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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 ra 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 n © lin by e L au ec th tu or re L DREAM? Low cost – close to zero CLABSI? ID O 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$ ES • • • • • • C M 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) n © lin by e L au ec th tu or re L 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 ib ra Device Hub Colonization (0.2–0.7) Fibrin sheath Hematogenous Seeding Widmer AF. In: Wenzel RP: Prevention and Control of Nosocomial Infections, 1997 ES C M ID O Crnich CJ & Maki DG. CID 2002; 34:1232–42 BiofilmFormationonCatheters 1 day Widmer AF. J Infect Dis 1990;162:96-100 ES C M ID O n © lin by e L au ec th tu or re L 10 days PBS ib ra MHB ry 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 ib ra Parameters n © lin by e L au ec th tu or re L 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 O 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 ES 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 O n © lin by e L au ec th tu or re L ib ra Infection Control Activity Coating of Catheters InVivoAntiinfective Efficacy of the NewCoated CHX/SDDCatheter In-vitro ES C M 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 ib ra Coated Control <0.01 Teaching NS NS n © lin by e L au ec th tu or re L Outcome ry Infection Control Activity ID O 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 ES C 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 n © lin by e L au ec th tu or re L ib ra 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 ry 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 O 25 TheIntervention ES C M 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 ES C M 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 O n © lin by e L au ec th tu or re L ib ra ry 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 n © lin by e L au ec th tu or re L ib ra ry 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 ES C M ID O 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 n © lin by e L au ec th tu or re L ib ra 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 O Infection_Control_11 Rosenthal VD et al, Infect Control Hosp Epidemiol 2010; 31(12):1264-1272 ES C 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) n © lin by e L au ec th tu or re L ib ra ry 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 O Ho KM & Letton E, J Antimicrob Chemother 2006 Jun Sensitivityanalysisofkeyinputparametersinthemodel. CRBSI,catheterrelatedbloodstreaminfection ES C M 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 n © lin by e L au ec th tu or re L Cost per CRBSI ib ra 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 ra ry AmulticenterRCTcomparingsilvercoated orCHXbiopatch tostandardCVCsinGreekICUs n © lin by e L au ec th tu or re L 1 week ID O Arvaniti K Crit Care Med 2012 Vol. 40, No. 1 M Education,Trainingand Staffing ES C 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 n © lin by e L au ec th tu or re L • Biopatch,Tegaderm CHX,daily disinfection with remanentdisinfectant – Coated catheters – Staff perpatient ID O – CHX,Octenidin,Polihexanid M C – Surveillanceof CLABSI – Handantisepsis with alcoholic compound – Optimalchoice of access site and catheter ib ra – Catheters,sterilesupplies – Dressings/disinfectants ES CONCLUSIONS