1. Prevention of Intravascular Device-Associated Infections

2. Learning objectives 1.Describe the relevance and impact of intravascular Device-Associated infections. 2. Identify infection sources and routes of transmission for intravascular infections. 3. Outline the main recommendations to prevent those infections. December 1, 2013 2

3. Time involved 30 minutes December 1, 2013 3

4. Introduction Intravenous (IV) infusions among the commonest invasive procedures (peripheral or central) IV central catheters are the main source of bloodstream infection (CLABSI) Infections associated: Cellulitis, abscess, thrombophlebitis, bacteraemia, endocarditis Principles to prevent infections similar for central and peripheral catheters December 1, 2013 4

5. Key points Strict asepsis for insertion and maintenance of catheters Insertion site dry and protected with a sterile dressing No touch technique IV line secure without movements Closed system Inspection of the insertion site daily Remove the catheters as soon as possible No reuse of catheters intended for single use Healthcare personnel educated and their knowledge assessed Alternative routes for hydration or parenteral therapy December 1, 2013 5

6. Sites of possible contamination of intravascular infusions December 1, 2013 6

7. Sources and Routes of Transmission - 1 Sources of contamination intrinsic or extrinsic Most microorganisms from the patient’s skin flora Contamination of device hub also a source of infection S. aureus - 60 to 90% of infections December 1, 2013 7

8. Flora del paciente Contamination of insertion site Contaminación de las conexiones Contamination of fluids Seed from distant site Hands of staff Skin flora Injections ports 8 Sources and Routes of Transmission - 2

9. Prevention of Infections - 1 Main source of infection Prevention Infusion fluidsMonitor sterilisation Ensure fluid is pyrogen free. Avoid damage to containers Inspect containers Addition of medications Aseptic technique Sterile medications Carry out procedures in the pharmacy. Sterile device for accessing the system. Single-dose vials If multi-dose vials have to be used: Refrigerate after opening Wipe diaphragm with 70% isopropanol Warming- container Ensure no contamination Dry warming systems are preferred. December 1, 2013 9

10. Prevention of Infections - 2 Main source of infection Prevention Insertion of catheter Thorough hand disinfection and sterile gloves Thoroughly disinfect the skin insertion site. Catheter siteCover with sterile dressing Remove catheter if signs of infection occur. Inspect site every 24 hours. Change dressing only when necessary. Do not use antimicrobial ointments. Injection portsClean with 70% isopropanol and allow to dry Close ports that are not needed with sterile stopcocks. Changing of infusion set Replace no more frequently than 72 hours (blood and lipids every 24 hours). Thorough hand disinfection Use good aseptic technique. December 1, 2013 10

11. General Comments - 1 Routine changes of peripheral IV catheters not required In adults recommendation to change every 72-96 hours to reduce phlebitis In children should not be replaced routinely Routine replacement of central catheters not necessary Central catheters used only when indicated Non-essential catheters removed Risk of infection increases with length of catheterisation December 1, 2013 11

12. General Comments - 2 Teflon or polyurethane catheters associated with fewer infections Steel needles same rate of infection as Teflon catheters Steel needles complicated by infiltration of IV fluids Well-trained staff to set up and maintain infusions Masks, caps, and gowns not necessary for insertion of peripheral IV lines Use of non-sterile barriers will protect the operator if blood exposure likely December 1, 2013 12

13. Protocol for peripheral infusions - 1 Place arm on a clean sheet or towel Hand hygiene (alcohol hand rub or antiseptic soap) Dry hands on a paper or unused linen towel Hand hygiene (gloves does not replace it) Not remove hair (if necessary clip, avoid shaving) Disinfect skin site, a pply for 30 seconds and allow drying 0.5% chlorhexidine-alcohol, 2% tincture of iodine, 10% alcoholic povidone-iodine, or isopropanol). Chlorhexidine products should not be used in children younger than 2 months December 1, 2013 13

14. Protocol for peripheral infusions - 2 Cannula preferably in an upper limb Secure sterile dressing Transparent dressings allow inspection of the site Secure cannula, label with insertion date Assess need for catheter every 24 hours Inspect catheter daily Avoid cut downs, especially in the leg Cannulae and sets must be sterile December 1, 2013 14

15. Additional guidelines for central catheters Selection of site Higher infections for jugular and femoral Maximum barriers Disinfect skin with 2% chlorhexidine/alcohol Change transparent dressings once a week or if soiled, loose, or damp, gauze every two days Replace sets not for blood or lipids no more than 72 hours December 1, 2013 15

16. Measures that should not be considered as part of a general prevention policy : Systemic antibiotic prophylaxis Topical use of antimicrobial ointments Routine replacement of central venous catheters Routine use of antibiotic locks for central venous catheters Routine use of in-line filters December 1, 2013 16

17. References - 1 Marschall J, et al. Strategies to prevent central line- associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol 2008; 29(suppl. 1): S22-S30. http://www.jstor.org/stable/10.1086/591059 http://www.jstor.org/stable/10.1086/591059 Marchaim D, et al. Epidemiology of bacteraemia episodes in a single center: increase in Gram-negative isolates, antibiotics resistance, and patient’s age. Eur J Clin Microbiol Infect Dis 2008; 27:1045-51. Standards for infusion therapy. Royal College of Nursing, 2010. http://www.rcn.org.uk/__data/assets/pdf_file/0005/785 93/002179.pdf http://www.rcn.org.uk/__data/assets/pdf_file/0005/785 93/002179.pdf December 1, 2013 17

18. References - 2 Marschall J. Catheter-associated bloodstream-infections: Looking outside of the ICU. Am J Infect Control 2008; 36:172.e5-8. Collignon PJ, et al. Intravascular catheter bloodstream infections: an effective and sustained hospital-wide prevention program for 8 years. Med J Austr 2007; 187:551-554. Guidelines for the Prevention of Intravascular Catheter- Related Prevention of Intravascular Device-Associated Infections Infections, 2002. MMWR 2002; 51:1-26. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110 a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110 a1.htm December 1, 2013 18

19. Quiz 1.IV central catheters are the main source of bloodstream infection. T/F? 2.The main strategy to prevent CLABSI is a)Avoid unnecessary catheters b)Good selection of insertion site c)Teflon catheters d)Change peripheral catheters every 72 hours 3.Which measure should not be considered to prevent intravascular infections? a)Aseptic technique in insertion and maintenance of catheters b)Skin antisepsis with 2% chlorhexidine/alcohol c)Routine replacement of central venous catheters d)Maximum barriers for insertion of central catheters December 1, 2013 19

20. International Federation of Infection Control IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe. The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. For more information go to http://theific.org/http://theific.org/ December 1, 2013 20