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2011 CLABSI Master Class Monitoring of CVC-associated bloodstream infections in Victorian hospitals VICNISS Coordinating Centre.

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Presentation on theme: "2011 CLABSI Master Class Monitoring of CVC-associated bloodstream infections in Victorian hospitals VICNISS Coordinating Centre."— Presentation transcript:

1 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 –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

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 criteriaNNISNHSN Recognised pathogen in 1 or more blood cultures YY Skin contaminant in 2 or more blood cultures drawn on separate occasions YY Skin contaminant in 1 blood culture, where clinician institutes appropriate antimicrobial therapy YN *case-definition for CLABSI, adult patients

14 NNIS/NHSN CLABSI rates* Surveillance period ICU type Jan 02-Jun 04Jan 06-Dec 06Jan 06-Dec 07 Cardiothoracic Medical Medical/surgical - major teaching all others Surgical Trauma inclusive of criterion 2b & 3b2b & 3b removed *published pooled mean rates 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

15 CLABSI rates - Victoria pooled mean: 6.05/1000 CVC days pooled mean: 2.06/1000 CVC days Updated NHSN definition: 1 July 2008

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 ,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 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 AprAdmitted to hospital 1 MayAdmitted to ICU 2 CVC inserted (2200) 3 Blood culture (0600) - Acinetobacter spp Tracheal aspirate - MSSA 4 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 Aerococcus speciesStaphylococcus auricularis Aerococcus urinaeStaphylococcus capitis ss capitis Aerococcus viridansStaphylococcus capitis ss unspecified Bacillus cereusStaphylococcus capitis ss urealyticus Bacillus species (not B. anthracis)Staphylococcus coagulase negative Bacillus subtilisStaphylococcus cohnii Corynebacterium aquaticumStaphylococcus epidermidis Corynebacterium bovisStaphylococcus gallinarum Corynebacterium cystitidisStaphylococcus haemolyticus Corynebacterium glutamicumStaphylococcus hominis Corynebacterium group G-2Staphylococcus lentus Corynebacterium jeikeiumStaphylococcus lugdunensis Corynebacterium kutscheriStaphylococcus saccharolyticus Corynebacterium matruchotiiStaphylococcus saprophyticus Corynebacterium minutissimumStaphylococcus schleiferi Corynebacterium mycetoidesStaphylococcus sciuri Corynebacterium pilosumStaphylococcus simulans Corynebacterium pseudodiphtheriticumStaphylococcus species Corynebacterium pseudotuberculosisStaphylococcus warneri Corynebacterium renaleStaphylococcus xylosus Corynebacterium speciesStreptococcus anginosus Corynebacterium striatumStreptococcus bovis Corynebacterium ulceransStreptococcus mitis Corynebacterium urealyticumStreptococcus mutans Corynebacterium xerosisStreptococcus salivarius DiphtheroidsStreptococcus 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.

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