1. Device (catheter ) Related Infection Husain Abdulaziz Alawadhi MD Consultant intensivist & Infectious diseases

2. Agenda What are the Devices. Epidemiology. Pathogenesis. Diagnosis. Treatment. Prevention.

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7. Device (catheter ) Related Infection Husain Abdulaziz Alawadhi MD Consultant intensivist & Infectious diseases

10. Nonvalvular Cardiovascular Device–Related Infections Circulation. 2003;108:2015-2031. AHA Scientific Statement:

11. Downloaded from: Infectious Diseases (on 16 November 2007 12:04 PM) © 2007 Elsevier Device( catheter related )infections

12. IF YOU REMEMBER ONE THING PLEASE WASH YOUR HANDS

13. Alcohol Based Hand Sanitizers Recommended by CDC based on strong experimental,clinical, epidemiologic and microbiologic data Antimicrobial superiority Greater microbicidal effect Prolonged residual effect Ease of use and application

14. Agenda

15. Epidemiology In the United States, the use of central venous catheters is associated with an estimated 80,000 CRBI( or > 250 000 Bactremia and Fungemia) that result in 28,000 deaths among ICU patients. These infections may result in >$2 billion in annual health care expenditures.

17. Types of catheter Peripheral IV Multiple Lumen central lines PICC Chemotherapy port Quinton catheter Swan Ganze catheter others

18. Agenda

19. The major cause of infection during the first weeks of indwelling time is from skin microorganisms. Rannem, et. al., 1990 Maki, et. al., 1991 Maki (review), 1994 Widmer (review), 1997

20. MECHANISM Of INFECTION Operator Skin flora Contamination of catheter hub and Lumen. Contamination of Infusate.

22. Risk factors Loss of skin integrity. Severity of underlying illness. Thrombogenicity. Number of catheter lumens. Availability of IV team Arch Intern Med. 1998;158:473. Location of catheter Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. JAMA. 2001;286:700 Duration of placement (more or less than 72 hrs) Emergent placement > elective Nursing staffing variables (nurse-to-patient ratio)

23. Infusate related Infections Primary (i.e. no source site identified) nosocomial bacteremia caused by psychrophilic (cold-growing) organisms, such as non-aeruginosa pseudomonads, Achromobacter, Flavobacterium, Enterobacter, Serratia, Salmonella or Yersinia spp.,

24. Agenda

25. When to suspect Local cellulites. Bactremia without source. Clinically septic without source. Non functioning catheter. Positive tip culture. Pus at insertion site. Shivering during the use of catheter (Quinton).

26. Definitions 1. Catheter Colonization: Considered significant growth if > 15 cfu of organism is isolated from catheter segment, or more > 1000 cfu/ml is isolated from the lumen or hub, in the absence of clinical infection. 2. Catheter Related Blood Stream Infection CR-BSI. 3. Phlebitis: induration or erythema, warmth, and pain or tenderness around catheter exit site.

27. Definitions 1. Tunnel infection: tenderness, erythema, and/or induration >2 cm from the catheter exit site, along the subcutaneous tract of a tunneled catheter (e.g., Hickman or Broviac catheter). 2. Exit-site infection : erythema, induration, and/or tenderness within 2 cm of the catheter exit site; may be associated with other signs and symptoms of infection, such as fever or pus emerging from the exit site, with or without concomitant bloodstream infection

29. Groeger, J. S. et. al. Ann Intern Med 1993;119:1168-1174 Microbiologic Isolates: First Device-related Bacteremia or Fungemia

30. How To Diagnose? A positive result of semiquantitative Culture ( 15 CFU per catheter segment) Maki D, et al NEJM 1977;296:1305 or quantitative ( 10 2 CFU per catheter segment) catheter culture, whereby the same organism isolated from a catheter segment and a peripheral blood sample Simultaneous quantitative cultures of blood samples with a ratio of 5 : 1 (CVC vs. peripheral) Differential time to positivity :positive result of culture from a CVC is obtained at least 2 hr earlier than is a positive result of culture from peripheral blood )

31. Remember…………. If You put a central line in a patient with documented Bacteremia, then later next day somebody may obtain a blood culture from both the central lien and from periphery, >>>>>>> a positive blood culture from both sites, does not mean that the central lien is the source.

32. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Issam Raad, Dennis Maki

33. A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID 2007 march ;44:820-826

34. A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID march 2007 A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID march 2007 Conclusions. CR-BSI can be assessed without catheter withdrawal in patients without neutropenia or blood disorders who have catheters inserted for a short time and are hospitalized in the intensive care unit. Because of ease of performance, low cost, and wide availability, we recommend combining semiquantitative superficial cultures and peripheral vein blood cultures to screen for CR-BSI, leaving differential quantitative blood cultures as a confirmatory and more specific technique.

35. Agenda

36. Treating the garbage!!!!!!!!! A central line is removed and it is growing less than 15 CFU. Patient is not septic and blood Culture is negative. >>> No indication to treat the infected or colonized central line, which is in the garbage.

37. Coagulase Negative Staphylococci CVC can be retained, if necessary, in patients with uncomplicated, catheter- related, bloodstream infection. If the CVC is retained, patients should be treated with systemic antibiotic therapy for 7 days. Treatment failure is a clear indication for removal of the catheter.

38. Staphylococcus Aureus Staphylococcus Aureus REMOVE the central line. Systemic antibiotics for minimal 14 days. Failure to clear bactremia within 72 hours Or patient with high risk for endovascualr infection or having prostheis may be indicative for longer 3-6 weeks of treatment. TTE or TEE are strongly advised. Blood Culture should be repeated during therapy and1-2 weeks after completion of therapy, looking for relapses.

39. Staphylococcus Aureus Relapse WARNING

40. Gram Negative Organisms IF gram negative organism were the cause of CR-BSI, then central line should be removed, unless other sources can be found. Antimicrobial should be given for 7-10 days.

41. Fungal Infection Remove the central line and give anti-fungal for 14 days, from the day of the last negative culture. It is advisable to repeat the culture at the end of therapy, to document clearance of the Fungemia. Some authorities advise funduscopical examination.

42. Septic Thrombosis 1. Remove the Central line 2. Systemic antibiotics for 4-6 weeks or more 3. Remove the infected vein if patient clinically not improving 4. Systemic anticoagulation is also highly recommended.

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45. Treatment Of local Infections Antibiotics for 7 days or less + Removal of central line, as far as patient does NOT have bactremia. Do NOT change over Guide wire if patient has local infection. Antimicrobial Therapy WITHOUT catheter removal is also an option, provided the patient does not have systemic signs and symptoms of infection. it is IMPERATIVE that patient should be closely monitored. Tunnel or Pocket infection >>> catheter MUST be removed.

46. Do NOT think of treating local infection with local antibiotics ointment

48. Agenda

49. If you remember one thing : WASH YOUR HANDS

50. Alcohol based hand hygiene solutions Quick: 5- 15 seconds Easy to use Very effective antisepsis due to bactericidal properties of alcohol

51. Hand washing : Historical Perspectives 1846, Ignaz Semmelweis postulated that the puerperal fever was caused by "cadaverous particles" transmitted from the autopsy suite to the obstetrics 1847, he insisted that students and physicians clean their hands with a chlorine solution between each patient examination in the clinic.

52. Center For Disease control (CDC) guidelines

53. CDC RECCOMENDATION

55. Cutaneous Antisepsis and Topical Anti-Infectives Maki and Band prospectively studied three regimens of catheter care: (1) application of polymyxin-neomycin-bacitracin ointment at insertion and every 48 hours, (2) application of iodophor ointment at insertion and every 48 hours, or (3) no ointment. In their study of 827 random catheter insertions, there were no differences in either catheter-acquired sepsis (two cases in each group) or local inflammation (38.9% vs. 41.9% vs. 41.7% percent, respectively). The only difference noted was in semiquantitative cultures of catheter tips. Am J Med. 1981;70:739.

56. Using Chlorhexidine 0.5% A meta-analysis determined that chlorhexidine gluconate significantly reduces the incidence of bacteremia in patients with central venous catheters compared to povidone-iodine for insertion-site skin disinfection.chlorhexidine gluconate Chaiyakunapruk et al. Chlorhexidine compared with povidone- iodine solution for vascular catheter-site care: A meta-analysis. Ann Intern Med. 2002;136:792.

57. Chlorhexidine Skin Antisepsis Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol. Pinch wings on the applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad. Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. completely Allow antiseptic solution time to dry completely before puncturing the site (~ 2 minutes).

58. The inanimate environment is a reservoir of pathogens ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. X represents a positive Enterococcus culture The pathogens are ubiquitous

59. Compliance with hand washing % of HCWs reporting compliance >80% PositionN (%)Handwashing Contact isolation Airborne isolation Registered nurses118 (36)775974 Resident physicians99 (31)626192 Attending physicians33 (10)627282 LPNs, patient care assistants 29 (9)597276 Others45 (14)737969 Total 324 (100) 696580 Berhe M, Edmond MB, G Bearman in AJIC 33;1 February 2005, 55-57 Majority of respondents reported excellent compliance with IC practices

60. Alcohol based hand hygiene solutions Quick: 5- 15 seconds Easy to use Very effective antisepsis due to bactericidal properties of alcohol

61. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med Pronovost P, et al: 355(26):2725-2732, 2006 (1) hand washing, (2) use of full-barrier precautions during placement of catheters, (3) cleansing of the skin with chlorhexidine, (4) use of sites other than the femoral vein when possible, (5) removal of catheters that were no longer needed. The analysis included almost 2000 ICU- months and >375,750 catheter-days of data.

62. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med Pronovost P, et al: 355(26):2725-2732, 2006 Catheter infection rate reduced from 7.7 to 1.4 over 16 months( p< 0.002) 375757 catheter days included.

63. CDC RECCOMENDATION

65. The Central Line Bundle* …is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually. *Bundle: Grouping of best practices

66. Central Line Bundle Elements 1. Hand hygiene 2. Maximal barrier precautions 3. Chlorhexidine skin antisepsis 4. Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters in adults 5. Daily review of line necessity with prompt removal of unnecessary lines

67. If other professions can impose much tighter regulations to minimize risks, should we do the same? Are 3-5 infections/ 1000 patient days acceptable? United States & Canada: accident rates as of 12.31.2004 AirlineRateEventsNo. Flights Air Canada0.6334.75 Million Alaska Airlines0.7434.05 Million Aloha Airlines0.4911.34 Million American AirlinesAmerican Airlines/EagleEagle0.591017.0 Million Continental AirlinesContinental Airlines/ExpressExpress0.6358.00 Million Delta Air Lines0.30620.0 Million http://www.airdisaster.com/statistics/

68. Intranet Based Training Module