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

2. 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)

3. 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.

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

5. 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

6. Permanent Vs. Temporary Catheters

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

8. 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

9. 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 (< - 250 mmHg)  Venous pressure increased (> 250 mmHg)

10.   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

11. 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:

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

13. 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

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

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

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

17. 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

18. The blood should be free from microbes CATHETER RELATED BACTEREMIA

19. 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

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

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

22. 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

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

24. To Reduce Device Days & Optimise Care CATHETER RELATED BACTEREMIA

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

26. Indication for Removal of HD Catheter 1. 1. Persistence of fever and positive blood culture while being on appropriate Antibiotics for 36-48 hrs. 2. 2. Exit site infection extending to catheter tunnel with sever sepsis. 3. 3. CRBSI associated with hypotension or signs of cerebral hypoperfusion. 4. 4. Septic thrombosis of great veins as determined by Doppler flow study. 5. 5. Infective Endocarditis and systemic embolisation. Based upon NKF – DOQI clinical practice Guidelines for vascular access

27. 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/ 674 5.527.653.691.6815.93.787.145.453.943.863.232.96 CDC and JCAHO recommended that CRBSI be reported in terms of infections per 1000 catheter days

28. Infection rate

29. 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. THE USE OF CATHETER LOCKING SOLUTIONS/TAUROLOCK AND HEPARIN 7. NASAL SWAB SCREENING FOR STAPH AUREUS BEFORE INSERTION OF CATHETER 8. CATHETER REMOVAL WHEN NO LONGER INDICATED 9. TO AVAIL THE 2% CHLORHEXIDINE GLUCONATE AS SKIN ANTISEPSIS 10. QUALITY OF CATHETER AND DRESSING MATERIALS 11. CONTINUING STAFF AND PATIENT EDUCATION 12. MONTHLY SURVEILLANCS AND AUDIT.

30. o monthly audit, report and analysis. o Evaluation: The central line audit tool was utilized to track the number and nature of infections, via the monthly audit, report and analysis. o o Action and follow up: continuous monthly audit, report and analysis of the outcomes. continuous monthly audit, report and analysis of the outcomes. Monitor Staff compliance with hospital policies and procedures mainly the Standard precaution policy. Monitor Staff compliance with hospital policies and procedures mainly the Standard precaution policy. Reduction of the temporary CVC. Reduction of the temporary CVC. o o Results: Seven consecutive months reduction in the CVC infections were noted following the practice change. Only one month went raised up again due to un availability of Vascular surgeon so the use of temporary catheter increased. Summary of PDCA /Haemodialysis unit -DH

31. 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.

33. THANK YOU!

34. 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): 1-29 2. 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 37,764-771. 3. Drewett, SR.(2002), Complications of central venous catheters: Nursing care, British Journal of Nursing, Volume 9(8), pages 466-478. 4. Dogra, G.(2006) Preventing catheter related infections with antibiotic lock solutions: are we spoilt for choice? Nephrology,11: 297-298 5. Dougherty L. (2000), Central venous access devices,Nursing Standard,14(43),45- 50,July 12. 6. Field J.(2002), Prevention of Infection:central venous catheters, Nursing Standard, 16(38)42-44,June 5. 7. 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),1598-1602 8. 8. NKF – DOQI clinical practice Guidelines for vascular access