The ideal management of theexit site: antisepsis, dressing, securement Giancarlo Scoppettuolo Catholic University, Rome
Targeting ZeroTargeting Zero is the philosophy that everyhealthcare institution should be working toward agoal of zero healthcare-associated infections(HAIs). While HAI prevention is challenging andcomplex, APIC believes that all organizationsshould set the aspirational goal of elimination andstrive for zero infections. Every HAI impacts thelife of
VAD SELECTIONAND HEALTHCARE WORKERS INSERTIONEDUCATION AND TRAINING CRBSI Prevention DISINFECTION OF CATHETER HUBS, CARE OF EXITE SITE CONNECTORS AND INJECTION PORTS
Prevention of extra and intraluminal colonization CHG Skin CHG Eluting Disk Preparation (applied after catheter insertion and with every (applied before catheter dressing change) insertion and with every Swabable dressing change) Needleless Connector Intraluminal colonizationExtraluminalcolonization Modified, Courtesy of R. Garcia, MD
Why Proper CL Maintenance is CriticalInsertion Period= 30 min = 0.3% Maintenance Period = 167.5h = 99.7% 0 1 2 3 4 5 6 7 Average Central Line Days Modified, courtesy of J. LeDonne, MD
Manteinance of Exit Site• Which antiseptic?• Which Dressing?• When to change?• Is there any indication for chlorhexidine impregnated dressing?• Which securement?
Guidelines for CRBSI Prevention• CDC Atlanta 2002• RCN 2005• INS 2006• BCSH 2006• EPIC 2007• SHEA/IDSA 2008• ESPEN 2009• RCN 2010• INS 2011• CDC 2011
Advantages of chlorhexidine• Bactericidal• Broad activity against Gram positive and Gram negative bacteria, facultative anaerobes, yeasts and some lipid-enveloped viruses, including HIV (but not sporicidal)• Rapid onset of activity• Prolonged antimicrobial effect• Synergistic effect with alcohol• Lack of inactivation when exposed to blood and serum
Premature Infant Skin• Stratum corneum poorly developed or absent• Thin epidermis• Dermis not fully formed and deficient of structural proteins“Shaping the Future of Pediatric Vascular Access 2012”
Full Term Infant Skin Healthy infants • Well-formed stratum corneum…..note multiple layers • Thick epidermis • Structural proteins present in the dermis“Shaping the Future of Pediatric Vascular Access 2012”
CHG versus PI in Neonates • Pilot parallel comparison: 2% CHG (alcohol) vs. 10% Povidone Iodine • 48 neonates ≥ 1500 g (~ 30wks GA) and ≥ 7 days • No catheter related BSIs in either group • No dermatitis - CHG or PI (i.e., ≥ 2,no pink-red all area) • CHG absorption occurred: • 7 of 10 had blood CHG between 13 – 100 ng/ml • No neurotoxicity Studies needed in younger preterms Garland J, et al. J Perinatol (2009); 29:808-813“Shaping the Future of Pediatric Vascular Access 2012”
CHG Use in NICUs • A survey of 90 NICU training units found: 55 Used CHG, central venous catheter care 27 No restrictions 28 Restrictions: GA, actual age or birth weight 28 Reported adverse reactions, all skin related 17 burns, 2 erosions, 9 erythema 55 Had concerns: Off label use, Immature skin, Limited safety data Tamma P, et al. Infect Control Hosp Epidemiol (2010);31(3):846-849“Shaping the Future of Pediatric Vascular Access 2012”
Advantages of Semipermeable Transparent Dressing• Visibility of insertion site• Better stabilization of catheter, avoiding “in and out” movements• Better protection against secretions, mostly if catheter’sexit site is near tracheostomy or oral and nose secretions• Longer time between dressing changes (7 days vs 2 days)
Is there any indication forchlorhexidine impregnated dressing?
Disadvantages of sutures• Sutures disrupt the skin around the catheter exit site, causing inflammation and heavy colonization• Bad securement of catheter, with movement of “in and out” and increased risk of thrombosis and infection• Patient discomfort• Risk of sharps injury to healthcare workers from inadvertent needlestick injury
RCN 2005 RCN 2010 INS 2006 INS 2011BCSH 2006CDC 2011
Conclusions• A proper care of the catheter exit site is critical for CRBSI prevention• The preferred antiseptic for skin during the dressing change is 2% chlorhexidine (preferably in isopropyl alcohol)• To cover and protect the exit site , you can use gauze and tapes or semipermeable transparent dressing, taking into account the differences in terms of replacing (2 vs 7 days)• To secure the catheter, use sutureless devices instead of sutures.
Last Conclusion…• All this works and is really effective not as an isolate strategy, but only if it is part of a bundle of recommendations…
• Hands hygiene and maximal barrier precautions• Ultrasound guided insertion• Use of 2% chlorhexidine, for skin antisepsis before insertion and for continous or discontinous antisespis of exit site• Use of sutureless devices for catheter securement, whenever possible• Use of transparent dressings, whenever possible• Prompt removal of unnecessary lines
Targeting zero CLABSI in patients with PICC lines: a case-control studyG. Scoppettuolo§, L. Dolcetti§, C. Taraschi§, C. Chiarini§, C. Donato§, S. Lardo§, A. La Greca*, M. Pittiruti* § Clinic of Infectious Diseases, * Dpt. of Surgey, Catholic University, Rome AVA 2011
Results CASES CON TROLS P ( I nfe ct ious ( Ot h e r w a r ds) D ise a se s)CRBSI 0 14 < 0.001CLABSI / 1 0 0 0 ca t h e t e r da y s 0 2.66 < 0.001D ia gn osis · D TP 10 · Blood cu lt u re + t ip 4 cult ur eM e dia n t im e for CLABSI NA 21+12on se tEt iology of CLABSI NA · Ca n dida a lbica n s 3 · Ca n dida pa r a psilosis 2 · CON S 3 · S. a u r e u s 1 · E. coli 3 · K. pn e u m on ia e 2CLABSI r e la t e d de a t h s 0 0 NS
Thank you for your attention!Giancarlo Scoppettuolo, MDCatholic University“ A. Gemelli” Hospital, RomeE-mail: email@example.comWeb: www.gavecelt.infowww.evanetwork.infowww.policlinicogemelli.it