MANUAL CATHETER ASSOCIATED BLOOD STREAM INFECTION (CABSI) SURVEILLANCE November 2012 Infection Control Unit Quality in Medical Care Section Medical Development Division Ministry of Health

INTRODUCTION Regardless of the numerous reports on the adverse impact associated with the use of catheters as a vascular access for haemodialysis (HD), Central Venous Catheters (CVCs) remains as an important tool in the delivery of adequate dialysis. In incident HD patients, CVCs provide an instant access to the circulation. In chronic or prevalent HD patients, CVCs are useful as a bridging gap for patients who have problems with poor maturation of their native fistula and while awaiting fistula maturation.

INTRODUCTION - Cont The use of CVCs is associated with a high morbidity, mortality and increased health care costs due to infectious complications. The risk of infection in CVCs is 5-10 fold higher than dialyzing with a native fistula or graft(1). Vascular access related infection and other complications frequently result in prolonged hospitalization and account for more than one third of the cost of ESRD management. The reported mortality rate ranges between 12 to 25.9%

INTRODUCTION - Cont Despite numerous attempts to encourage the use of fistula, the usage of CVCs in the USA remains high with nearly 65% of patients using CVCs at the first outpatient HD treatment (1) The 19th Report of Malaysian Dialysis and Transplant Registry showed that the prevalence rate of End Stage Renal Disease has increased from 368 per million population in 2002 to 900 per million population in 2011. The usage of CVC in prevalent or chronic HD patients has also increased from 3% to 8.1% during the same period. This is an underestimation as the predominant usage of CVCs for HD is in the incident patients.

INTRODUCTION - Cont The growing numbers of patients who require haemodialysis combined with the increasing number of patients who are unable to use native vascular access other than a CVC stress the need to monitor the rate of CABSI and the importance of strategies to prevent it.

OBJECTIVES General to assess the rate of CABSI in CVC for HD in MOH hospitals with the aim to reduce morbidity and mortality related to CABSI

OBJECTIVES - Cont Specific: To determine the incidence rate of CABSI in CVC for HD in selected MOH hospitals to identify risk factors that predispose patient to CABSI in CVC for HD to compare the rate of CABSI among the selected hospitals to determine the average catheter days before infection to determine rate of CVC removal due to infection

METHODOLOGY Population under surveillance All patients who has a CVC for HD inserted and receiving haemodialysis or extracorporeal therapy in Ministry of Health facilities. 

Case Definition All patients who are currently receiving haemodialysis receiving haemodialysis or extracorporeal therapy via CVC in Ministry of Health facilities with CABSI. CABSI is defined as: clinical signs and symptoms of infection (fever, chills and/or hypotension) AND a positive peripheral blood culture AND no other apparent source of infection.

Exclusion Criteria Patient defaulted treatment more than 72hours from the last haemodialysis treatment Patient from private haemodialysis facility with evidence of current infection during presentation CVC inserted outside MOH facilities

End of Catheter Days The end of catheter days can be determined through one of the following: Date of discharge (Discharge date from HD facilities plus 72hours; to allow cases that developed CABSI within the specified period) Date of Catheter removal Date of Death

DATA COLLECTION All patients who have a CVC inserted for HD will be identified by a designated personnel . Upon insertion of CVC for HD , CABSI Coordinator (Staff Nurse or Medical Assistant) should fill up : Surveillance Form For Catheter Associated Blood Stream Infection In Ministry Of Health Haemodialysis Facility CABSI/MOH/2012/1 (Appendix I )

DATA COLLECTION - Cont fill up item A, B, C (1 to 4) - Upon CVC insertion fill up item C (5 to 6) - Upon removal of catheter or discharge (discharge from haemodialysis facility or died) If patient developed infection, proceed to item D and fill up Surveillance Form For Catheter Associated Blood Stream Infection In Ministry Of Health Haemodialysis Facility CABSI/MOH/2012/2 as in Appendix II

DATA COLLECTION - Cont Data to be collected and analyzed by the CABSI Coordinator on monthly basis. CABSI Database (Appendix III to VIII) provided by the MOH will be used as a tool in analysis. It will generate results automatically. Upon completion, CABSI Coordinator has to fill up Reporting Form of Catheter Associated Blood Stream Infection in MOH Haemodialysis Facility CABSI/MOH/2012/3 as in Appendix IX according to the results generated from the CABSI Database.

DATA COLLECTION - Cont Completed CABSI/MOH/2012/3 form to be verified by the respective Hospital Nephrologists. CABSI/MOH/2012/1 and CABSI/MOH/2012/2 forms to be kept at respective hospital. A completed and verified CABSI/MOH/2012/3 form to be submitted to the National Secretariat by 10th of every 2 subsequent month. Further reporting and analysis will be performed by the National Secretariat.

DATA ANALYSIS AND REPORTING The Catheter Days will be used as denominators to calculate the incidence rate of CRBSI in each hospital. Following data will be collected: Monthly catheter days Cumulative catheter days 

CABSI RATE Monthly CABSI Rate = No. of CABSI for X Month x 1000 Total Catheter Days for X Month Cumulative CABSI Rate =Total No. of CABSI for Cumulative Month x 1000 Total Catheter Days for Cumulative Month

Rate for CVC Removal Due to Infection = No. of CVC Removed Due To CABSI x 100 No. of Patient with CVC a) Monthly b) Cumulatively

DATA ANALYSIS AND REPORTING - Cont All hospitals should send the aggregated data (Reporting Form of Catheter Associated Blood Stream Infection in MOH Haemodialysis Facility CABSI/MOH/2012/3 ) on monthly basis to the National Secretariat. The data will be analyzed and result will be disseminated every 6-monthly. A yearly report will be published and disseminated to all the states.

PROCESS FLOW CHART FOR CABSI SURVEILLANCE MANAGEMENT APPENDIX VIII Patient in the facility with newly inserted catheter [NEW CASE] Patient receiving haemodialysis or extracorporeal therapy in MOH facility with existing catheter [OLD CASE] Fill up CABSI/MOH/2012/1 form (Appendix I) Calculate the monthly and cumulative denominator (catheter days) at the end of the month Development of Infection NO Fill up CABSI/MOH/2012/2 form (Appendix II) YES Data compilation

Fill up CABSI/MOH/2012/3 form (Appendix IX) Completed CABSI/MOH/2012/3 form (Appendix III) to be verified by Nephrologist Verified CABSI/MOH/2012/3 form to be sent to Infection Control Unit, MOH Data management

REFERENCE United States Renal Data System 2011 Annual Data Report: Chapter 2. Clinical Indicators and Preventive Care. USRDS website: www.usrds.org Burr R et al. The cost of vascular access infections: three years experience from a single outpatient dialysis center. Hemodialysis International 2003;7: 73 -104 Liu JW et al. Nosocomial blood-stream infections in patients with ESRD; excess length of stay, extra cost and attributed mortality. Hosp Infect 2002; 50: 224-7 19th Report Of The Malaysian Dialysis & Transplant Registry 2011. Ed Lim YN, Ong LM, Goh BL. Available on the MSN website: http://www.msn.org.my.nrr Deborah Tomlinson et all. Defining Bloodstream Infections Related to Central Venous Catheters in Patients With Cancer: A Systematic Review. Available on http://cid.oxfordjournals.org/  An APIC Guide 2000 . Guide to the Elimination of Catheter-Related Bloodstream Infections

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