheter material
IB
11. Use a sterile sleeve for all pulmonary artery catheters
IB
12. ped
13. No recommendation is made for other types of chlorhexidine dressings.
UI
14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a
regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the
insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the
dressing should be removed to allow thorough examination of the site
IB
15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider.
II
CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011
Differences between industralized and less
industrialized contries
• Lowinfection rates with CVCis feasible at low cost
(<2CLABSI/1000patient days)
ry
• Infrastructureof hospitals
• AverageEducationininfection control
– SHEAESGNIcourses
– Accessto medical data
• CVC:Jugular access <1week /Suclavian >1week
– Full barrier precautions at insertion
– Steriledressing afterinsertion
– Insertionsite care with chlorhexidine
• Resources
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• Biopatch,Tegaderm CHX,daily disinfection with remanentdisinfectant
– Coated catheters
– Staff perpatient
ID
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– CHX,Octenidin,Polihexanid
M
C
– Surveillanceof CLABSI
– Handantisepsis with alcoholic compound
– Optimalchoice of access site and catheter
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– Catheters,sterilesupplies
– Dressings/disinfectants
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CONCLUSIONS