Presentation on theme: "Catheter-Associated Bloodstream Infections"— Presentation transcript:
1Catheter-Associated Bloodstream Infections Loreen A. Herwaldt, MD
24JCE Catheter-Associated Bloodstream Infection Rate This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity & mortality
3SICU Catheter-Associated Bloodstream Infection Rate This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity & mortality
4MICU CVC-Associated BSI This material was prepared for use by a UIHC Committee investigating ways to reduce morbidity & mortality
5Central Venous Catheters A CVC is an intravenous catheter whose tip ends in the central venous system.CVC’s are commonly inserted through the jugular, subclavian, femoral, cephalic, & basilic veins.IndicationsAdminister IV fluids, medications, blood productsTotal parenteral nutrition (TPN)Hemodynamic monitoring
6Types of Central Venous Catheters Long-term (>4-6 weeks): totally implantable port, tunneled cathetersIntermediate (>2 weeks, but <6 weeks): peripherally inserted central catheter (PICC)Short-term (<2weeks): non-tunneled central catheter (e.g., triple lumen catheter)Short-term, non-tunneled CVC Account for 90% of CA-BSI
8CVC-associated Bloodstream Infections 200,000 (80,000 ICU) CVC-associated BSI in the hospital per year.10-20% attributable mortality w/ CVC infections in the ICU.Costs of $3,700-$28,000 per line infection and total of $2.3 billion per year in US.
9Median Catheter-associated BSI Rates by ICU Type in US Am J Infect Control 2001; 29:
10Sources of Catheter-associated Bloodstream Infections CONTAMINATION OF DEVICE PRIOR TO INSERTIONExtrinsic >>ManufacturerSKIN ORGANISMSEndogenous FloraHCW handsContam DisinfectantInvading WoundCONTAMINATIONOFCATHETER HUBExtrinsic (HCW)Endogenous (Skin)CONTAMINATEDINFUSATEFluidMedicationExtrinsicManufacturerVeinHEMATOGENOUSFrom Distant Local InfectionFibrin Sheath,ThrombusSkin
11Prevention of Catheter-Associated Bloodstream Infections: Central venous catheter insertion
12Reducing Risk of CVC Infections Do not routinely replace CVC without indication (NEJM 1992;327:1062-8).Remove CVC as soon as possible.Strict adherence hand hygiene & aseptic technique during CVC insertion.Use subclavian vein first, IJ second, and femoral vein last (if possible).Replace lines placed under emergency circumstances within 24 hours.
13Reducing Risk of CVC Infections Always use maximum sterile barrier precautionsSterile gloves and gownNonsterile masks and hatsLarge sterile drapes that cover wide areaPrep site with chlorhexidine gluconate (CHG)Prep with side to side scrub for 30 secondsLet dry for 30 seconds
14Prevention of Central Venous Catheter-Related Infection by Using Maximal Sterile Barrier Precautions During InsertionControlMSBN167176% Colonization7.2%2.3%*Colonization per 1000 catheter days1.00.3*Sepsis per 1000 catheter days0.50.08**p<0.05 vs. controlRaad et al, Infect Control Hosp Epidemiol 1994;15:
15Prevention of Catheter-Associated Bloodstream Infections: Central venous catheter care
16Reducing Risk of CVC Infections Insertion site should be dressed immediately after placing catheter.Do not use topical antibiotic ointment or creams at insertion site.Transparent dressing should be changed weekly, ORDressing should be changed if becomes damp with fluids of any type, soiled, or is non-occlusive.
17Site Care for CVCs Change dressing when wet, soiled or bloody Change transparent dressings q 7 daysChange gauze dressings q 2 days
18Site Care for CVCs Perform hand hygiene. Assemble supplies. Using clean gloves, remove old dressing down to the insertion site.Pull the dressing toward the insertion site of the catheter (this helps prevent pulling out the line).Remove the remainder of the dressing by pulling off the dressing toward the insertion site
19Site Care for CVCsObserve site for erythema, exudate or other signs of infection; notify MD if present.Examine sutures anchoring line to ensure they are intact.Put on sterile gloves & palpate the area for tenderness, swelling or fluctuance.
20Site Care for CVCsClean area around site with CHG in side to side motionAllow CHG to dry for 30 seconds.Do not fan or blow on the site.Apply appropriate dressing.Securely anchor catheter to skin.Record date, time and initials on tape or dressing.
21Maintaining IV Sets Change: IV tubing q 96 hours, except Blood tubing q 24 hoursLipid tubing q 24 hoursPropofol tubing q 12 hoursIV fluids q 96 hours or when meds outdateTransducers, stopcocks, flush devices, and flush solutions q 96 hours
22Reducing Risk of CVC Infections Cleanse outside of hubs with alcohol before each use – allow to air dry.Use TPN only when appropriate & administer through dedicated port.
23Reducing Risk of CVC Infections Guidewire exchanges of CVC
24A Controlled Trial of Scheduled Replacement of Central Venous and Pulmonary-Artery Catheters Cobb et al (NEJM 1992;327:1062-8)Randomized pts. to one of four study Groups:Routine CVC change Q 3 day by GWXRoutine CVC change Q 3 day to new siteCVC change by GWX only when CVC change indicatedCVC change to new site only when CVC change indicated.
25A Controlled Trial of Scheduled Replacement of Central Venous and Pulmonary-Artery Catheters Cobb et al (NEJM 1992;327:1062-8)No difference in infection rate in pts. undergoing scheduled change vs. those undergoing line change when indicated.Higher rate CR-BSI in patients undergoing GWX (p=0.06).High rate of mechanical complications in patients undergoing new stick (p=0.005).
26Guidewire ExchangeRoutine GWX of lines as prophylaxis against CVC infection not supported by literature.Acceptable when line infection not suspected.Do not use guidewire techniques to replace CVC for which there is strong suspicion of CVC-associated infection.Tunneled CVC should never be changed over a guidewire.Ok for line malfunction, new port for TPN, need to change type of line if no fever, elevated WBC or other clinical evidence of line infectionPotential indications for GWX when infection suspectedHistory of difficult line placementNo site for a new puncture (burns, venous thrombosis, etc.)High or catastrophic risk of pneumothorax (e.g.. pneumonectomy patient on contralateral side from surgery)Anticoagulation (guidewire exchange still not risk free)
27Recommended Procedure for Guidewire Exchange of CVC Wide skin prep as with all CVC placements.Double glove and use MSB technique.Once old line removed, remove outer gloves prior to handling new line.Use new sterile caps on ports & new IV tubing.When prepping, hold catheter with one hand, which is now contaminated (like Foley placement). Prep with other hand, starting with skin and then working up the line. Place prepped line either on to chest or on to a sterile barrier opened for this purpose, but not onto the bed (contaminating prep).CAUTION: do not cut if patient is unstable or this is the only access!
28Blood Cultures and Central Venous Catheter Infections Diagnosis of catheter-associated bloodstream infection depends on a positive blood cxContamination of cultures can result in unnecessary use of antibiotics and possible CVC removal
29Blood Cultures and Central Venous Catheter Infections Peripheral sites are preferable to CVC hubs for obtaining blood cx.Antiseptic should be applied to both skin or catheter hub, and blood cx bottle/ tube (air dry – no blowing or fanning).Drawing less than the correct amount (8-10 mls) into a blood cx bottle reduces culture sensitivity.