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Risk factors for long-term catheter-related infections

Risk factors for long-term catheter-related infections. Jean-François TIMSIT Medical ICU Epidemiology, INSERM U 578. ESICM Barcelona – Sept 25th 2006. Routes of catheter contamination. Extraluminal: Skin infection: Hematogenous seeding. Endoluminal: Hub contamination

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Risk factors for long-term catheter-related infections

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  1. Risk factors for long-term catheter-related infections Jean-François TIMSIT Medical ICU Epidemiology, INSERM U 578 ESICM Barcelona – Sept 25th 2006

  2. Routes of catheter contamination • Extraluminal: • Skin infection: • Hematogenous seeding • Endoluminal: • Hub contamination • Infusate contamination

  3. Skin vs. hub originated CRS Long-term catheter-related infection are mainly hub-related CATH TIME SKIN HUB 7 15 18 21 24 110 65% 35% 50% 10% 30% 30% 35% 25% 50% 70% 70% 70% Guidet (1994) Fan et al. (1988) Cicco et al. (1989) Liñares (1985) Salzman (1993) Weightman (1988)

  4. Many more data for short-term CRILong-term hemodialysis CVCs • Cuffed tunneled, silicone rubber elastomer catheters (Hickman type) • Frequent access • Totally implanted venous access ports • Mainly intermittent use

  5. Main risk factors • Time • Type of devices • Rank of the device • Underlying illness • Handling  specialized team, education • Thrombosis  anticoagulants and fibrinolytics • Potential for the use of antiseptic and antimicrobials??

  6. 80 70 60 50 40 30 20 10 0 CRS and catheterization time Prevalence of CRS 2,5 5 7,5 10 12,5 15 17,5 20 22,5 25 Catheter days Sitges-Serra A 1988

  7. Rate of BSI are different according to the type of devices… Crnich CJ & Maki DG – Clin Infect Dis 2002; 34:1362

  8. Influence of the Rank of the catheter Nephrol Dial transplant 2001; 16:2194 573 CVCs, 336 patients, half-life 312 days 1 episode of CRS per 25.6 Pts months

  9. HIV > Cancer • 10-month (1995) Prospective follow-up, 12 hospitals, Paris • Hickman CVCs and Ports • Cancer (n=255) and HIV (n=201) infected patients Cancer HIV 3.78 vs 0,39 per 1000 CVC-days, p<0.001 Astagneau P et al – ICHE 1999; 20:494

  10. Hematologic malignancies > solid tumors Groeger et al - Ann Intern Med 1993

  11. Risk factor of CRI in onco-hematology: the major role of neutropenia Risk factors Nb CRI / nb of devices days RR IC 95% hosp vs home therapy 6/2732 7/4100 1,3 0,4 - 3,8 Neutropenia 6/1259 0/1473 15,1 2,6 - 86,5 New CVC 3/1118 3/1614 1,4 0,3 - 7,1 TPN 0/499 3/1525 0,4 0,0 - 69,4 ARA - C 3/981 0/378 2,7 0,9 - 8,3 BMT 3/708 3/2024 2,9 0,6 - 13,1 Howell PB et al Cancer 1995; 75 : 1367-75

  12. Risk factors for BMT recipients 81/242 BMT recipients with 100 episodes of CR infections Propective follow up, during the hospitalisation (7 to 187 days) Cox model, neutropenia as a time-dependant covariate • Univariately: More septicemia during neutropenic than non neutropenic days 17.82 vs 5.51 per 1000 catheter days • Cox’s model: • Age > 18y: RR=2.03, p=0.003 • Presence of VOD: RR=1.65, p=0.028 Elishoov H et al - Medicine. 1998 Mar;77(2):83-101.

  13. 215 Hickman, 125 Cook, 324 PICC,155 Midline, 70 Ports 69532 device days (1 to 395, med 44) Rate of infection: 0.99/1000 cvc days * (*) outpatient clinics or physician’s office Ann Intern Med 1999; 131:340

  14. Frequency of CVC handling Astagneau P et al – ICHE 1999; 20:494 HIV 3.04/1000 cvc-days  20-40% days in use 5.07/1000 cvc-days  80-100% days in use Cancer patients 0.17/1000 cvc-days  0-20% days in use 4.9 /1000 cvc-days  60-80% days in use

  15. Change of the CVC extension set or the dressing more than once a week • HIV infected patients • Change of CVC extension more than once per week: • 4.8 vs 2.61/1000 CVC-days, p=0.03 • Change of dressings more than once per week: • 4.6 vs 2.54/ 1000 CVC-days , p=0.04 Astagneau P et al – ICHE 1999; 20:494

  16. Prevention of CRS CRS rate before (%) after (%) Freeman (1972) 21 2.3 Sanders (1976) 28.6 4.7 Stotter (1987) 39 8 Kehoane (1983) 33 4 Tomford (1984) 2.1 0.2 Faubion (1986) 24 3.5 Nelson (1986) 28.8 3.3 Impact of catheter care teams on the rate of catheter-related sepsis

  17. Patient education Moller T et la - Journal Hosp. Infect (2005) 61, 330–341 • 82 tunneled Hickman cath., hematology • Individualized training vs control • General information • Pratical guidance in principles and techniques • Controlled testing of the patients’ theoretical knowledge and behavior • 3 modules: sterile dressing + flushing techniques + drawing blood samples

  18. Relationship between thrombosis and infection • Post-mortem study: long term catheter • Thrombus of the vein wall in 38% of catheterized veins • 7/31 patients with thombosis have had a CR-BSI • 0/41 patients with a normal catheterized vein have developped CR-BSI Raad - JAMA 1994; 271:1014

  19. Continuous infusion of low dose Unfractionated heparin in Patients with onco-hematologic diseases Abdelkefi et al – J Clin Oncol 2005; 23:7864 UH: 100 U/Kg/dys vs Saline Subclavian, investigator blinded 210 eligible/ 204 included Thrombosis: 2 vs10, p=0.017 CR-BSI: 7 vs 17, p=0.03 (4.2 vs 2.5/1000 dys)

  20. Occlusive events 23% v 31%, P .006 2.6 vs 3.9 / 1000 CVCs days External cath. Ports Urokinase lock in pediatric oncologic patients Dillon et al - J Clin Oncol. 2004;22(13):2718-23 • 577 patients, 29 centers • 281 ports, 288 external CVCs (86% bi-lumen) • Stratified allocation, unblind • Urokinase 5000 IU at least 1 hour/2 weeks + heparin vs heparin alone • Rate of occlusive events • Rate of infections 1.6 vs 2.2 CR-BSI, p=0.07, logrank test

  21. Thrombolysis • Urokinase > 5000 IU every 1-2 or 3-4 weeks • Reduced incidence of thrombosis • Reduced the incidence of premature IVD loss • Tendency of benefit to reduce CR-BSI • Cost-benefit analysis? Adapted From Ray CE 1999, Dillon 2004, Solomon 200, Aquino 2002

  22. MRSA carriage at insertion Jean G et al – Nephron 2002; 91:399 * p<0.05 **p<0.001 ***p<0.0001

  23. Mupirocin.(meta-analysis).is effective.. But emergence of resistant strains is frequent Taconelli et al- 2003;37:1629-1638

  24. In vitro efficacy of Taurolidine-citrate solution Shah CB et al – AAC 2002; 46:1674

  25. Taurolidine + citrate vs Heparin

  26. Antibiotic lock therapy • 117 Long-term CVCs Hematologic patients with neutropenia • 10 UI/ml of heparin + 25µg/ml de Vanco • 1 heure/2 days Potential ecological impact Carratala AAC 1999; 43:2200

  27. Ab lock therapyHenrickson 2000; J Clin Oncol 18:1269-1278 =Vanco+heparin =Vanco+heparin+cipro

  28. Long-term Abx impregnated vs cuffed tunneled CVC Darrouiche RO et al – Ann Surg 2005; 242:193 •  Rafael Sierra…

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