1. Prevention of CRBSI: Current
Evidence
Dr Deven Juneja
DNB, FNB, EDIC, FCCP, FICCM, FCCM
Associate Director,
Institute of Critical Care Medicine,
Max super speciality hospital, Saket
2. CRBSI – A Global Problem
Infection Control, HAIs and CRBSIs are significant health care
problems of increasing concern
3. Epidemiology
• Occur world wide and affect both developed and
resource-poor countries
• 80,000 CRBSIs occur in ICUs each year, out of 250,000
cases of BSIs
• These infections independently increase hospital costs
and length of stay, but have not generally been shown
to independently increase mortality
• Attributable cost of CLABSIs has been found to vary
from $3,700 to $39,000 per episode
4. Definitions of CRBSI and CLABSI
• 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
5. Independent risk factors for CLABSI
Factors associated with increased risk
1. Prolonged hospitalization
2. Prolonged duration of catheterization
3. Heavy microbial colonization at insertion
site
4. Heavy microbial colonization of catheter
hub
5. Internal jugular catheterization
6. Femoral catheterization in adults
7. Neutropenia
8. Prematurity (ie, early gestational age)
9. Reduced nurse-to-patient ratio in the ICU
10. Total parenteral nutrition
11. Substandard catheter care
12. Transfusion of blood products
Factors associated with reduced risk.
1. Female sex
2. Antibiotic administration
3. Minocycline-rifampin-
impregnated catheters
6. CRBSI
• Concordant growth between catheter tip or hub (by quantitative
or semi-quantitative methods), or exit site exudate, or infusate
and percutaneously drawn blood cultures
• Cocordant growth between catheter drawn & percutaneously
drawn quantitative blood cultures and [Cbc]:[Pbc]≥3:1
• Cocordant growth between catheter & percutaneously drawn
blood cultures and time from blood draw to detection by
automated blood culture system is atleast 2 hours earlier for the
catheter drawn culture
8. Follow proper insertion practices
• Perform hand hygiene before insertion.
• Adhere to aseptic technique.
• Use maximal sterile barrier precautions (i.e., mask, cap, gown, sterile
gloves, and sterile full body drape).
• Choose the best insertion site
• Choose the right catheter
• Prepare the insertion site with >0.5% chlorhexidine with alcohol.
• Place a sterile gauze dressing or a sterile, transparent, semipermeable
dressing over the insertion site.
• For patients 18 years of age or older, use a chlorhexidine impregnated
dressing
9. Handle and maintain central lines
appropriately
• Bathe ICU pts over 2 months of age with a chlorhexidine preparation on a daily
basis.
• Scrub the access port or hub with friction immediately prior to each use with an
appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70%
alcohol).
• Immediately replace dressings that are wet, soiled, or dislodged.
• Change gauze dressings at least every two days or semipermeable dressings at
least every seven days.
• Change administrations sets for continuous infusions no more frequently than
every 4 days, but at least every 7 days.
• If blood or blood products or fat emulsions are administered change tubing every
24 hours.
• If propofol is administered, change tubing every 6-12 hours or when the vial is
changed.
• Perform daily audits to assess whether each central line is still needed.
10. Antibacterial Impregnated Catheters
Most typically:
a. Chlorhexidine- Silver Sulfadiazine (CSS)
b. Minocycline- Rifampicin (MR)
More effective than uncoated catheters
Low doses may not influence resistance
JAMA 1999; 281: 261-7
CCM 2000; 28: 3332-8
11. • 57 studies with 16,784 catheters and 11 types of impregnation
• Overall, catheter impregnation signifi reduced CRBSI, with an ARR of 2% (95% CI 3% to
1%), RR of 0.62 (95% CI 0.52 to 0.74) and NNTB of 50 (high-quality evidence).
• Catheter impregnation also reduced catheter colonization, with an ARR of 9% (95% CI
12% to 7%), RR of 0.67 (95% CI 0.59 to 0.76) and NNTB of 11 (moderate-quality
evidence).
• However, catheter impregnation made no significant difference to rates of sepsis (RR
1.0, 95% CI 0.88 to 1.13; moderate-quality evidence), all-cause mortality (RR 0.92, 95%
CI 0.80 to 1.07; high-quality evidence) and catheter-related local infections (RR 0.84, 95%
CI 0.66 to 1.07; 2688 catheters, moderate quality evidence).
Conclusions
• This review confirms the effectiveness of antimicrobial CVCs in reducing rates of CRBSI
and catheter colonization. However, the magnitude of benefits regarding catheter
colonization varied according to setting, with significant benefits only in studies
conducted in ICUs.
12.
13.
14. • 23 studies revealed significant differences in the rate of CRBSIs per 1000
catheter-days between antimicrobial-impregnated and standard CVCs (RR 0.70,
95% CI 0.53–0.91, p = 0.008).
• 33 trials, 10,464 pts who received one of four types of CVCs.
• Chlorhexidine/silver sulfadiazine and antibiotic-coated catheters were associated
with lower numbers of CRBSIs per 1000 catheter-days (ORs and 95% CrIs: 0.64
(0.40–0.955) and 0.53 (0.25–0.95), respectively) and a lower incidence of
catheter colonization (ORs and 95% CrIs: 0.44 (0.34–0.56) and 0.30 (0.20–0.46),
respectively).
• Conclusions: Outcomes are superior for catheters impregnated with
chlorhexidine/silver sulfadiazine or other antibiotics than for standard catheters
in preventing CRBSIs and catheter colonization under bundles. Compared with
silver ion-impregnated CVCs, chlorhexidine/silver sulfadiazine antiseptic catheters
resulted in fewer cases of microbial colonization of the catheter but did not
reduce CRBSIs.
15. Use antiseptic- or antimicrobial-impregnated
CVCs
• The risk of CLABSI is reduced (chlorhexidine– silver sulfadiazine,
minocycline-rifampin) catheters.
• Use such catheters in the following instances
• Units with CLABSI rate above institutional goals despite compliance with basic
CLABSI prevention practices.
• Pts have limited venous access and a history of recurrent CLABSI.
• Pts are at heightened risk of severe sequelae from a CLABSI (recently
implanted intravascular devices, such as a prosthetic heart valve or aortic
graft).
16. KEY STRATEGY
Use maximum sterile barrier
Cap, mask, sterile gown, sterile gloves, large sterile sheet
Prepped site
Sterile barrier
17. KEY STRATEGY
Clean & disinfect the skin with an effective antiseptic1
CHG SITE PREP
Apply 30 seconds with friction
Allow 30 seconds to dry
18. • 12 studies contributed data, with a total of 3446 CVCs
• low quality evidence that skin antisepsis with chlorhexidine may also
reduce catheter colonisation relative to povidone iodine (RR of 0.68,
95% CI 0.56 to 0.84)
Conclusions
• Skin cleansing with chlorhexidine solution may reduce rates of CRBSI
and catheter colonisation compared with cleaning with povidone
iodine.
• Further RCTs are needed to assess the effectiveness and safety of
different skin antisepsis regimens in CVC care
19. Transparent Plastic Dressing
May trap moisture/ blood
More expensive
Palpate & inspect daily without
removal
Replace if loose,
or if moisture or blood
accumulates
No difference in infection rates
compared with gauze & tape
20. • 22 studies involving 7436 participants
• 9 different types of securement device or dressing
• It is unclear whether there is a difference in CRBSI between securement
with gauze and tape and standard polyurethane (SPU) (RR 0.64, 95% CI
0.26 to 1.63, low quality evidence)
• There is high quality evidence that medication-impregnated dressings
reduce the incidence of CRBSI relative to all other dressing types (RR 0.60,
95% CI 0.39 to 0.93).
• Sutureless securement devices: effective at reducing CRBSI (low quality
evidence)
Authors’ conclusions
• Medication-impregnated dressing products reduce the incidence of CRBSI
21. How to implement a CRBSI reduction program
• Educate healthcare professionals, who place and maintain
catheters
• Periodically assess knowledge of and adherence to
guidelines
• Designate only trained personnel
• Ensure appropriate nursing staff levels in ICUs
• Optimum catheter and site selection
• Hand hygiene and aseptic techniques
• Daily review of line necessity
22. 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
23. Education, knowledge and staffing
Selection of catheter and site
Hand hygiene
Antiseptic techniques
Maximal sterile barrier precautions
Skin preparation
Sutureless securement device
Antimicrobial/antiseptic impregnated
catheter
Education, knowledge and staffing
Minimize CVC manipulation
Consolidate blood draws
Avoid Dextrose, TPN and blood
Daily site inspection (visual & palpation)
Dressing change protocol
Chlorhexidine impregnated sponge
Chlorhexidine wash
Hand hygiene prior to accessing hubs
Hub antisepsis prior to accessing
Tubing replaced after blood, blood
product or fat infusions
Hubs replaced after any opening
Protocol for CVC removal
No routine replacement
Insertion
Maintenance
Use of Bundles
