Presentation on theme: "VICNISS Coordinating Centre"— Presentation transcript:
1VICNISS Coordinating Centre 2011 CLABSI Master Class Monitoring of CVC-associated bloodstream infections in Victorian hospitalsVICNISS Coordinating Centre
2Outline VICNISS CLABSI surveillance module NHSN CLABSI surveillance – revisionsCLABSI rates in Victoria – how do we compare?Prevention of CLABSI – what does the literature say?CLIP surveillance – VICNISS pilot resultsEnsuring accuracy & reproducibilityCase studies for discussion
4VICNISS Coordinating Centre Quarterly data submission commenced collecting hospital acquired infection data in 2002Quarterly data submissionlarge & small acute public hospitalsprivate hospitalsCDC – NHSN (NNIS)Collate, analyse & report ‘hospital rates vs. State rate’; notify CEOs and DoH if significantly high rates identifiedBased on USA CDC processes and data
5VICNISS surveillance modules SSIICU CLABSIICU VAPHaemodialysisSurgical prophylactic antibiotics+ Type 2 process & outcomes
6CLABSI – a significant outcome Mortalityattributable mortality 12-25%Increased LOS2.4 ICU dayshospital daysHealthcare costsUS $Higuera F et al. ICHE 2007Warren DK et al. Crit Care Med 2006Posa PJ et al. AACN Adv Crit Care 2006Siempos II et al. Crit Care Med 2009Tacconelli E et al. J Hosp Infect 2009
7CLABSI case definitions: clinical NumerousApplications: diagnostic dilemmas, clinical trialsSpecialised laboratory testing methods:catheter tip culturesquantitative blood and catheter tip culturesdifferential time to positivity
8Clinical 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 bloodRemission 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 CVCFatkenheuer G, et al. Ann Hematol. 2003
9CLABSI case definition: surveillance Uniform & standardisedApplications:public health reportingIC monitoringFeasible to apply across range of healthcare facilitiesLaboratory and clinical criteria
10NHSN CLABSI surveillance definition for benchmarking Edwards JR, et al. Am J Infect Control 2009
11Monitoring in infection control CLABSI surveillance definition to monitor an intervention Pronovost PJ, et al. N Engl J Med 2006
13The question of definition* Case-definition criteriaNNISNHSNRecognised pathogen in 1 or more blood culturesYSkin contaminant in 2 or more blood cultures drawn on separate occasionsSkin contaminant in 1 blood culture, where clinician institutes appropriate antimicrobial therapyN*case-definition for CLABSI, adult patients
14NNIS/NHSN CLABSI rates* Surveillance periodICU typeJan ‘02-Jun ‘04Jan ‘06-Dec ‘06Jan ‘06-Dec ‘07Cardiothoracic3.01.61.4Medical126.96.36.199Medical/surgical- major teaching3.92.0- all others188.8.131.52Surgical184.108.40.206Trauma6.04.64.0inclusive of criterion 2b & 3b2b & 3b removedNNIS Report, Am J Infect Control 2004Edwards JA, et al. Am J Infect Control 2007Edwards JA, et al. Am J Infect Control 2008*published pooled mean rates
15CLABSI rates - Victoria Updated NHSN definition:1 July 2008pooled mean: 6.05/1000 CVC dayspooled mean: 2.06/1000 CVC days
17NHSN CLABSI definition modifications: June 2011 ‘skin contaminants’ → ‘common commensals’revised & expanded organism listRelatedness of infecting organismssusceptibility profile not requiredgenus/species sufficient
18Modifying a case-definition considerations for a surveillance strategy Comparison with historical dataEstablishing a new baseline for trend analysisConfidence intervalsEvidence for prevention & treatment strategiesConsider as ‘new’ infection
23International data: CLABSI NHSN rates by ICU type Edwards JR, et al. Am J Infect Control 2009
24Prevention of CLABSI – what does the literature say?
25Prevention of CLABSI interventions with proven efficacy Educationphysicians & nursing staffAnatomical sitesubclavian < jugular < femoralSkin asepsisalcoholic chlorhexidine gluconateMaximal barrier precautionsLobo RD, et al. Am J Infect Control 2005Eggimann P, et al. Ann Intern Med 2005Hamilton HC, et al. Cochrane database Syst Rev 2007Pratt RJ, et al. J Hosp Infect 2007Raad II, et al. infect Control Hosp Epidemiol 1994
26Impregnated & coated devices Chlorhexidine-silver sulfadiazine and minocycline-rifampicin impregnated devices reduce colonisation & CLABSICDC guidelines recommend if CLABSI rates are highThreshold 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 2009Casey AL, et al. Lancet Infect Dis 2008Maki DG, et al. Ann Intern Med 1997
27The ‘beneficial bundle’ Strategy/intervention consisting of a series of componentseach component evidence-based & demonstrated impactprocess measuresImplementationfeasibleachieved by multi-faceted strategy – education, credentialing, product selection
28Bloodstream infections in ICU US experience with ‘bundle intervention’ Bloodstream infections associated with CVCs are preventableBundle comprised of 5 interventions:maximal barrier precautionshand washingavoidance of femoral siteremoval of unnecessary deviceschlorhexidine for skin asepsisSignificant & sustained impact in reducing rates of infection at multiple US centresPronovost PJ, et al. N Engl J Med 2006
29Zero tolerance?Proposal for zero tolerance of CLABSI rates – simple hospital performance indicatorModification in case-definition will reduce CLABSI ratesOther contributing factors:barrier precautions, hand-hygiene, skin preparation, removal of unnecessary devices, avoidance of femoral siteeducation, simulator training, credentialing of HCW
32ICU ‘bundle intervention’ a lesson for Victorian centres Variable uptake of ICU bundle in Australian centresVictorian centres with high rates of infection - bundle components used by VICNISS as basis for recommendationsVICNISS literature review of evidence-based bundle components (2009)Australian & NZ Intensive Care Society (ANZICS) collaboration & support for implementation
33CLABSI: process monitoring Central line insertion practices (CLIP)HICPAC CVC insertion guidelinesSurveillance module: NHSNReporting commenced 2008CLABSI prevention bundlehand hygieneappropriate skin asepsisdry antiseptic before skin puncturemaximal barrier precautions (cap, sterile gown, gloves, mask, full drape)
34NHSN CLIP data preliminary findings Mar 2008 – Sep 200972,216 CVC insertions, 744 healthcare facilitiesMajority in ICU (84%), and upper extremity devices (62%)6,356 (8.8%) did not adhere to bundle:16% did not perform hand hygiene20% did not use appropriate skin antiseptic21% did not allow antiseptic to dry60% did not adhere to maximal barrier precautionscap omitted in 63%full patient drape omitted in 34%Allen-Bridson K, et al. SHEA 2010, abstract 686
35CLIP data: Victorian experience Pilot study, Jan – June 20114 Victorian centres participating in CLABSI surveillanceAudit of CVC insertion practices in ICUMinimum 3 month continuous audit periodAssessment of compliance with NHSN bundleEvaluation of feasibility of data collection
38A role for CLABSI process monitoring in Victoria? Following pilot – ongoing participation requestedProposed 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 centreMonitoring in non-ICU environments, where CLABSI may be less frequent or more difficult to monitor (interventional radiology, ward, other)CLIP module available 10/2011
40Validation of CLABSI data (VICNISS) Accuracy of data important for benchmarking & longitudinal analysis, but few validation studies performed by non-US centresReview of hospital medical records comparing reported surveillance data with gold standard6 Victorian centres, Jan-Dec 2006Gold standard = blinded assessment by trained VICNISS ICCNNIS case-definitionMcBryde ES, et al. Infect Control Hosp Epidemiol 2009
41OutcomesTotal 398 bacteraemias, 81 reported as CLABSI. Sample set of 46 reported CLABSIs and 62 not reported as CLABSIs67% inter-rater agreement with VICNISS reviewPPV 59% (43-73%), NPV 73% (60-83%)Sensitivity 35% (23-48%), specificity 87% (82-92%)Hypothetical sensitivity 50% [NHSN]
42Reproducibility of CLABSI data VICNISS Questionnaire review of Victorian ICCs assessing reproducibility of case-definition when compared to international gold standard18/21 VICNISS centres, 200611-item questionnaire, classification of clinical cases (CLABSI/not CLABSI)NNIS case-definitionGold standard = blinded CDC staff specialistWorth LJ, et al. Am J Infect Control 2009
43Assessment 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 CLABSI⃞ this is not an ICU-acquired CLABSI
44OutcomesOverall 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]
45Enhancing CLABSI surveillance Credentialing tool for IC staffon-line, periodic, rotation of contentVICNISS websiteFAQs, case studiesOthereducation opportunitiesmulti-disciplinary engagement; collaboration with ANZICS ‘CLAB’ project
47Scenario 1 Trauma patient, day 18 post MVA Blood cultures collected at the same time:from PICC - Enterobacter gergoviaefrom peripheral site – no growth
48Scenario 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).
49Scenario 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.
50Scenario 4 28 Apr Admitted to hospital 1 May Admitted to ICU 2 CVC inserted (2200)3 Blood culture (0600) - Acinetobacter sppTracheal aspirate - MSSANotes: "febrile, ? Source GNB on blood culture”7 ID documented “Acinetobacter cause of line sepsis” CXR essentially clear May8 CXR increasing consolidation, collapse in the LLL & increasing consolidation R) lung baseAcinetobacter spp isolated from tracheal aspirate
51Scenario 5A 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".
52Scenario 6A patient is undergoing treatment for acute myeloid leukaemiahas chemotherapy-induced mucositis (mouth ulcers, nausea, vomiting).Hickman line in situblood culture taken peripherally - Enterococcus sppmultiple occasions.
54Gut 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.
55CLABSI 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.
56CLABSI surveillance definition 2 proposed changes Inclusion of an “indeterminate source” for some BSIs, andAcknowledgement that a single blood culture positive for Enterococci has little clinical significance, similar to the interpretation of a single blood culture positive for CNS.
57CLABSIs could be divided into 3 categories: primarysecondary, orindeterminate 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.
58Scenario 7Patient with relapsed acute myeloid leukaemia presented with documented febrile neutropenia.CVC in situ.Streptococcus viridians spp grown from two separate blood draws.
59Common commensals, NHSN, 2011 Aerococcus speciesStaphylococcus auricularisAerococcus urinaeStaphylococcus capitis ss capitisAerococcus viridansStaphylococcus capitis ss unspecifiedBacillus cereusStaphylococcus capitis ss urealyticusBacillus species (not B. anthracis)Staphylococcus coagulase negativeBacillus subtilisStaphylococcus cohniiCorynebacterium aquaticumStaphylococcus epidermidisCorynebacterium bovisStaphylococcus gallinarumCorynebacterium cystitidisStaphylococcus haemolyticusCorynebacterium glutamicumStaphylococcus hominisCorynebacterium group G-2Staphylococcus lentusCorynebacterium jeikeiumStaphylococcus lugdunensisCorynebacterium kutscheriStaphylococcus saccharolyticusCorynebacterium matruchotiiStaphylococcus saprophyticusCorynebacterium minutissimumStaphylococcus schleiferiCorynebacterium mycetoidesStaphylococcus sciuriCorynebacterium pilosumStaphylococcus simulansCorynebacterium pseudodiphtheriticumStaphylococcus speciesCorynebacterium pseudotuberculosisStaphylococcus warneriCorynebacterium renaleStaphylococcus xylosusCorynebacterium speciesStreptococcus anginosusCorynebacterium striatumStreptococcus bovisCorynebacterium ulceransStreptococcus mitisCorynebacterium urealyticumStreptococcus mutansCorynebacterium xerosisStreptococcus salivariusDiphtheroidsStreptococcus viridans speciesGram-positive cocci unspecifiedMicrococcus speciesPropionibacterium acnesPropionibacterium avidumPropionibacterium granulosumPropionibacterium lymphophilumPropionibacterium propionicumPropionibacterium speciesRhodococcus equiRhodococcus speciesCommon commensals, NHSN, 2011
60Scenario 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.
62Case 9 A patient with CVC in situ for 9 days becomes febrile 1/5 - E. coli is isolated in blood culture2/5 - Klebsiella pneumoniae is isolated in blood cultureChest X-ray is clear and no organism is isolated from urine. No other primary source of infection is identified.
63Case 10In 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.