What’s New in the 2011 Guideline for Preventing Catheter Related BSI? Naomi P. O’Grady, MD Critical Care Medicine Department National Institutes of Health

I have no disclosures.

Objectives Highlight some areas of controversy, including catheter site selection, antimicrobial locks, and chlorhexidine impregnated sponge dressings Discuss the recommendations in the updated guideline Outline some of the data to support the new recommendations

Clinical Infectious Diseases 2011; 52(9) e162-e193

Site Selection

Old Recommendation Use a subclavian site (rather than a jugular or a femoral site) in adult patients to minimize infection risk for non-tunneled CVC placement

Site Selection Rather than focus on one specific site to select, we now focus on one specific site to avoid. Avoid the femoral vein for central venous access in adults Femoral site associated with greater risk of infection and DVT Merrer; JAMA, 2001 Parienti; JAMA, 2008

JAMA, 2001; 286:700-07

Catheter Complications Randomized patients to femoral (145) vs subclavian (144) 8 ICU’s; 3 years Mechanical complications similar in both groups Infection and thrombosis higher in femoral group

Catheter Complications

Catheter Complications * Thrombotic complications were 21% in femoral group and 1.9% in subclavian group ( p<0.001) with 2 PE’s

JAMA 2008

Femoral vs Jugular Catheterization 375 patients in each arm over a 3 year period Primary endpoint was colonization on removal Insertion complications, CR-BSI, and thrombosis were secondary endpoints

Mechanical Complications Jugular catheters: longer insertion times, more failed attempts and more crossover Arterial punctures no different (5.1% vs 3.6%), although hematoma formation higher in jugular 2 patients required intubation in jugular group 1 patient required vascular surgery for carotid artery insertion 1 patient with acute leg ischemia required limb amputation

Infectious Complications JAMA 2008

Controversy. . . JAMA 2008

Skin Antisepsis

Old Recommendation Disinfect clean skin with an appropriate antiseptic. A chlorhexidine-based preparation with >2% is preferred. Alternatively, tincture of iodine, an iodophor, or 70% alcohol could be used.

New Recommendation Disinfect clean skin with an appropriate antiseptic. A chlorhexidine-based preparation with >0.5% is preferred. Alternatively, tincture of iodine, an iodophor, or 70% alcohol could be used.

Chlorhexidine significantly reduces risk of colonization and BSI Annals of Internal Medicine 2002

Catheter Site Dressing Regimens

Old Recommendation: No recommendation

Efficacy of Chlorhexidine Impregnated Sponges for Prevention of Intravascular Catheter Related Infections Chlorhexidine Sponge N = 665 Control N = 736 RR Catheter Colonization Blood Stream Infection 109 (16%) 8 (1.2%) 216 (29%) 24 (3.3%) 0.62 (0.49-0.78) 0.38 (0.16-0.29) ICAAC 2000

Timsit JF et al. JAMA 2009

Chlorhexidine sponge dressings reduce risk of infection and colonization 2 x 2 factorial RCT to evaluate chx dressing vs standard and to evaluate 3 day vs 7 day dressing changes 1653 patients 3778 catheters 28,931 catheter days

Chlorhexidine sponge dressings reduce risk of infection and colonization Timsit JF et al. JAMA 2009

Catheter Site Dressing Regimens Use a chlorhexidine sponge dressing in adult patients with short-term catheters to reduce the incidence of infection catheter-related infection.

Antimicrobial Lock Solutions

Use prophylactic antimicrobial lock solution in patients with long term catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique.

Catheter Locks Technique by which an antimicrobial solution is used to fill a catheter lumen and then allowed to dwell for a period of time while the catheter is idle. Antibiotics of various concentrations that have been used either alone (when directed at a specific organism) or in combination (to achieve broad empiric coverage) Formulations made in-house Studies are limited; populations are hemodialysis, neonates, patients with neutropenia

Needleless Connectors

Mechanical Valve

Split Septum

Recommendation When needleless systems are used, a split septum valve may be preferred over a mechanical valve due to increased risk of infection with some mechanical valves. Category II

Bundles and Checklists

Eliminating Catheter Related Infections Crit Care Med; October 2004

Eliminating Catheter Related Infections Educational intervention to increase provider awareness Created CVC insertion cart Asking providers daily if the CVC is needed Checklist at bedside for nurses Empowering nurses to stop the procedure Did not include tunneled of PA catheters

Eliminating Catheter Related Infections Implemented simple strategies No impregnated catheters Reduced infection rate from 11.3/1000 catheter days to 0/1000 catheter days during study period Performance sustained Jan-April 2003 only 2 infections (0.54/1000 catheter days)

Eliminating Catheter Related Infections

Eliminating Catheter Related Infections Excluded PICCS Implemented teaching program CVC carts Checklist for compliance with handwashing and barrier precautions

Eliminating Catheter Related Infections

Antibiotic/Antiseptic Catheters

Antibiotic/Antiseptic Catheters Use an antimicrobial or antiseptic-impregnated CVC in adults whose catheter is expected to remain in place >5 days if, after implementing a comprehensive strategy to reduce rates of CR-BSI, the rate has not sufficiently decreased. The comprehensive strategy should include the following 3 components: educating persons who insert and maintain catheters, use of maximal barrier precautions, and a 0.5% chlorhexidine preparation for skin antisepsis during central venous catheter insertion.

Blood Stream Infection RR Efficacy of Chlorhexidine-Silver Sulfadiazine Catheters for Prevention of CR-BSI Mermel, Ann Intern Med 2000; 132:391-402 Eggimann and Pittet, Advances in Sepsis, 2000 Reference Colonization RR Blood Stream Infection RR Maki, 1997 van Heerden, 1997 Heard, 1998 Bach,1996 Collin, 1999 George, 1999 Pemberton, 1996 Logghe, 1997 0.56 (0.36-0.89)* 0.4 (0.1-1.0)* 0.59 (0.34-0.97)* 0.6 (0.4-0.9)* 0.1 (0.0-0.7)* 0.3 (0.2-0.6)* -- 0.2 (0.03-0.95)* -- 0.5 (0.4-0.7)* 0.8 (0.2-4.7) 1.2 (0.6-2.3)

Efficacy of Chlorhexidine-Silver Sulfadiazine Catheters for Prevention of Catheter Colonization Collin, 1999 George, 1999 van Heerden, 1997 Maki, 1997 Heard, 1998 Bach, 1996 -0.2 0.2 0.4 0.6 0.8 1 1.2 Odds ratio, 95% CI Decreasing risk Increasing risk

Efficacy of Chlorhexidine-Silver Sulfadiazine Catheters for Prevention of CR-BSI Maki, 1997 Bach, 1996 Pemberton, 1996 Logghe, 1997 Collin, 1999 Odds ratio, 95% CI Decreasing risk Increasing risk -1 1 2 3 4 5

Time to Occurrence of CR-BSI with Minocyline-Rifampin Catheter Minocycline-rifampin catheters Uncoated catheter 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.1 0.0 5 10 15 20 25 30 Duration of Catheterization (Days) Proportion of Patients without Infection Catheters (n) 266 170 50 11 6 1 0 Raad, Annals Intern Med 1997

Proportion of Catheters without Infection Risk of Bloodstream Infections Using Two Types of Impregnated Catheters 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.1 0.0 5 10 15 20 25 30 Minocycline-rifampin catheters Chlorhexidine-silver sulfadiazine catheters Proportion of Catheters without Infection Duration of Catheterization (Days) M/R C/SS 365 382 214 246 93 96 48 39 20 18 9 5 4 2 No. at Risk Darouiche NEJM 1999 Catheter

Eliminating Catheter Related Infections Annals of Internal Med 2005

Eliminating Catheter Related Infections 777 Catheters 393 Control catheters and 384 antiseptic catheters Funding source: Arrow Sponsor collected and analyzed the data Difference in BSI not significant (0.42/1000 catheter days vs 1.24/1000 catheter days)

Eliminating Catheter Related Infections

Summary Educate healthcare workers and provide training for the insertion and maintenance of catheters Use chlorhexidine preferentially for skin antisepsis Use maximal barrier precautions Use a chlorhexidine sponge dressing in adults with short-term catheters Use an antibiotic/antiseptic catheters if CRI rates have not sufficiently declined Use a bundled strategy for simplicity

Conclusions Prevention strategies have measurable impact Multiple interventions may be needed Performance improvement programs will be focused on moving toward elimination of CA-BSIs rather than “benchmark goals” Focus of prevention moving away from insertion phase and into maintenance phase

Thank you.