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Catheter Related Blood Stream Infections - Bundle

Catheter Related Blood Stream Infections - Bundle

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  • 1. The presentation is solely meant forAcademic purpose
  • 2.  Vascular access by the central route epitomizes ICU care In the US more than 5 million catheters are inserted every year In the United States,15 million CVC days (i.e., the total number of days of exposure to CVCs by all patients in the selected population during the selected time period) occur in ICUs each year
  • 3.  These vascular devices become a important source of nosocomial blood stream infection. Almost 250000 cases of nosocomial BSI occur per year in US. Almost 65% of nosocomial BSI are Primary and are associated with Vascular access 90% are due to central venous catheters. Second leading cause of Nosocomial sepsis in the ICU
  • 4.  If the average rate of CVC-associated BSIs is 5.3 per 1,000 catheter days in the ICU, approximately 80,000 CVC-associated BSIs occur in ICUs each year. The attributable mortality for these BSIs has ranged from no increase in mortality in studies that controlled for severity of illness to 35% increase in mortality in prospective studies that did not use this control
  • 5.  The attributable cost per infection is an estimated $34,508–$56,000, and the annual cost of caring for patients with CVC- associated BSIs ranges from $296 million to $2.3 billion
  • 6. Terminology
  • 7.  Microbiologic criteria for diagnosis: Concordant growth of the same organism from peripheral blood and one of the following: ◦ quantitative catheter blood culture (C:P ratio of 3:1 to 5:1) ◦ quantitative catheter segment ( 103 CFU) or semiquantitative catheter segment (>5 CFU) regardless of pathogen ◦ culture of inner catheter hub ( 103 CFU for skin colonizers, any growth for other pathogens) ◦ culture of catheter entry site exudate (regardless of pathogen) ◦ culture of infusate (regardless of pathogen)
  • 8.  Catheter Maintained: ◦ quantitative blood cultures ◦ differential time to positivity
  • 9.  Differential time to positivity ◦ early studies indicated utility primarily in immunocompromised patients with long-term or tunneled catheters ◦ recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as < 30 days)*  diagnosis of CRBSI based on semiquantitative catheter tip and/or quantitative cultures)  sensitivity was lower in short-term catheters and specificity was lower in long-term catheters *Raad I, et al. Ann Intern Med 2004;140:18-25.
  • 10.  Catheter Maintained (continued): Problems associated with catheter-maintained diagnostics: ◦ inability to aspirate blood back for culture ◦ which lumen of the catheter should be cultured ◦ establishment of appropriate threshold for positive result Problems associated in particular with quantitative blood cultures: ◦ not available in many institutions ◦ long turn-around time (48-72 hours)
  • 11.  Catheter removal required ◦ quantitative or semi-quantitative catheter tip or segment cultures Problems associated with catheter segment diagnostics: ◦ needless removal of uninfected catheters ◦ retrospective diagnosis of CRBSI ◦ establishment of appropriate threshold for positive result ◦ potential inhibitory effect of antimicrobial impregnated catheters on subsequent catheter cultures
  • 12.  Do we need the catheter culture data? General consensus of the 1999 AIDAC was yes, particularly where the predominant pathogen is also the most frequent blood culture contaminant Alternative definitions have been proposed: ◦ probable or suspected CRBSI  positive peripheral blood culture (second positive independent blood culture for organisms associated with skin contamination - CNS)  no other secondary source of infection identified  catheter cultures not done or no catheter versus peripheral blood differential was demonstrated
  • 13.  CRBSI is a clinical definition, used when diagnosing and treating patients, that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI. A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site.
  • 14. Epidemiology of CLABSI
  • 15.  The most commonly reported causative pathogens remain coagulase-negative staphylococci, Staphylococcus aureus, enterococci, and Candida spp . Gram negative bacilli accounted for 19% and 21% of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database, respectively
  • 16.  CVC–Associated Bloodstream Infection The rate of CVC-associated bloodstream infection ranged from 7.8 to 18.5 per 1000 CVC days and was 12.5 per 1000 CVC days overall
  • 17.  Central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in Mumbai. Chopdekar K, Chande C, Chavan S, Veer P, Wabale V, Vishwakarma K, Joshi A. Source Department of Microbiology, Grant Medical College and Sir J.J. Hospital, Mumbai 400 008, India. Abstract Blood stream infections related to central venous catheterization are one of the major device-associated infections reported. Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI). The CRBSI rate was 9.26 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27.02/1000 days). Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate. Coagulase- negative Staphylococci were the predominant cause. Mortality of 33% was observed in patients with CRBSI. Since central venous catheters are increasingly being used in the critical care, regular surveillance for infection associated them are essential.
  • 18. Organisms Isolated from Blood cultures (2010-2011) Acinetobacter, 38, 5% Enterococcus faecalis, 32, 5%Staph aureus, 279, Esch.coli, 96, 14% 41% Klebsiella sp, 85, 12% Pseudomonas aeruginosa, 29, 4% Candida sp, 73, 10% Pseudomonas sp, Salmonella typhi / 17, 2% paratyphi A, 50, 7%
  • 19.  1) migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with colonization of the catheter tip; this is the most common route of infection for short-term catheters 2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices 3) less commonly, catheters might become hematogenously seeded from another focus of infection 4) rarely, infusate contamination might lead to CRBSI .
  • 20.  1) the material of which the device is made; 2) the host factors consisting of protein adhesions, such as fibrin and fibronectin, that form a sheath around the catheter ; and 3) the intrinsic virulence factors of the infecting organism, including the extracellular polymeric substance (EPS) produced by the adherent organisms.
  • 21. Microbial biofilmsdevelop whenmicroorganismsirreversibly adhere to asubmerged surface andproduce extracellularpolymers that facilitateadhesion and provide astructural matrix.
  • 22.  Education, training and staffing Selection of catheters and sites Hand Hygeine and aseptic techniques Antimicrobial/antiseptic impregnated catheter Systemic antibiotics and local antibiotics Antimicrobial lock prophylaxis Replacement of Catheters
  • 23.  is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.
  • 24.  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 6. Line secure and dressing clean and intact
  • 25.  Hand hygiene before catheter insertion or maintenance, combined with proper aseptic technique during catheter manipulation, provides protection against infection . Proper hand hygiene can be achieved through the use of either an alcohol-based product or with soap and water with adequate rinsing Appropriate aseptic technique does not necessarily require sterile gloves for insertion of peripheral catheters; a new pair of disposable nonsterile gloves can be used in conjunction with a "no-touch" technique for the insertion of peripheral venous catheters. Sterile gloves must be worn for placement of central catheters since a "no-touch" technique is not possible.
  • 26.  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 6. Line secure and dressing clean and intact
  • 27.  Maximum sterile barrier (MSB) precautions are defined as wearing a sterile gown, sterile gloves, and cap and using a full body drape (similar to the drapes used in the operating room) during the placement of CVC. Maximal sterile barrier precautions during insertion of CVC were compared with sterile gloves and a small drape in a randomized controlled trial. The MSB group had fewer episodes of both catheter colonization and CR-BSI
  • 28.  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 6. Line secure and dressing clean and intact
  • 29.  Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, an iodophor or chlorhexidine gluconate) before peripheral venous catheter insertion Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives
  • 30.  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 6. Line secure and dressing clean and intact
  • 31.  The density of skin flora at the catheter insertion site is a major risk factor for CRBSI. No single trial has satisfactorily compared infection rates for catheters placed in jugular, subclavian, and femoral veins. In retrospective observational studies, catheters inserted into an internal jugular vein have usually been associated with higher risk for colonization and/or CRBSI than those inserted into a subclavian
  • 32.  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 6. Line secure and dressing clean and intact
  • 33.  1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site 2. If the patient is diaphoretic or if the site is bleeding or oozing, use gauze dressing until this is resolved 3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled
  • 34.  Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings Replace dressings used on short-term CVC sites every 2 days for gauze dressings.
  • 35.  Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site
  • 36.  Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007; 167:2073–9.
  • 37.  Application of antibiotic ointments (e.g., bacitracin,mupirocin, neomycin, and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi Promotes the emergence of antibiotic- resistant bacteria, and has not been shown to lower the rate of catheter-related bloodstream infections
  • 38.  Group of interventions ie bundles are the best way forward to prevent device related infections Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles