1. © 2009 On the CUSP: STOP BSI The Role of Technology in CLABSI Prevention

2. © 2009 Learning Objectives To review considerations for picking new technology to reduce CLABSI To review currently available data regarding the efficacy of several technologies in reducing CLABSI – Chlorhexidine bathing – Chlorhexidine impregnated sponges – Antiseptic-coated catheters

3. © 2009 Considerations When Picking New Technology Is technology needed to reduce CLABSI in your units? – Has best practice been fully adopted? CDC guidelines recommend consideration if rates remain high after implementation of basic prevention strategies Risk of overreliance on technology – Exercise caution in implementing new technology if rates rise after implementing best practice First go back and make sure they are doing what they are supposed to be doing

4. © 2009 Considerations When Picking New Technology When are CLA-BSIs occurring? – < ~10 days often associated with extraluminal contamination of the exit site – > ~10 days often associated with intraluminal contamination via hub or connector – Best approach is prevention of both extraluminal and intraluminal contamination What are central line use patterns in the unit? – Removed within 24-72 hours or in for long periods of time? May need patient-level protocol to direct technology to those at higher risk for CLABSI

5. © 2009 Chlorhexidine Bathing Theory: decolonization of skin decreases organisms that might contaminate the insertion site at the time of placement and while the line is in situ – May also reduce hub colonization if reduce overall microbial burden – May offer the additional advantages of Decreasing rate of blood culture contamination Decreasing rates of other organisms (MRSA, VRE, etc.) Moro ML et al. Infect Control Hosp Epidemiol. 1994;15:253-64. Vernon MO et al. Arch Intern Med. 2006;166:306-12.

6. © 2009 Chlorhexidine Bathing: Evidence 52 week crossover study in 2 MICUs in one center Chlorhexidine (CHG) washcloths vs. soap & water bath daily Primary BSI rate – CHG: 4.1 infections/1000 patient days – Soap & water: 10.4 infections/1000 patient days – Incidence difference 6.3 (95% CI 1.2-11.0) Bleasdale SC et al. Arch Intern Med. 2007;167:2073.

7. © 2009 CHG Impregnated Sponge (Biopatch) Theory: decolonization of the catheter insertion site decreases chance of extraluminal catheter infection Considerations – Learning curve for optimal application—may initially have extra manipulation of insertion site; incorrect application, etc. – Insertion site not visible – No affect on hub

8. © 2009 CHG Impregnated Sponge RCT comparing Biopatch to standard dressings Lines included: arterial catheters and central venous catheters; none antiseptic or antimicrobial coated Outcome: Catheter-related infection – Catheter-related bloodstream infection ≥ 1 positive peripheral blood culture, a quantitative catheter tip culture growing the same organism or differential time to positivity of blood cultures ≥ 2 hours, and no other source – Catheter-related clinical sepsis without bloodstream infection Fever, positive cath tip, pus at line site, and no other source Timsit JF et al. JAMA. 2009;301:1231-41.

9. © 2009 CHG Impregnated Sponge 1636 catheters Median duration of insertion: 6 days Major catheter-related infection rate – CHG sponge: 0.6 infections/1000 catheter days – Standard dressing: 1.4 infections/1000 catheter days – Hazard ratio 0.39 (95% CI 0.16-0.93) 8 episodes of contact dermatitis in sponge group

10. © 2009 Coated Catheters Theory: decrease extraluminal catheter colonization and intraluminal colonization if interior surface of catheter also coated Types – Heparin + benzalkonium bonded (activity on inner and outer surface) – Silver + platinum coating on inner & outer surface – Chlorhexidine and silver sulphadiazine Outer ± inner coating – Antibiotic coating on outer & inner surface: minocycline and rifampin Casey AL et al. Lancet Infect Dis. 2008;8:763-76 Gilbert RE and Harden M. Curr Opin Infect Dis. 2008;21:235

11. © 2009 1 st Generation Chlorhexidine and Silver Sulphadiazine vs. Standard RR 0.68 (0.47-0.98)

12. © 2009 2 nd Generation Chlorhexidine and Silver Sulphadiazine vs. Standard No additional benefit of outer and inner coating OR 0.47 (0.20-1.10)

13. © 2009 Minocycline/Rifampin vs. Standard Minocycline/Rifampin vs. Chlorhexidine RR 0.12 (0.02-0.67) RR 0.29 (0.16-0.52)

14. © 2009 Coated Catheters: Considerations Heparin and Minocycline/Rifampin coatings appear to be more effective than other coatings Limited data regarding: – Risk of development of minocycline or rifampin resistance – Risk of selection of fungal organisms In a different pooled analysis: – Treatment effect seen with catheters in place for 5-12 days but not 13-20 days – Treatment effect seen for femoral and internal jugular insertion sites but not in studies using exclusively subclavian insertion sites Hockenhull JC et al. Health Technol Assess. 2008;12(12).

15. © 2009 Coated Catheters: Considerations Decision to use coated catheters depends on local factors – Extent of adoption of best practice – Duration of catheterization May need to make protocol based on expectations of duration of catheterization at individual patient level rather than unit level – Usual sites of catheters – Concerns about rifampin resistance May choose not to use catheters with rifampin coating in patients with endovascular hardware

16. © 2009 Other Technologies Antiseptic hubs – No published clinical data supporting efficacy Dressings containing chlorhexidine (e.g. Tegaderm™ CHG dressing) – No published clinical data supporting efficacy Antimicrobial lock solutions – Not recommended for routine use – Could be considered in individual patients with limited venous access & history of recurrent CLABSI or in patients at risk for severe sequelae of CLABSI (e.g. new prosthetic heart valve)

17. © 2009 Needleless Intravenous Access Devices “Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assessment of risk, benefits, and education regarding proper use (B-II) – Routine use of the currently marketed devices that are associated with an increased risk of CLABSI is not recommended” Marschall J et al, Infect Control Hosp Epidemiol 2008;29:S22-S30

18. © 2009 Action Items Assess compliance with best practice for CLABSI prevention in your institution If new technologies are desired, evaluate which ones are most appropriate for your patients Monitor for any unexpected effects associated with adoption of new technologies