Prevention of Catheter-Related Infections in the Adult and Pediatric Population Darcy Doellman RN BSN PICC/CVC Resource Nurse Cincinnati Children’s Hospital Medical Center

Central Venous Catheters Background & Complications Essential in managing chronic & critically ill patients Essential in managing chronic & critically ill patients 41% of PICU patients have 1 or more CVC 41% of PICU patients have 1 or more CVC 57% of adult ICU patients have 1 or more CVC 57% of adult ICU patients have 1 or more CVC Complications: Complications: Mechanical (migration, hole in catheter) Mechanical (migration, hole in catheter) Catheter obstruction, occlusion & thrombosis Catheter obstruction, occlusion & thrombosis Catheter-Related BSI Catheter-Related BSI

Catheter-Related Infections Clinical Implications Medical costs up to $25,000 to treat a Catheter-related infection Medical costs up to $25,000 to treat a Catheter-related infection Average rate of CR-BSI is 5.3/1,000 catheter days in the ICU, approx 80,000 CR-BSI occur annually in the US Average rate of CR-BSI is 5.3/1,000 catheter days in the ICU, approx 80,000 CR-BSI occur annually in the US Morbidity Morbidity Mortality Mortality Terminology Terminology

Noscomial Infections Vast majority of noscomial infections are device or procedure related Vast majority of noscomial infections are device or procedure related Twenty fold increase of candida since 1965 Twenty fold increase of candida since 1965

CSR-BSI Considerations and Central Venous Access Devices Infection Control Issues Short-term CVCs PICCs Tunneled Catheters Implanted Ports Dwell Times Reported mean 30+ days 4 days 1+ years 6 weeks 1+ years 6 months 3+ years 3 years Rate of CR-BSI 5.3/1000 catheter days 0.51/1000 catheter days 2.77/1000 catheter days 0.21/1000 catheter days Insertion Issues Bedside Medical Providers Bedside Nurses IR/OR Medical Providers IR/OR Medical Providers Sources: CDC 2002, Moreau, 2002, Ryder, 1996, Lowenthal et. Al. 2002, Skiest, 2000, Thiagajarian, 1997,Alhimyary, 1996, Abi-Nader, 1993, Ng, 1997, Graham, 1991 Site Preparation

Practice Issues Desired Outcomes: Provide best care possible Provide best care possible Evidence-based practice Evidence-based practice Minimize complications of central lines Minimize complications of central lines Reality We use what’s available Unaware of complications Limitations of literature Do not consider overall costs

Challenge for Clinicians Multi-tasking Multi-tasking Information overload Information overload Time intensive Time intensive Staffing issues Staffing issues Experienced personnel Experienced personnel

Catheter Occlusion Prevention – CCHMC Studies Simple (n=150) Valve (n=149) PPV1+ Heparin (n=150) PPV1+ Saline (n=150) PPV2+ Saline (n=161) Patient Age (Months) 45.6      8.0 Catheter Type: Non-Tunneled PICC Tunneled 63 (66%) 31 (32%) 2 (2%) 64 (71%) 23 (26%) 3 (3%) 76 (89%)# 9 (11%)# 0 69 (79%) 18 (21%) 0 56 (73%) 20 (26%) 1 (1%) Catheter Duration (days) 9.7   0.6*7.4  0.7#7.4  0.5*8.3  0.9* Complete Occlusions18 (12.0%)2 (1.3%)$5 (3.3%)#6 (4%)*6 (3.7%)* Partial Occlusions7 (4.7%)11 (7.4%)6 (4%) 13 (8.1%) Complete + Partial Occlusions 25 (16.7%)13 (8.7%)10 (6.7%)*12 (8%)*19 (11.8%)

INCIDENCE OF CR-BSI Catheter duration (Raad et al J Hosp Infect 1993) Catheter duration (Raad et al J Hosp Infect 1993) Insertion Site ( IJ site associated with fourfold increase as compared to subclavian site) Insertion Site ( IJ site associated with fourfold increase as compared to subclavian site) Geography (Mermel et al Am J Med 1991) Geography (Mermel et al Am J Med 1991) High risk patients High risk patients Multiple lumens/catheters Multiple lumens/catheters Catheter material (polyvinyl chloride or polyethyl) Thrombogenicity/phlebitis Catheter material (polyvinyl chloride or polyethyl) Thrombogenicity/phlebitis

CR-BSI Microbes colonize skin at the insertion site and the catheter hub (Mermel et al Am J Med 1991) Microbes colonize skin at the insertion site and the catheter hub (Mermel et al Am J Med 1991) Sutures go through skin, inflammation Sutures go through skin, inflammation

Biofilm Basics Planktonic and sessile cells interact Planktonic and sessile cells interact As sessile bacteria attach to a surface, they begin to excrete a slimy material (biofilm). Single cells – Early structure – Mature biofilm (nutrients flow through complex structures) As sessile bacteria attach to a surface, they begin to excrete a slimy material (biofilm). Single cells – Early structure – Mature biofilm (nutrients flow through complex structures) Researchers have shown that bacterium attached to a surface “turns on” a whole different set of genes. This makes it a different organism to deal with Researchers have shown that bacterium attached to a surface “turns on” a whole different set of genes. This makes it a different organism to deal with

Biofilm Lifestyles Free Floating UbiquitousPlanktonic Rapid growth Fairly sensitive Embedded Ubiquitous Sessile Phenotype Slow growth Highly resistant

Biofilm Basics Researchers at the “Center for Biofilm Engineering” have discovered a different level of expression of genes, a division of labor Researchers at the “Center for Biofilm Engineering” have discovered a different level of expression of genes, a division of labor Some cells use energy turned on by metabolic pathways and effects the partial degradation while others use the degradation products to produce new cells (cell to cell communication) Some cells use energy turned on by metabolic pathways and effects the partial degradation while others use the degradation products to produce new cells (cell to cell communication)

BIOFILM The “Iceberg Effect” The “Iceberg Effect” Described by Maki and Mermel Described by Maki and Mermel Difficult to treat, best to remove it. Patient may be asymptomatic Difficult to treat, best to remove it. Patient may be asymptomatic Cultures may grow planktonic cells Cultures may grow planktonic cells Biofilm in “high flow” areas may seed other parts of the body Biofilm in “high flow” areas may seed other parts of the body

FUTURE TREATMENT Biofilm inhibitor (RAP, TRAP, RIP is biofilm inhibitor) Biofilm inhibitor (RAP, TRAP, RIP is biofilm inhibitor) Biofilm inhibitor plus antibiotic in dacron cuff Biofilm inhibitor plus antibiotic in dacron cuff With the use of ultrasound, the inhibitor and antibiotic would be released With the use of ultrasound, the inhibitor and antibiotic would be released Biofilm inhibitor in antibiotic beads as they dissolve Biofilm inhibitor in antibiotic beads as they dissolve

Prevention Handwashing Handwashing Chlorohexidine scrub ( 1a recommendation from the CDC) Chlorohexidine scrub ( 1a recommendation from the CDC) BioPatch ( chlorhexidine- impregnated synthetic disk) BioPatch ( chlorhexidine- impregnated synthetic disk) Anti-infective lock solution in long-term devices Anti-infective lock solution in long-term devices Maximal sterile barriers Maximal sterile barriers Specialty teams Specialty teams Multidisciplinary approach Transparent dressing Antimicrobial-infected catheters Securement devices

Handwashing 50% of nosocomial infections could be eliminated by handwashing alone 50% of nosocomial infections could be eliminated by handwashing alone Hands are only washed 50% of the times indicated Hands are only washed 50% of the times indicated Wearing gloves does not eliminate need to wash hands before or after patient contact Wearing gloves does not eliminate need to wash hands before or after patient contact 15 second vigorous hand wash with soap and running water 15 second vigorous hand wash with soap and running water Primary infection control measure Primary infection control measure

Chlorhexidine Skin Antiseptic Superior efficacy Superior efficacy Rapid onset (30 seconds) and prolonged antimicrobial efficacy Rapid onset (30 seconds) and prolonged antimicrobial efficacy Recent meta-analysis suggest CR-BSI is significantly reduced in patients receiving chloraprep vs providine- iodine for site disinfection Recent meta-analysis suggest CR-BSI is significantly reduced in patients receiving chloraprep vs providine- iodine for site disinfection 80% of resident and transient flora live in the 1 st 5 layers of dry skin (1 st 10 layers of wet skin) Friction is necessary 80% of resident and transient flora live in the 1 st 5 layers of dry skin (1 st 10 layers of wet skin) Friction is necessary (Chalyakunapruk N, et al. Ann Intern Med. 2002;135, 792) (Chalyakunapruk N, et al. Ann Intern Med. 2002;135, 792)

BIOPATCH Foam patch with chlorhexidrine gluconate with antimicrobial and antifungal properties Foam patch with chlorhexidrine gluconate with antimicrobial and antifungal properties Highly absorbent Highly absorbent Inhibits growth of bacteria for 7 days Inhibits growth of bacteria for 7 days Shown to significantly reduce bacterial colonization of CVC sites (Hanazaki et al, J Hosp Inf 1999) Shown to significantly reduce bacterial colonization of CVC sites (Hanazaki et al, J Hosp Inf 1999) Associated with localized contact dermatitis in infants of very low birthweight (Garland et al, Pediatrics Associated with localized contact dermatitis in infants of very low birthweight (Garland et al, Pediatrics 20010

ANTI-INFECTIVE LOCK SOLUTION Prophylaxis with vancomycin lock (More studies needed) Risk of VRE Prophylaxis with vancomycin lock (More studies needed) Risk of VRE Ethanol instillation (to be published soon) 25% ethanol instilled for one hour each day Ethanol instillation (to be published soon) 25% ethanol instilled for one hour each day

PREVENTION The use of maximal sterile barrier, including the use of hair covering, face mask, sterile gown and gloves and large sterile drapes, have been shown to reduce the risk of infection by six to seven times over the use of sterile gloves and drapes alone (Maki, 1994) The use of maximal sterile barrier, including the use of hair covering, face mask, sterile gown and gloves and large sterile drapes, have been shown to reduce the risk of infection by six to seven times over the use of sterile gloves and drapes alone (Maki, 1994) AHRQ AHRQ

SPECIALTY TEAMS IV Teams/PICC teams IV Teams/PICC teams Clinical resource for clinicians Clinical resource for clinicians Routine assessment of CVC sites Routine assessment of CVC sites Monitoring of CVC for potential complications Monitoring of CVC for potential complications Goal is to provide appropriate access from the start Goal is to provide appropriate access from the start

PREVENTION Uniform Guidelines Uniform Guidelines INS Standards/ CDC Guidelines INS Standards/ CDC Guidelines Policies available and user-friendly Policies available and user-friendly Yearly competencies Yearly competencies Resources available Resources available Process Improvement Process Improvement Ongoing educational opportunities Ongoing educational opportunities

PREVENTION EDUCATION Mandatory education program for ICU nurses and physicians in a 19-bed medical ICU at Washington University Mandatory education program for ICU nurses and physicians in a 19-bed medical ICU at Washington University 10-page self-study module on risk factors and practice modifications relating to CR-BSI and inservices 10-page self-study module on risk factors and practice modifications relating to CR-BSI and inservices Pre and post-test. Fact sheets and posters reinforced the information Pre and post-test. Fact sheets and posters reinforced the information Results: Results: 24 months before the education, CR-BSI occurred in 9.4/1,000 catheter days ( 74 in 7,879 catheter days) 24 months before the education, CR-BSI occurred in 9.4/1,000 catheter days ( 74 in 7,879 catheter days) After implementing new program, CR-BSI occurred in 5.5/1,000 catheter day (41 in 7,455 catheter days) After implementing new program, CR-BSI occurred in 5.5/1,000 catheter day (41 in 7,455 catheter days) Estimated cost savings with decreased CR-BSI was between $103,600 and 1,573,000. Estimated cost savings with decreased CR-BSI was between $103,600 and 1,573,000. Warren DK. “The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infections in a Medical Center.” Chest 2004;126: Warren DK. “The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infections in a Medical Center.” Chest 2004;126:

TRANSPARENT DRESSING Semi-permeable polyurethane dressings Semi-permeable polyurethane dressings Dry and intact Dry and intact Routine dressing changes Routine dressing changes Special attention to immunocompromised patients and neonates Special attention to immunocompromised patients and neonates

ANTIMICROBIAL IMPREGNATED CATHETERS PREVENTION Purpose: Evaluate efficacy of long- term non-tunneled silicone catheters impregnated with minocycline and rifampin (M-R) in reducing CR-BSI Purpose: Evaluate efficacy of long- term non-tunneled silicone catheters impregnated with minocycline and rifampin (M-R) in reducing CR-BSI Prospective, randomized, double- blind study N=356 Prospective, randomized, double- blind study N= M-R Catheter duration days CR-BSI M-R Catheter duration days CR-BSI control Catheter duration days CR-BSI control Catheter duration days CR-BSI 14 Hanna H, et al. “Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial.” J Clin Oncol Aug 1;22(15): Hanna H, et al. “Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial.” J Clin Oncol Aug 1;22(15): CR=BSI rates: M-R 0.25/1,000 catheter days Control 1.28/1,000 catheter days P=.003 Gram-positive cocci accounted for the majority of positive cultures No allergic reactions

ANTISEPTIC IMPREGNATED CATHETERS AND CUFFS Catheters coated with chlorhexidine/silver sufadiazine on the catheter surface can reduce the risk for CR-BSI Catheters coated with chlorhexidine/silver sufadiazine on the catheter surface can reduce the risk for CR-BSI Antimicrobial activity decreases over time, benefit will be realized within the 1 st 14 days. Antimicrobial activity decreases over time, benefit will be realized within the 1 st 14 days. Although rare, anaphylaxis has been reported Although rare, anaphylaxis has been reported More expensive than standard catheters, may be cost effective for high risk patients i.e. patients with burns, neutropenia More expensive than standard catheters, may be cost effective for high risk patients i.e. patients with burns, neutropenia Veenstra DL et al, “Efficacy of antiseptic-impregnated central venous catheters in preventing catheter- related blood stream infections: a meta-analysis.” JAMA 1999;281;261-7.

SECUREMENT DEVICES Decrease irritation Decrease irritation Decrease needlesticks Decrease needlesticks Decrease catheter migration Decrease catheter migration Increase patient comfort Increase patient comfort Decrease infection (Shears et al, 2000 ) Decrease infection (Shears et al, 2000 )

ADDITIONAL STRATEGIES Catheters inserted into new sites, not old sites over a guidewire (avoid routine replacement of central lines) Catheters inserted into new sites, not old sites over a guidewire (avoid routine replacement of central lines) Warfarin and Heparin Prophylaxis (Thrombus formation on indwelling CVC associated with CR- BSI) S. aureus, S. epidermidis, and Candida species adhere to different protein components of thrombus) Warfarin and Heparin Prophylaxis (Thrombus formation on indwelling CVC associated with CR- BSI) S. aureus, S. epidermidis, and Candida species adhere to different protein components of thrombus) Subcutaneously tunneled short term catheters (Cuffed dialysis catheters decreases risk of CR-BSI by 2/3) Subcutaneously tunneled short term catheters (Cuffed dialysis catheters decreases risk of CR-BSI by 2/3) Minimize hub manipulations Ointments to insertion site; may lead to increased colonization of candida species. (Ointment to insertion sites of temporary HD central lines reduces CR-BSI)

“KEEP ME SAFE” Patient campaign from the Oley foundation Patient campaign from the Oley foundation Specific instructions for central line care Specific instructions for central line care Goal is to prevent infection Goal is to prevent infection