Catheter Related Blood Stream Infection Presented by: Mrs. Lima Aboul Hosn Dubai Hospital- UAE

Introduction Intravascular catheters represents an essential part of the management of critically ill patients who present as acute emergency. However, their use is often complicated by serious infections, mostly catheter related-blood stream infections (CRBSIs), which are associated with increased morbidity, increase in duration of hospitalization, and additional medical costs. The incidence of CRBSIs varies considerably by the type of catheter, frequency of catheter manipulation, and patient related factors, such as underlying disease and severity of illness. (Centers for Disease Control and Prevention, 2002) (Centers for Disease Control and Prevention, 2002)

Objectives: 1.To identify problems related to vascular catheter infections & dysfunction. 2.To educate the concerned staff about strategies for prevention of catheter related blood stream infection. 3.To reduce patient morbidity & mortality rates and hence this will reduce hospital length stay and total cost.

GOAL: To reduce catheter related blood stream infection in the dialysis unit based on the international standard measures.

Indications for Venous Catheters TemporaryPermanent Acute emergency access in the sitting of acute renal failure, overload, metabolic disturbance Cuffed Catheters for long time Sudden loss Vascular AccessChildren Transfer temporarily from PDMultiple access failures No accessPatient Medical Condition as elderly or patients with generalized atherosclerosis. For CVVH/CVVHD/Plasma Exchange

Permanent Vs. Temporary Catheters

PROBLEMS COMMONLY IDENTIFIED, IN THE DIALYSIS UNIT OF DUBAI HOSPITAL RELATED TO VASCULAR CATHETER: 1. CATHETER DYSFUNCTION 2. INFECTION

PROBLEMS COMMONLY IDENTIFIED, IN THE DIALYSIS UNIT OF DUBAI HOSPITAL RELATED TO VASCULAR CATHETER: 1. CATHETER DYSFUNCTION  EARLY  Kinks  Catheter Malposition  Patient position  Catheter integrity – holes, cracks  LATE  Thrombosis

Assessment of Catheter Dysfunction:  Blood pump rate < 300 ml/min  Unable to aspirate blood freely  Frequent pressure alarms  URR progressively < 65% (or Kt/V < 1.2)  Arterial pressure increased (< mmHg)  Venous pressure increased (> 250 mmHg)

  Method for treatment based on Dubai Hospital Protocol  Thrombolytics, using either an intraluminal thrombolytic.  Repositioning of a malpositioned catheter.  Catheter exchange MANAGEMENT OF CATHETER DYSFUNCTION

2. INFECTION: 2. INFECTION:  BREAK IN ASEPTIC TECHNIQUE DURING INSERTION AND PRIOR CANNULATION  SITE AND QUALITY OF THE CATHETER  DRESSING MATERIALS  PATIENT LACK OF EDUCATION/NON COMPLIANCE PROBLEMS COMMONLY IDENTIFIED, IN DIALYSIS UNIT OF DUBAI HOSPITAL RELATED TO VASCULAR CATHETER:

Types of Infections:  EXIT SITE INFECTIONS  TUNNEL INFECTIONS  BLOOD STREAM INFECTION

Exit Site Infection Localized, negative blood culturesLocalized, negative blood cultures Local treatment measuresLocal treatment measures Removal of catheter: Failure to respond to treatmentFailure to respond to treatment sepsissepsis

Tunnel & Port Pocket Infection Infection above the cuffInfection above the cuff Negative blood cultureNegative blood culture TreatmentTreatment  Catheter removal if persist.  Intravenous antibiotics

Definition of CRBSI Catheter related blood stream infection resulting from bacterial colonization of an intravascular catheter.

CATHETER RELATED BACTEREMIA  Positive blood cultures  No other obvious source  Variable symptoms.  Different degrees of severity

SIGNS & SYMPTOMS OF Catheter-Related Bloodstream Infection: LOCAL INFECTIONS  LOCAL INFLAMMATION  DISCHARGE AROUND THE CATHETER EXIT/TUNNEL SITE  ERYTHEMA  PAIN SYSTEMIC INFECTIONS  FEVER  RIGORS MAINLY WHEN THE LINE IS USED  TACHYCARDIA  METASTATIC INFECTION

The blood should be free from microbes CATHETER RELATED BACTEREMIA

Healthcare interventions, like the use of Central Vascular Catheters make patients exposed to infection – as organisms can get direct entry to the blood. CATHETER RELATED BACTEREMIA

Infections start locally at the catheter insertion site,, but then… CATHETER RELATED BACTEREMIA

If the infection is not treated effectively, the organisms can infect the blood

Once the organisms are in the blood a Staph aureus bacteraemia has occurred (Usual organisms are Staph. aureus, however gram negative, polymicrobial can occur) CATHETER RELATED BACTEREMIA

The best way to prevent microbes from getting into the blood is…. CATHETER RELATED BACTEREMIA

To Reduce Device Days & Optimise Care CATHETER RELATED BACTEREMIA

 Secondary complications  Pneumonia  Septic arthritis  Endocarditis  Epidural abscess  Death

Indication for Removal of HD Catheter Persistence of fever and positive blood culture while being on appropriate Antibiotics for hrs Exit site infection extending to catheter tunnel with sever sepsis CRBSI associated with hypotension or signs of cerebral hypoperfusion Septic thrombosis of great veins as determined by Doppler flow study Infective Endocarditis and systemic embolisation. Based upon NKF – DOQI clinical practice Guidelines for vascular access

CR-BSI/ 1000 CATHETER DAYS RESULTS: BSIBSI JanFebMarAprMa y JunJulAugSepOctNovDec 2/ 362 3/ 392 2/ 542 1/ 505 8/ 501 2/ 528 4/ 560 3/ 550 2/ 507 2/ 518 2/ 619 2/ CDC and JCAHO recommended that CRBSI be reported in terms of infections per 1000 catheter days

Infection rate

RECOMMENDATIONS: 1. GOOD HAND HYGIENE 2. STRICT ASEPTIC TECHNIQUE DURING CHANGING OF DRESSINGS 3. RELEVANT OBSERVATION OF THE EXIT SITE/DOCUMENTATION 4. MAXIMAL STERILE BARRIER PRECAUTIONS DURING CATHETER INSERTION 5. USE STERILE DEVICE ON MULTI DOSE VIAL 6. NASAL SWAB SCREENING FOR STAPH AUREUS BEFORE INSERTION OF CATHETER 7. CATHETER REMOVAL WHEN NO LONGER INDICATED 8. TO AVAIL THE 2% CHLORHEXIDINE GLUCONATE AS SKIN ANTISEPSIS 9. QUALITY OF CATHETER AND DRESSING MATERIALS 10. CONTINUING STAFF AND PATIENT EDUCATION 11. MONTHLY SURVEILLANCS AND AUDIT. 12. THE USE OF CATHETER LOCKING SOLUTIONS/TAUROLOCK AND HEPARIN

CONCLUSION: MANY CATHETER RELATED BLOOD STREAM INFECTIONS ARE PREVENTABLE INFECTIONS THAT NEED TO BE APPROACHED SYSTEMATICALLY AT A MULTIDISCIPLINARY LEVEL THAT EMPHASIZE THE PATIENT SAFETY AND QUALITY IMPROVEMENT, THEREFORE ALL STAFF INVOLVE IN THE MANAGEMENT OF THE VASCULAR CATHETER MUST BASED THEIR PRACTICE ON WHAT IS AGREED IN THE LITERATURE AND RECOMMENDATIONS AS BEING EFFECTIVE IN REDUCING THE RISKS OF CATHETER RELATED BLOOD STREAM INFECTIONS. MANY CATHETER RELATED BLOOD STREAM INFECTIONS ARE PREVENTABLE INFECTIONS THAT NEED TO BE APPROACHED SYSTEMATICALLY AT A MULTIDISCIPLINARY LEVEL THAT EMPHASIZE THE PATIENT SAFETY AND QUALITY IMPROVEMENT, THEREFORE ALL STAFF INVOLVE IN THE MANAGEMENT OF THE VASCULAR CATHETER MUST BASED THEIR PRACTICE ON WHAT IS AGREED IN THE LITERATURE AND RECOMMENDATIONS AS BEING EFFECTIVE IN REDUCING THE RISKS OF CATHETER RELATED BLOOD STREAM INFECTIONS.

THANK YOU!

REFERENCES 1. Centers for Disease Control and Prevention(2002): Guidelines for the prevention of intravascular catheter-related infections. MMWR Reccom, 51 (RR-10): 1-29 MMWR Reccom, 51 (RR-10): Chaiyakunapruk N, Veenstra D, Lipsky B, Sullivan S, Saint S(2003) Vascular catheter site care:The clinical and economic and benefits of chlorhexidine gluconate compared with povidone-iodine,Clinical Infectious Disease,Volume 37, Drewett, SR.(2002), Complications of central venous catheters: Nursing care, British Journal of Nursing, Volume 9(8), pages Dogra, G.(2006) Preventing catheter related infections with antibiotic lock solutions: are we spoilt for choice? Nephrology,11: Dougherty L. (2000), Central venous access devices,Nursing Standard,14(43),45- 50,July Field J.(2002), Prevention of Infection:central venous catheters, Nursing Standard, 16(38)42-44,June Pittet D, Tarara D, Wenzel RP (1994), Nosocomial blood stream infection in critically ill patients:excess length of stay, extra cost and attributable mortality,Journal of the American Medical Association(JAMA),271(20), NKF – DOQI clinical practice Guidelines for vascular access