Download presentation
Presentation is loading. Please wait.
1
VICNISS Coordinating Centre
2011 CLABSI Master Class Monitoring of CVC-associated bloodstream infections in Victorian hospitals VICNISS Coordinating Centre
2
Outline VICNISS CLABSI surveillance module
NHSN CLABSI surveillance – revisions CLABSI rates in Victoria – how do we compare? Prevention of CLABSI – what does the literature say? CLIP surveillance – VICNISS pilot results Ensuring accuracy & reproducibility Case studies for discussion
3
VICNISS & the CLABSI module
4
VICNISS Coordinating Centre Quarterly data submission
commenced collecting hospital acquired infection data in 2002 Quarterly data submission large & small acute public hospitals private hospitals CDC – NHSN (NNIS) Collate, analyse & report ‘hospital rates vs. State rate’; notify CEOs and DoH if significantly high rates identified Based on USA CDC processes and data
5
VICNISS surveillance modules
SSI ICU CLABSI ICU VAP Haemodialysis Surgical prophylactic antibiotics + Type 2 process & outcomes
6
CLABSI – a significant outcome
Mortality attributable mortality 12-25% Increased LOS 2.4 ICU days hospital days Healthcare costs US $ Higuera F et al. ICHE 2007 Warren DK et al. Crit Care Med 2006 Posa PJ et al. AACN Adv Crit Care 2006 Siempos II et al. Crit Care Med 2009 Tacconelli E et al. J Hosp Infect 2009
7
CLABSI case definitions: clinical
Numerous Applications: diagnostic dilemmas, clinical trials Specialised laboratory testing methods: catheter tip cultures quantitative blood and catheter tip cultures differential time to positivity
8
Clinical definitions: heterogeneity
Diagnostic criteria ‘Definite’ Same organism cultured from catheter tip & blood (using DTP or quantitative catheter & peripheral cultures) ‘Probable’ Local infection at insertion site and organism cultured from blood Remission of previously refractory fever within 48 hours of catheter removal with organism cultured from blood. ‘Possible’ Pathogen cultured in blood that is typically implicated in causing catheter-related infections (e.g. S. aureus, Candida) Organism cultured from blood and no other focus identified in a patient with an indwelling CVC Fatkenheuer G, et al. Ann Hematol. 2003
9
CLABSI case definition: surveillance
Uniform & standardised Applications: public health reporting IC monitoring Feasible to apply across range of healthcare facilities Laboratory and clinical criteria
10
NHSN CLABSI surveillance definition for benchmarking
Edwards JR, et al. Am J Infect Control 2009
11
Monitoring in infection control CLABSI surveillance definition to monitor an intervention
Pronovost PJ, et al. N Engl J Med 2006
12
NHSN CLABSI surveillance – revisions
13
The question of definition*
Case-definition criteria NNIS NHSN Recognised pathogen in 1 or more blood cultures Y Skin contaminant in 2 or more blood cultures drawn on separate occasions Skin contaminant in 1 blood culture, where clinician institutes appropriate antimicrobial therapy N *case-definition for CLABSI, adult patients
14
NNIS/NHSN CLABSI rates*
Surveillance period ICU type Jan ‘02-Jun ‘04 Jan ‘06-Dec ‘06 Jan ‘06-Dec ‘07 Cardiothoracic 3.0 1.6 1.4 Medical 5.1 2.9 2.4 Medical/surgical - major teaching 3.9 2.0 - all others 3.3 2.2 1.5 Surgical 4.4 2.7 2.3 Trauma 6.0 4.6 4.0 inclusive of criterion 2b & 3b 2b & 3b removed NNIS Report, Am J Infect Control 2004 Edwards JA, et al. Am J Infect Control 2007 Edwards JA, et al. Am J Infect Control 2008 *published pooled mean rates
15
CLABSI rates - Victoria
Updated NHSN definition: 1 July 2008 pooled mean: 6.05/1000 CVC days pooled mean: 2.06/1000 CVC days
16
CLABSI aetiology following definition change
VICNISS reporting period CNS 36.6% MRSA 17.4% enterococci 9.6% VICNISS reporting period CNS 12.3% MRSA 11.3% enterococci 26.2%
17
NHSN CLABSI definition modifications: June 2011
‘skin contaminants’ → ‘common commensals’ revised & expanded organism list Relatedness of infecting organisms susceptibility profile not required genus/species sufficient
18
Modifying a case-definition considerations for a surveillance strategy
Comparison with historical data Establishing a new baseline for trend analysis Confidence intervals Evidence for prevention & treatment strategies Consider as ‘new’ infection
19
CLABSI rates in Victoria – how do we compare?
20
National trends: CLABSI
Currently available reports: WA 7 contributing hospitals peripherally- and centrally-inserted devices reported separately SA 12 contributing hospitals all bloodstream infections; denominator ‘bed days’
21
Healthcare Infection Surveillance WA (HISWA)
Aggregate ICU CLABSI rate = 0.77/1000 CVC days (Q1 2011)
22
SA Healthcare associated BSI report
23
International data: CLABSI NHSN rates by ICU type
Edwards JR, et al. Am J Infect Control 2009
24
Prevention of CLABSI – what does the literature say?
25
Prevention of CLABSI interventions with proven efficacy
Education physicians & nursing staff Anatomical site subclavian < jugular < femoral Skin asepsis alcoholic chlorhexidine gluconate Maximal barrier precautions Lobo RD, et al. Am J Infect Control 2005 Eggimann P, et al. Ann Intern Med 2005 Hamilton HC, et al. Cochrane database Syst Rev 2007 Pratt RJ, et al. J Hosp Infect 2007 Raad II, et al. infect Control Hosp Epidemiol 1994
26
Impregnated & coated devices
Chlorhexidine-silver sulfadiazine and minocycline-rifampicin impregnated devices reduce colonisation & CLABSI CDC guidelines recommend if CLABSI rates are high Threshold CLABSI rates not proposed (cost-benefit demonstrated for use of chlorhexidine-and-silver-sulfadiazine–impregnated catheters if CLABSI > 2%). Hockenhul JC, et al. Crit Care Med 2009 Casey AL, et al. Lancet Infect Dis 2008 Maki DG, et al. Ann Intern Med 1997
27
The ‘beneficial bundle’
Strategy/intervention consisting of a series of components each component evidence-based & demonstrated impact process measures Implementation feasible achieved by multi-faceted strategy – education, credentialing, product selection
28
Bloodstream infections in ICU US experience with ‘bundle intervention’
Bloodstream infections associated with CVCs are preventable Bundle comprised of 5 interventions: maximal barrier precautions hand washing avoidance of femoral site removal of unnecessary devices chlorhexidine for skin asepsis Significant & sustained impact in reducing rates of infection at multiple US centres Pronovost PJ, et al. N Engl J Med 2006
29
Zero tolerance? Proposal for zero tolerance of CLABSI rates – simple hospital performance indicator Modification in case-definition will reduce CLABSI rates Other contributing factors: barrier precautions, hand-hygiene, skin preparation, removal of unnecessary devices, avoidance of femoral site education, simulator training, credentialing of HCW
31
CLIP surveillance – VICNISS pilot results
32
ICU ‘bundle intervention’ a lesson for Victorian centres
Variable uptake of ICU bundle in Australian centres Victorian centres with high rates of infection - bundle components used by VICNISS as basis for recommendations VICNISS literature review of evidence-based bundle components (2009) Australian & NZ Intensive Care Society (ANZICS) collaboration & support for implementation
33
CLABSI: process monitoring
Central line insertion practices (CLIP) HICPAC CVC insertion guidelines Surveillance module: NHSN Reporting commenced 2008 CLABSI prevention bundle hand hygiene appropriate skin asepsis dry antiseptic before skin puncture maximal barrier precautions (cap, sterile gown, gloves, mask, full drape)
34
NHSN CLIP data preliminary findings
Mar 2008 – Sep 2009 72,216 CVC insertions, 744 healthcare facilities Majority in ICU (84%), and upper extremity devices (62%) 6,356 (8.8%) did not adhere to bundle: 16% did not perform hand hygiene 20% did not use appropriate skin antiseptic 21% did not allow antiseptic to dry 60% did not adhere to maximal barrier precautions cap omitted in 63% full patient drape omitted in 34% Allen-Bridson K, et al. SHEA 2010, abstract 686
35
CLIP data: Victorian experience
Pilot study, Jan – June 2011 4 Victorian centres participating in CLABSI surveillance Audit of CVC insertion practices in ICU Minimum 3 month continuous audit period Assessment of compliance with NHSN bundle Evaluation of feasibility of data collection
37
CLIP data: Victorian experience
38
A role for CLABSI process monitoring in Victoria?
Following pilot – ongoing participation requested Proposed scope for CLABSI process monitoring in Victoria: Optional surveillance module for healthcare facilities currently participating in CLABSI surveillance (periodic/continuous) If higher than expected CLABSI rates at a single centre Monitoring in non-ICU environments, where CLABSI may be less frequent or more difficult to monitor (interventional radiology, ward, other) CLIP module available 10/2011
39
Ensuring accuracy & reproducibility
40
Validation of CLABSI data (VICNISS)
Accuracy of data important for benchmarking & longitudinal analysis, but few validation studies performed by non-US centres Review of hospital medical records comparing reported surveillance data with gold standard 6 Victorian centres, Jan-Dec 2006 Gold standard = blinded assessment by trained VICNISS ICC NNIS case-definition McBryde ES, et al. Infect Control Hosp Epidemiol 2009
41
Outcomes Total 398 bacteraemias, 81 reported as CLABSI. Sample set of 46 reported CLABSIs and 62 not reported as CLABSIs 67% inter-rater agreement with VICNISS review PPV 59% (43-73%), NPV 73% (60-83%) Sensitivity 35% (23-48%), specificity 87% (82-92%) Hypothetical sensitivity 50% [NHSN]
42
Reproducibility of CLABSI data VICNISS
Questionnaire review of Victorian ICCs assessing reproducibility of case-definition when compared to international gold standard 18/21 VICNISS centres, 2006 11-item questionnaire, classification of clinical cases (CLABSI/not CLABSI) NNIS case-definition Gold standard = blinded CDC staff specialist Worth LJ, et al. Am J Infect Control 2009
43
Assessment tool: an example
A patient with sub-arachnoid haemorrhage is admitted to hospital directly into ICU and a CVC is inserted. The patient becomes febrile after 24 hrs, with no localising symptoms or signs. Blood culture taken at 24 hrs isolates Staphylococcus aureus, and treatment with intravenous flucloxacillin is commenced: ⃞ this is an ICU-acquired CLABSI ⃞ this is not an ICU-acquired CLABSI
44
Outcomes Overall concordance with external comparator 57.1% (range %) Mean concordance higher for 1A hospitals compared with non-1A (60.6 vs. 55.3%) Proportion of congruently classified cases, by NNIS criteria: criterion 1, 52.8%; criterion 2a, 83.3%; criterion 2b, 58.3% Hypothetical concordance 62.5% [NHSN]
45
Enhancing CLABSI surveillance
Credentialing tool for IC staff on-line, periodic, rotation of content VICNISS website FAQs, case studies Other education opportunities multi-disciplinary engagement; collaboration with ANZICS ‘CLAB’ project
46
Case studies for discussion
47
Scenario 1 Trauma patient, day 18 post MVA
Blood cultures collected at the same time: from PICC - Enterobacter gergoviae from peripheral site – no growth
48
Scenario 2 Patient with 60% burns.
After prolonged hospital stay, central line in situ, blood culture: Enterobacter spp. On same day as blood culture - patient had clinically infected burns with tissue cultures growing multiple organisms (not Enterobacter).
49
Scenario 3 Patient admitted 5 days ago following head injury.
Central line in situ. Single blood culture from central venous line - Pseudomonas spp. No peripheral blood culture taken. The patient was not febrile or septic at the time of the culture and was not commenced on antibiotics.
50
Scenario 4 28 Apr Admitted to hospital 1 May Admitted to ICU
2 CVC inserted (2200) 3 Blood culture (0600) - Acinetobacter spp Tracheal aspirate - MSSA Notes: "febrile, ? Source GNB on blood culture” 7 ID documented “Acinetobacter cause of line sepsis” CXR essentially clear May 8 CXR increasing consolidation, collapse in the LLL & increasing consolidation R) lung base Acinetobacter spp isolated from tracheal aspirate
51
Scenario 5 A patient grew an Enterococcus spp from a single peripheral blood culture. Patient in ICU for severe pneumonia but was clinically improving (extubated the day before, no longer febrile, white cell count decreasing). Medical History - ID physician notes: “Enterococcus - probable contaminant".
52
Scenario 6 A patient is undergoing treatment for acute myeloid leukaemia has chemotherapy-induced mucositis (mouth ulcers, nausea, vomiting). Hickman line in situ blood culture taken peripherally - Enterococcus spp multiple occasions.
54
Gut source or CLABSI? Gram-negative bacteraemia (or fungaemia) in ICU patients may occur either because of translocation of microorganisms from oedematous, abnormal, or adynamic segments of bowel or because of microscopic or macroscopic defects in the bowel wall. Absence of proof (of an established infection at a site other than a central vascular catheter as a source of bacteraemia) cannot be cited as proof of absence.
55
CLABSI due to Enterococci?
The issue of using a single blood culture positive for enterococci as evidence of a laboratory-confirmed case of CLABSI is not a trivial. Evidence that Enterococci are frequent contaminants of blood cultures is compelling. Infectious diseases specialists routinely perform a repeat blood culture as a first step to assess patients who have a single blood culture positive for Enterococci. If the repeat culture result is negative, most infectious diseases specialists would conclude that the single positive blood culture result represents contamination.
56
CLABSI surveillance definition 2 proposed changes
Inclusion of an “indeterminate source” for some BSIs, and Acknowledgement that a single blood culture positive for Enterococci has little clinical significance, similar to the interpretation of a single blood culture positive for CNS.
57
CLABSIs could be divided into 3 categories:
primary secondary, or indeterminate source. Acceptance of an “indeterminate source” category for some patients with BSI would allow hospital epidemiologists to acknowledge that we can not determine the source of every infection with certainty.
58
Scenario 7 Patient with relapsed acute myeloid leukaemia presented with documented febrile neutropenia. CVC in situ. Streptococcus viridians spp grown from two separate blood draws.
59
Common commensals, NHSN, 2011
Aerococcus species Staphylococcus auricularis Aerococcus urinae Staphylococcus capitis ss capitis Aerococcus viridans Staphylococcus capitis ss unspecified Bacillus cereus Staphylococcus capitis ss urealyticus Bacillus species (not B. anthracis) Staphylococcus coagulase negative Bacillus subtilis Staphylococcus cohnii Corynebacterium aquaticum Staphylococcus epidermidis Corynebacterium bovis Staphylococcus gallinarum Corynebacterium cystitidis Staphylococcus haemolyticus Corynebacterium glutamicum Staphylococcus hominis Corynebacterium group G-2 Staphylococcus lentus Corynebacterium jeikeium Staphylococcus lugdunensis Corynebacterium kutscheri Staphylococcus saccharolyticus Corynebacterium matruchotii Staphylococcus saprophyticus Corynebacterium minutissimum Staphylococcus schleiferi Corynebacterium mycetoides Staphylococcus sciuri Corynebacterium pilosum Staphylococcus simulans Corynebacterium pseudodiphtheriticum Staphylococcus species Corynebacterium pseudotuberculosis Staphylococcus warneri Corynebacterium renale Staphylococcus xylosus Corynebacterium species Streptococcus anginosus Corynebacterium striatum Streptococcus bovis Corynebacterium ulcerans Streptococcus mitis Corynebacterium urealyticum Streptococcus mutans Corynebacterium xerosis Streptococcus salivarius Diphtheroids Streptococcus viridans species Gram-positive cocci unspecified Micrococcus species Propionibacterium acnes Propionibacterium avidum Propionibacterium granulosum Propionibacterium lymphophilum Propionibacterium propionicum Propionibacterium species Rhodococcus equi Rhodococcus species Common commensals, NHSN, 2011
60
Scenario 8 Haematology patient with refractory B-cell lymphoma.
Day 3 post allograft - blood cultures from both Hickman lumens and peripherally - E. coli . Patient has an anal fissure. CT scan: no abscess. Ongoing abdominal pain, Laparotomy 1 week earlier - NAD. Abdominal pain still under investigation. Hickman was not removed by the treating team, TPN was ongoing.
62
Case 9 A patient with CVC in situ for 9 days becomes febrile
1/5 - E. coli is isolated in blood culture 2/5 - Klebsiella pneumoniae is isolated in blood culture Chest X-ray is clear and no organism is isolated from urine. No other primary source of infection is identified.
63
Case 10 In the setting of fever, a patient with CVC in situ isolates Staphylococcus epidermidis from a single blood culture. The treating clinician commences vancomycin for targeted therapy.
Similar presentations
