1. Catheter-related bloodstream infections Wanida Paoin Thammasat University

2. Catheter-related bloodstream infections Incidence in PICU: 7.3-13.8 central line-associated bloodstream infections/1000 cath days Risk factors  premature < 1000 g  low immunity  multiple CVC  long term CVC insertion  reduced ICU Nurse:Patient Ratio  using Non-ICU-Trained Nurses in ICUs

3. From: Mermel L, Rhode Island Hospital POTENTIAL ROUTES OF INFECTION

4. Strategies for Prevention of Catheter- Related Infections Quality Assurance and Continuing Education Surveillance  Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis,  Manifestations suggesting local or BSI, the dressing should be removed to allow thorough examination of the site Hand Hygiene and Aseptic Technique  Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape) during the insertion of CVCs  Hand hygiene before and after inserting, replacing, accessing, or dressing an intravascular catheter.  Washing hands with conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams.

5. Catheter Insertion Efficacy of Barrier Precautions During CVC Insertion Barrier precautions Minimal Maximal Cath colonization 7.2% 2.3%* Cath sepsis 3.6% 0.6%* *p<0.05 Raadet al, ICHE 1994

6. Strategies for Prevention of CR Infections Site of Catheter Insertion  Femoral catheters: relatively high colonization rates, higher risk for deep venous thrombosis  Internal jugular cath: higher risk for infection than those inserted into a subclavian or femoral vein

7. Catheter Placement Prospective, Randomized, Multicenter Study of Femoral vs Subclavian CVC Insertion Femoral cath Subclavian cath Cath colonization 14.2% 2.2% Cath sepsis 4.4% 1.5% Cath thrombosis 6% 0% Merrer et al JAMA 2001

8. Strategies for Prevention of CR Infections Skin Antisepsis  2% aqueous chlorhexidine gluconate lowered BSI rates compared with site preparation with 10% povidone-iodine or 70% alcohol

9. Cutaneous Antisepsis CR Infection Prevention w/ Chlorhexidine Cath colonization CRBSI CHX Control 2.3% 7%*†0.5% 2.6% (Maki `91) 2% 7%*0.6% 0.6% (Sheehan`93) 4.7% 9.3%* 0 0.5% (Garland `95) 12/10 3 31/10 3 * 0.1/10 3 0.9/10 3 (Minoz`96) 34% 27%*3.5/10 3 4.1/10 3 (Humar`97) red values = p<0.05 *= povidone iodine † = alcohol

10. Strategies for Prevention of CR Infections Catheter Site Dressing Regimens  Transparent, semipermeable polyurethane dressings: Reliably secure the device, Permit continuous visual inspection of the catheter site, Permit patients to bathe Require less frequent changes than do standard gauze A meta-analysis: The risk for CRBSIs did not differ between the groups using transparent dressings versus groups using gauze dressing. If blood is oozing from the catheter insertion site, gauze dressing might be preferred.

11. Strategies for Prevention of CR Infections Catheter Site Dressing Regimens  Chlorhexidine-impregnated sponge (Biopatch™) placed over the site A multi-center study: reduced the risk for catheter colonization and CRBSI. No adverse systemic effects resulted from use of this device.

12. Chlorhexidine-Impregnated Sponge Chlorhexidine-Impregnated Sponge (Biopatch) at Cath Insertion Site C-I sponge Control 665 736 Cath colonization 16% 29%* CRBSI 1.2% 3.3%*† *RR 0.62 (0.49-0.78) †RR 0.38 (0.16-0.89 Maki, Mermel, et al ICAAC 2000

13. Strategies for Prevention of CR Infections Antimicrobial/Antiseptic Impregnated Catheters and Cuffs  Chlorhexidine/Silver sulfadiazine.  Minocycline/Rifampin.  Platinum/Silver  Silver cuffs

14. Chlorhexidine-Impregnated Sponge Chlorhexidine-Silver Sulfadiazine-Impregnated 2ndGeneration Catheters CHSSControl #CVCs 368 374 Cath duration 7 d 7d Cathcoloniz 6.4% 12.8% (9/10 3 CD) (19/10 3 CD)† †p=0.006 Rupp et al, ICAAC 2001

15. Minocycline-Rifampin-Impregnated Catheters Minocycline-Rifampin-Impregnated vs 1stGen Chlorhexidine-Silver Sulfadiazine-Impregnated CVCs* M-R CHSS Duration 6 d7 d CRBSI0.3%3. 4% (RR 0.1, CI 0-0.6) *M-R impregnation intraluminal &extraluminal, CHSS impregnation only extraluminal Darouicheet al, NEMJ 1999

16. Silver Iontophoretic Catheter Silver-Iontophoretic Control CRBSI 3.1% 8%* CRBSI1% 3.9%† Combined OR 0.23 (0.07-0.66) *Bong et al, ICAAC 2001 †Ibanez-Nolla et al, ICAAC 2001

17. Silver Iontophoretic Catheter Catheter type Caths w/ significant growth Control 100% Chlorhexidine/silver sulfadiazine 67% Silver iontophoretic 20% insertion site of lab animals inoculated w/ S. aureus, caths quantitatively cultured at 7 d Raadet al, JID 1996

18. Strategies for Prevention of CR Infections Antibiotic/Antiseptic Ointments  Povidone-iodine ointment  Mupirocin ointment Antibiotic Lock Prophylaxis  Flushing and filling the lumen of the catheter with an antibiotic solution and leaving the solution to dwell in the lumen of the catheter.  Heparin plus 25 micrograms/ml of vancomycin  Vancomycin/ciprofloxacin/heparin combination  Minocycline and ethylenediaminetetraraacetic acid (EDTA)

19. Strategies for Prevention of CR Infections Anticoagulants  Prevent catheter thrombosis  Heparin flush  Heparin-bonded coating  Warfarin

20. Strategies for Prevention of CR Infections Replacement of intravascular catheters  Replace CVCs if purulence is observed at the insertion site  Replace CVCs if the patient is hemodynamically unstable and CRBSI is suspected  Do not use guidewire techniques to replace catheters in patients suspected of having catheter- related infection

21. Strategies for Prevention of CR Infections Replacement of administration sets  Replace administration sets, and add-on devices, no more frequently than at 72-hour intervals, unless catheter-related infection is suspected  Replace tubing used to administer blood, blood products, or lipid emulsions within 24 hours  If the solution contains only dextrose and amino acids, the administration set does not need to be replaced more frequently than every 72 hours

22. Strategies for Prevention of CR Infections Quality Assurance and Continuing Education+++ A subclavian site instead of a jugular or femoral site++ Hands hygiene, maximal barrier precautions for CVC insertion +++ Changing administration sets at appropriate intervals+++ Remove caths after intended use+++ Chlorhexidine-containing cutaneous antiseptics+ Transparent, semipermeable polyurethane dressings+ Antimicrobial/Antiseptic Impregnated Catheters and Cuffs +,+ Anticoagulants+ Antibiotic/Antiseptic Ointments-