1. 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

2. I have no disclosures.

3. 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

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

5. Site Selection

6. 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

7. 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

8. JAMA, 2001; 286:700-07

9. 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

10. Catheter Complications

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

12. JAMA 2008

13. 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

14. 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

15. Infectious Complications
JAMA 2008

16. Controversy. . .
JAMA 2008

17. Skin Antisepsis

18. 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.

19. 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.

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

21. Catheter Site Dressing Regimens

22. Old Recommendation:
No recommendation

23. 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 ( )
0.38 ( )
ICAAC 2000

24. Timsit JF et al. JAMA 2009

25. 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

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

27. 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.

28. Antimicrobial Lock Solutions

29. 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.

30. 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

31. Needleless Connectors

32. Mechanical Valve

33. Split Septum

34. 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

35. Bundles and Checklists

36. Eliminating Catheter Related Infections
Crit Care Med; October 2004

37. 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

39. 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)

40. Eliminating Catheter Related Infections

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

42. Eliminating Catheter Related Infections

43. Antibiotic/Antiseptic Catheters

44. 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.

45. Blood Stream Infection RR
Efficacy of Chlorhexidine-Silver Sulfadiazine Catheters for Prevention of CR-BSI
Mermel, Ann Intern Med 2000; 132:
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 ( )*
0.4 ( )*
0.59 ( )*
0.6 ( )*
0.1 ( )*
0.3 ( )* --
0.2 ( )* --
0.5 ( )*
0.8 ( )
1.2 ( )

46. 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

47. 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

48. 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)
Raad, Annals Intern Med 1997

49. 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

50. Eliminating Catheter Related Infections
Annals of Internal Med 2005

51. 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)

52. Eliminating Catheter Related Infections

53. 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

54. 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

55. Thank you.