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Catheter-related bloodstream infections

Catheter-related bloodstream infections. Wanida Paoin Thammasat University. Catheter-related bloodstream infections. Incidence in PICU: 7.3-13.8 central line-associated bloodstream infection s/1000 cath days Risk factors premature < 1000 g low immunity multiple CVC

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Catheter-related bloodstream infections

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

  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 MinimalMaximal 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 cathSubclavian cath Cath colonization14.2%2.2% Cath sepsis4.4%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 CHXControl 2.3%7%*†0.5%2.6% (Maki `91) 2%7%*0.6%0.6% (Sheehan`93) 4.7%9.3%*00.5% (Garland `95) 12/10331/103*0.1/1030.9/103 (Minoz`96) 34%27%*3.5/1034.1/103 (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 665736 Cath colonization 16%29%* CRBSI1.2%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 CHSS Control #CVCs 368374 Cath duration 7 d7d Cath coloniz 6.4%12.8%(9/103CD)(19/103CD)† †p=0.006 Rupp et al, ICAAC 2001

  15. Minocycline-Rifampin-Impregnated Catheters Minocycline-Rifampin-Impregnatedvs 1stGenChlorhexidine-Silver Sulfadiazine-Impregnated CVCs* M-RCHSS Duration6 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-IontophoreticControl 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 typeCaths w/ significant growth Control100% Chlorhexidine/silver sulfadiazine 67% Silver iontophoretic20% 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

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