Prevention of Catheter-Prevention of Catheter-Related Infections in Related Infections in

the Adult and Pediatric the Adult and Pediatric PopulationPopulation

Darcy Doellman RN BSNDarcy Doellman RN BSNPICC/CVC Resource NursePICC/CVC Resource Nurse

Cincinnati Children’s Hospital Cincinnati Children’s Hospital Medical CenterMedical Center

Central Venous Central Venous Catheters Catheters

Background & ComplicationsBackground & Complications Essential in managing chronic & critically ill Essential in managing chronic & critically ill

patients patients 41% of PICU patients have 1 or more CVC41% of PICU patients have 1 or more CVC 57% of adult ICU patients have 1 or more CVC57% of adult ICU patients have 1 or more CVC Complications:Complications:

Mechanical (migration, hole in catheter) Mechanical (migration, hole in catheter)

Catheter obstruction, occlusion & Catheter obstruction, occlusion & thrombosisthrombosis

Catheter-Related BSICatheter-Related BSI

Catheter-Related InfectionsCatheter-Related InfectionsClinical ImplicationsClinical Implications

Medical costs up to $25,000 to Medical costs up to $25,000 to treat a Catheter-related treat a Catheter-related infectioninfection

Average rate of CR-BSI is Average rate of CR-BSI is 5.3/1,000 catheter days in the 5.3/1,000 catheter days in the ICU, approx 80,000 CR-BSI ICU, approx 80,000 CR-BSI occur annually in the USoccur annually in the US

Morbidity Morbidity MortalityMortality TerminologyTerminology

Noscomial InfectionsNoscomial Infections

Vast majority of Vast majority of noscomial infections noscomial infections are device or are device or procedure relatedprocedure related

Twenty fold increase Twenty fold increase of candida since 1965of candida since 1965

CSR-BSI Considerations and Central Venous Access Devices

Infection Control IssuesInfection Control IssuesShort-term

CVCsPICCs Tunneled

CathetersImplanted

Ports

Dwell TimesReported mean

30+ days4 days

1+ years6 weeks

1+ years6 months

3+ years3 years

Rate ofCR-BSI

5.3/1000catheter

days

0.51/1000catheter

days

2.77/1000catheter

days

0.21/1000catheter

days

InsertionIssues

BedsideMedical

Providers

BedsideNurses

IR/ORMedical

Providers

IR/ORMedical

Providers

Sources: CDC 2002, Moreau, 2002, Ryder, 1996, Lowenthal et. Al. 2002, Skiest, 2000, Thiagajarian, 1997,Alhimyary, 1996, Abi-Nader, 1993, Ng, 1997, Graham, 1991

Site PreparationSite Preparation

Practice IssuesPractice Issues

Desired Desired Outcomes:Outcomes:

Provide best care Provide best care possiblepossible

Evidence-based Evidence-based practicepractice

Minimize Minimize complications of complications of central linescentral lines

RealityReality We use what’s We use what’s

availableavailable Unaware of Unaware of

complicationscomplications Limitations of Limitations of

literatureliterature Do not consider Do not consider

overall overall

costscosts

Challenge for CliniciansChallenge for Clinicians

Multi-taskingMulti-tasking Information overloadInformation overload Time intensiveTime intensive Staffing issuesStaffing issues Experienced personnelExperienced personnel

Catheter OcclusionCatheter Occlusion Prevention – CCHMC StudiesPrevention – CCHMC Studies

Simple (n=150)

Valve (n=149)

PPV1+Heparin (n=150)

PPV1+Saline (n=150)

PPV2+Saline

(n=161)

Patient Age (Months) 45.67.5 53.67.6 36.16.6 41.86.4 55.48.0

Catheter Type: Non-Tunneled PICC Tunneled

63 (66%)31 (32%)

2 (2%)

64 (71%)23 (26%)

3 (3%)

76 (89%)#9 (11%)#

0

69 (79%)18 (21%)

0

56 (73%)20 (26%)

1 (1%)

Catheter Duration (days) 9.70.7 8.20.6* 7.40.7# 7.40.5* 8.30.9*

Complete Occlusions 18 (12.0%) 2 (1.3%)$ 5 (3.3%)# 6 (4%)* 6 (3.7%)*

Partial Occlusions 7 (4.7%) 11 (7.4%) 6 (4%) 6 (4%) 13 (8.1%)

Complete + Partial Occlusions

25 (16.7%) 13 (8.7%) 10 (6.7%)* 12 (8%)* 19 (11.8%)

INCIDENCE OF CR-BSIINCIDENCE OF CR-BSI

Catheter duration Catheter duration (Raad et al J Hosp (Raad et al J Hosp Infect 1993)Infect 1993)

Insertion Site Insertion Site ( IJ site associated with ( IJ site associated with fourfold increase as compared to subclavian fourfold increase as compared to subclavian site)site)

Geography Geography (Mermel et al Am J Med 1991)(Mermel et al Am J Med 1991)

High risk patientsHigh risk patients Multiple lumens/cathetersMultiple lumens/catheters Catheter material Catheter material (polyvinyl chloride or (polyvinyl chloride or

polyethyl) polyethyl) Thrombogenicity/phlebitisThrombogenicity/phlebitis

CR-BSICR-BSI

Microbes Microbes colonize skin at colonize skin at the insertion the insertion sitesite and the and the catheter hub catheter hub (Mermel et al Am J (Mermel et al Am J Med 1991)Med 1991)

Sutures go Sutures go through skin, through skin, inflammationinflammation

Biofilm BasicsBiofilm Basics Planktonic and sessile cells interact Planktonic and sessile cells interact As sessile bacteria attach to a surface, As sessile bacteria attach to a surface,

they begin to excrete a slimy material they begin to excrete a slimy material (biofilm)(biofilm). Single cells – Early structure – . Single cells – Early structure – Mature biofilm (nutrients flow through Mature biofilm (nutrients flow through complex structures)complex structures)

Researchers have shown that bacterium Researchers have shown that bacterium attached to a surface “turns on” a attached to a surface “turns on” a whole different set of genes. This makes whole different set of genes. This makes it a different organism to deal withit a different organism to deal with

Biofilm LifestylesBiofilm Lifestyles

Free FloatingFree FloatingUbiquitousUbiquitous

PlanktonicPlanktonic

Rapid growthRapid growth

Fairly sensitiveFairly sensitive

EmbeddedEmbeddedUbiquitousUbiquitous

Sessile PhenotypeSessile Phenotype

Slow growthSlow growth

Highly resistantHighly resistant

Biofilm BasicsBiofilm Basics

Researchers at the “Center for Researchers at the “Center for Biofilm Engineering” have discovered Biofilm Engineering” have discovered a different level of expression of a different level of expression of genes, genes, a division of labora division of labor

Some cells use energy turned on by Some cells use energy turned on by metabolic pathways and effects the metabolic pathways and effects the partial degradation while others use partial degradation while others use the degradation products to produce the degradation products to produce new cells (cell to cell communication) new cells (cell to cell communication)

BIOFILMBIOFILM

The “Iceberg Effect”The “Iceberg Effect” Described by Maki and MermelDescribed by Maki and Mermel Difficult to treat, best to remove it. Difficult to treat, best to remove it.

Patient may be asymptomaticPatient may be asymptomatic Cultures may grow planktonic cellsCultures may grow planktonic cells Biofilm in “high flow” areas may seed Biofilm in “high flow” areas may seed

other parts of the bodyother parts of the body

FUTURE TREATMENTFUTURE TREATMENT Biofilm inhibitor (RAP, TRAP, RIP is Biofilm inhibitor (RAP, TRAP, RIP is

biofilm inhibitor)biofilm inhibitor)

Biofilm inhibitor plus antibiotic in Biofilm inhibitor plus antibiotic in dacron cuffdacron cuff

With the use of ultrasound, the inhibitor With the use of ultrasound, the inhibitor and antibiotic would be releasedand antibiotic would be released

Biofilm inhibitor in antibiotic beads as Biofilm inhibitor in antibiotic beads as they dissolvethey dissolve

PreventionPrevention HandwashingHandwashing Chlorohexidine scrub Chlorohexidine scrub

((1a recommendation from the 1a recommendation from the CDC)CDC)

BioPatch BioPatch ((chlorhexidine-chlorhexidine-impregnated synthetic disk)impregnated synthetic disk)

Anti-infective lock Anti-infective lock solution in long-term solution in long-term devicesdevices

Maximal sterile Maximal sterile barriersbarriers

Specialty teamsSpecialty teams

Multidisciplinary Multidisciplinary approachapproach

Transparent Transparent dressingdressing

Antimicrobial-Antimicrobial-infected cathetersinfected catheters

Securement Securement devices devices

HandwashingHandwashing 50% of nosocomial infections could be 50% of nosocomial infections could be

eliminated by handwashing aloneeliminated by handwashing alone Hands are only washed 50% of the Hands are only washed 50% of the

times indicatedtimes indicated Wearing gloves does not eliminate need Wearing gloves does not eliminate need

to wash hands before or after patient to wash hands before or after patient contactcontact

15 second vigorous hand wash with 15 second vigorous hand wash with soap and running watersoap and running water

Primary infection control measurePrimary infection control measure

Chlorhexidine Skin Chlorhexidine Skin AntisepticAntiseptic Superior efficacySuperior efficacy

Rapid onset (30 seconds) Rapid onset (30 seconds) and prolonged and prolonged antimicrobial efficacyantimicrobial efficacy

Recent meta-analysis Recent meta-analysis suggest CR-BSI is suggest CR-BSI is significantly reduced in significantly reduced in patients receiving patients receiving chloraprep vs providine-chloraprep vs providine-iodine for site disinfectioniodine for site disinfection

80% of resident and 80% of resident and transient flora live in the 1transient flora live in the 1stst 5 layers of dry skin (15 layers of dry skin (1stst 10 10 layers of wet skin) Friction layers of wet skin) Friction is necessaryis necessary

(Chalyakunapruk N, et al. Ann (Chalyakunapruk N, et al. Ann Intern Med. 2002;135, 792)Intern Med. 2002;135, 792)

BIOPATCHBIOPATCH

Foam patch with chlorhexidrine gluconate Foam patch with chlorhexidrine gluconate with antimicrobial and antifungal propertieswith antimicrobial and antifungal properties

Highly absorbentHighly absorbent Inhibits growth of bacteria for 7 daysInhibits growth of bacteria for 7 days Shown to significantly reduce bacterial Shown to significantly reduce bacterial

colonization of CVC sites colonization of CVC sites (Hanazaki et al, J Hosp Inf (Hanazaki et al, J Hosp Inf 1999)1999)

Associated with localized contact dermatitis Associated with localized contact dermatitis in infants of very low birthweight in infants of very low birthweight (Garland et al, (Garland et al, Pediatrics 20010Pediatrics 20010

ANTI-INFECTIVE LOCK ANTI-INFECTIVE LOCK SOLUTIONSOLUTION

Prophylaxis with Prophylaxis with vancomycin lock vancomycin lock (More (More

studies needed) studies needed) Risk of VRERisk of VRE Ethanol instillation Ethanol instillation (to be (to be

published soon) 25% ethanol published soon) 25% ethanol instilled for one hour each dayinstilled for one hour each day

PREVENTIONPREVENTION

The use of maximal sterile barrier, The use of maximal sterile barrier, including the use of hair covering, including the use of hair covering, face mask, sterile gown and gloves face mask, sterile gown and gloves and large sterile drapes, have been and large sterile drapes, have been shown to reduce the risk of infection shown to reduce the risk of infection by six to seven times over the use of by six to seven times over the use of sterile gloves and drapes alone (Maki, sterile gloves and drapes alone (Maki, 1994)1994)

AHRQAHRQ

SPECIALTY TEAMSSPECIALTY TEAMS IV Teams/PICC teamsIV Teams/PICC teams Clinical resource for Clinical resource for

cliniciansclinicians Routine assessment of CVC Routine assessment of CVC

sitessites Monitoring of CVC for Monitoring of CVC for

potential complicationspotential complications Goal is to provide appropriate Goal is to provide appropriate

access from the startaccess from the start

PREVENTIONPREVENTION

Uniform GuidelinesUniform Guidelines INS Standards/ CDC INS Standards/ CDC

GuidelinesGuidelines Policies available Policies available

and user-friendlyand user-friendly Yearly competenciesYearly competencies Resources availableResources available Process Process

ImprovementImprovement Ongoing educational Ongoing educational

opportunitiesopportunities

PREVENTIONPREVENTIONEDUCATIONEDUCATION

Mandatory education program for ICU nurses and Mandatory education program for ICU nurses and physicians in a 19-bed medical ICU at Washington physicians in a 19-bed medical ICU at Washington UniversityUniversity

10-page self-study module on risk factors and 10-page self-study module on risk factors and practice modifications relating to CR-BSI and practice modifications relating to CR-BSI and inservicesinservices

Pre and post-test. Fact sheets and posters reinforced Pre and post-test. Fact sheets and posters reinforced the informationthe information

Results: Results: 24 months before the education, CR-BSI occurred 24 months before the education, CR-BSI occurred

in 9.4/1,000 catheter days ( 74 in 7,879 catheter in 9.4/1,000 catheter days ( 74 in 7,879 catheter days) days)

After implementing new program, CR-BSI occurred After implementing new program, CR-BSI occurred in 5.5/1,000 catheter day (41 in 7,455 catheter days)in 5.5/1,000 catheter day (41 in 7,455 catheter days)

Estimated cost savings with decreased CR-BSI was Estimated cost savings with decreased CR-BSI was between $103,600 and 1,573,000between $103,600 and 1,573,000..

Warren DK. “The Effect of an Education Program on the Incidence of Central Warren DK. “The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infections in a Medical Center.” Chest Venous Catheter-Associated Bloodstream Infections in a Medical Center.” Chest 2004;126: 1612-1618.2004;126: 1612-1618.

TRANSPARENT TRANSPARENT DRESSINGDRESSING

Semi-permeable polyurethane Semi-permeable polyurethane dressingsdressings

Dry and intactDry and intact Routine dressing changesRoutine dressing changes Special attention to Special attention to

immunocompromised patients immunocompromised patients and neonatesand neonates

ANTIMICROBIAL ANTIMICROBIAL IMPREGNATED IMPREGNATED

CATHETERSCATHETERSPREVENTIONPREVENTION Purpose: Evaluate efficacy Purpose: Evaluate efficacy

of long-term non-tunneled of long-term non-tunneled silicone catheters silicone catheters impregnated with impregnated with minocycline and rifampin minocycline and rifampin (M-R) in reducing CR-BSI(M-R) in reducing CR-BSI

Prospective, randomized, Prospective, randomized, double-blind study N=356 double-blind study N=356

182 M-R Catheter duration 182 M-R Catheter duration 66.21 days CR-BSI 3 66.21 days CR-BSI 3

174 control Catheter 174 control Catheter duration 63.01 days CR-duration 63.01 days CR-BSI 14BSI 14

Hanna H, et al. “Long-term silicone Hanna H, et al. “Long-term silicone central venous catheters impregnated central venous catheters impregnated with minocycline and rifampin decrease with minocycline and rifampin decrease rates of catheter-related bloodstream rates of catheter-related bloodstream infection in cancer patients: a infection in cancer patients: a prospective randomized clinical prospective randomized clinical trial.” J trial.” J Clin Oncol. 2004 Aug 1;22(15):.3163-71Clin Oncol. 2004 Aug 1;22(15):.3163-71

CR=BSI rates: M-R CR=BSI rates: M-R 0.25/1,000 catheter days0.25/1,000 catheter days

Control 1.28/1,000 catheter Control 1.28/1,000 catheter days P=.003days P=.003

Gram-positive cocci Gram-positive cocci accounted for the majority of accounted for the majority of positive culturespositive cultures

No allergic reactionsNo allergic reactions

ANTISEPTIC ANTISEPTIC IMPREGNATED IMPREGNATED

CATHETERS AND CUFFSCATHETERS AND CUFFS Catheters coated with chlorhexidine/silver Catheters coated with chlorhexidine/silver

sufadiazine on the catheter surface can reduce sufadiazine on the catheter surface can reduce the risk for CR-BSIthe risk for CR-BSI

Antimicrobial activity decreases over time, Antimicrobial activity decreases over time, benefit will be realized within the 1benefit will be realized within the 1stst 14 days. 14 days.

Although rare, anaphylaxis has been reportedAlthough rare, anaphylaxis has been reported More expensive than standard catheters, may More expensive than standard catheters, may

be cost effective for high risk patients i.e. be cost effective for high risk patients i.e. patients with burns, neutropeniapatients with burns, neutropenia

Veenstra DL et al, “Efficacy of antiseptic-impregnated central venous catheters in Veenstra DL et al, “Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related blood stream infections: a meta-analysis.” JAMA preventing catheter-related blood stream infections: a meta-analysis.” JAMA 1999;281;261-7.1999;281;261-7.

SECUREMENT DEVICESSECUREMENT DEVICES

• Decrease irritationDecrease irritation• Decrease needlesticksDecrease needlesticks• Decrease catheter migrationDecrease catheter migration• Increase patient comfortIncrease patient comfort• Decrease infectionDecrease infection (Shears et al, 2000(Shears et al, 2000))

ADDITIONAL ADDITIONAL STRATEGIESSTRATEGIES

Catheters inserted into Catheters inserted into new sites, not old sites new sites, not old sites over a guidewire (over a guidewire (avoid avoid routine replacement of routine replacement of central linescentral lines))

Warfarin and Heparin Warfarin and Heparin Prophylaxis Prophylaxis (Thrombus (Thrombus formation on indwelling CVC formation on indwelling CVC associated with CR-BSI)associated with CR-BSI) S. S. aureus, S. epidermidis, and aureus, S. epidermidis, and Candida species adhere to Candida species adhere to different protein different protein components of thrombus)components of thrombus)

Subcutaneously tunneled Subcutaneously tunneled short term catheters short term catheters (Cuffed (Cuffed dialysis catheters decreases risk dialysis catheters decreases risk of CR-BSI by 2/3)of CR-BSI by 2/3)

Minimize hub Minimize hub manipulationsmanipulations

Ointments to insertion Ointments to insertion site; may lead to site; may lead to increased colonization increased colonization of candida species.of candida species. (Ointment to insertion sites of (Ointment to insertion sites of temporary HD central lines temporary HD central lines reduces CR-BSI)reduces CR-BSI)

““KEEP ME SAFE”KEEP ME SAFE”

Patient campaign from the Patient campaign from the Oley foundationOley foundation

Specific instructions for Specific instructions for central line carecentral line care

Goal is to prevent infectionGoal is to prevent infection