Vascular Catheter Related BSIs
Mechanical Circulating Support-Related BSIs
Vascular catheters are placed for intravascular medication, treatment or monitoring. Risk of bloodstream infection is higher when these vascular access devices (VADs) are placed as central lines. There are a number of VADs listed in Table I.
Mechanical Circulatory Support Devices (MCSDs) are placed in large veins or arteries to augment or maintain cardiac function in patients with severe heart failure. One of the major determinants of patient survival is device-related infection. The most recent generation of MCSDs use axial flow rotary pumps with contact bearings with and smaller percutaneous leads. Because of engineering improvements, this newer generation of devices is expected to have lower rate of device-related infectious complications. Data from clinical trials demonstrate a lower incidence of pocket infection. However, only one of these studies showed that the lower BSI was linked to second-generation devices. Long-term results from the large multicenter studies, the Interagency Registry for Mechanical Circulatory Support (INTERMACS) will be available in the near future.
Definitions of CLABSI for NHSN surveillance
Central line: Central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. Neither the insertion site nor the type of device may be used to determine if a line qualified as a central line.
Primary bloodstream infection: Primary BSIs are laboratory-confirmed (cultured blood grows organisms) bloodstream infections (LCBSI) that do not result from an infection at another body site.
Central line-associated bloodstream infection: The Centers of Disease Control and Prevention (CDC) develops definitions that are used for surveillance. surveillance system called the National Healthcare Surveillance Network (NHSN) the primary system. Of note the NHSN definitions for CLABSIs are being updated currently.
A bloodstream infection (culture blood growing organisms) is defined when a central catheter was in place at the time of, or within 48 hours before the infection onset. There is no minimum period of time that the central line must be in place in order to be considered as central line associated bloodstream infection (CLABSI).
Laboratory-confirmed bloodstream infections (LCBSI): To be considered the event must meet one of the following criteria in a patient:
has a “recognized pathogen” from cultured blood and the organism cultured is not related to an infection at another site. Organisms considered common skin contaminants are not included in the definition of a recognized pathogen.
has at least one of the following signs or symptoms:
fever (>38°C), chills, or hypotension if the patient is > 1 year of age OR
fever (>38°C core) hypothermia (<36°C core), apnea, or bradycardia if the patient is 1 year of age AND
microbiology results (blood cultures growing organisms) that not related to an infection at another site OR
a common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.
Attribution of BSI: The BSI is attributed to the location where the patient was housed on the date of the BSI event (first clinical evidence of BSI appeared or the date the specimen used to meet the BSI criteria was collected). If a CLABSI develops within 48 hours of transfer from one inpatient location to another in the same facility, the infection is attributed to the location that transferred the patient.
Measurement of CLABSI for NHSN Surveillance
Data collected by infection prevention programs is frequently reported to the NHSN and includes patient demographic information, the type of central line associated with the CLABSI, the patient location, the specific criteria to classify the event as a CLABSI, the patient outcome, the organism(s) isolated from cultured blood and the organisms’ antimicrobial susceptibilities.
Numerator data: Patients meeting criteria of CLABSIs will be used to calculate line-specific infection rate.
Denominator data: Two measures are used, patient days and device days. Patient days, while easier to obtain, may underestimate the CLABSI rate as not all patients have central lines. Most experts and regulatory bodies prefer the use of device days that can be used to calculate a risk adjustment rate. Ideally, the denominator data should be validated.
Device-days: Collection of “device days” data is done in a variety of ways. Generally, staff identifies all patients with a VAD in a specified patient care location during for a day. The data should be collected daily at the same time every day i.e. 12 midnight. If a patient has three catheters this is still considered one device day. The number of catheters is summed each day to provide a number of devices and then at the end of the month the total number of catheters for all the days in the month are summed. If electronic databases are available, this information may be used as long as the electronic counts are not substantially different (e.g. +/- 5%) from the manually counts.
The CLABSI rate is calculated by dividing the number of CLABSIs identified in a month or quarter by the number of central line days identified for the same period of time. The resulting number is multiplied by 1,000. Rates can be calculated by unit and for an entire unit. The most commonly used formula to calculate CLABSI rates is listed in Table II.
Rates can be calculated monthly or quarterly depending on the number of catheter days.
The Central line Utilization Ratio provides an estimate of how many patients days also have devices utilized. This ratio is calculated by dividing the number of central line days by the number of patient days. These calculations are performed separately for different types of intensive care units (ICUs), specialty care areas, and other locations in the institution. Separate rates and ratios are be calculated for different types of catheters in specialty care areas and neonatal intensive care units (NICUs), and stratified by birth weight categories for in NICUs, as appropriate. CLABSI rate and the utilization ratio are calculated and reported to promote performance improvement.
Clinical Definitions of Vascular Access Device-related Infections
These definitions are used to categorize different types of VAD-related infections and are useful if surveillance efforts need to be broadened.
Catheter colonization is most commonly defined as growth of > 15 colony-forming units (CFU) from a 5-cm segment of a catheter tip or subcutaneous catheter segment by semi-quantitative (roll-plate) culture or growth of > 102 CFU of on species of microorganism from a catheter by quantitative (sonication) broth technique.
Phlebitis is an inflammation along the tract of a catheter or recently catheterized vein. Signs and symptoms include induration, erythema, warmth, and pain or tenderness.
An exit site infection has two common used definitions. For a microbiological diagnosis, the culture exudate at catheter exit site must grow a microorganism. A concomitant bloodstream infection may or may not be present. The clinical diagnosis requires erythema, induration, and/or tenderness along 2 cm of the catheter exit site and may be associated with signs and symptoms of infection.
A tunnel infection is an infection along the subcutaneous tract that houses the catheter. It manifests with tenderness, erythema, and/or induration at least 2 cm from the catheter exit sit. Cultured blood may or may not grow organisms.
A pocket infection is diagnosed when infected fluid develops in the subcutaneous pocket of a totally implanted intravascular device such as a pacemaker. These infections are often associated with tenderness, erythema, and/or induration over the pocket and occasionally spontaneous rupture and drainage. Concomitant bloodstream infections can occur.
Primary bloodstream infections are bloodstream infections that are not secondary to other sources such as the urine or a surgical wound. These infections are generally associated with infusates, or related to the catheter. These definitions tend to be used clinically and in clinical trials but not for routine infection control surveillance.
An infusate-related bloodstream infection is diagnosed when an identical microorganism grows from both the infusate and cultured blood with no other identifiable source of infection.
A catheter-related bloodstream infection is bacteremia or fungemia that develops in a patient with an intravascular device and at least one culture of the blood growing an organism. Clinical signs and symptoms of infection include fever, chills, and/or hypotension. Again, no other source for the bloodstream infection (except the catheter) should be identified. One of the following should be present:
a semi-quantitative (>15 CFU per catheter segment) or quantitative (>102 CFU per catheter segment) result from catheter cultures, and the same organism (species) is isolated from a catheter segment and a peripheral blood culture;
simultaneous quantitative cultures of blood with a ratio of >3:1 CFU/mL of blood (catheter versus peripheral blood);
differential time to positivity (growth in a culture of blood obtained through catheter hub is detected at least 2 hours earlier than a culture of simultaneously drawn peripheral blood of equal volume).
What are the key guidelines and principles of preventing bloodstream infections?
Several federal public health authorities and professional organizations have developed guidelines and recommendations that have been published. The majority of these recommendations are based on studies conducted in the Intensive Care Units (ICUs) setting. Some recommendations are directed at high-risk patients in non-ICU setting such as hematological patients, or patients who need cardiac catheterization. The Society for Healthcare Epidemiology of America and the Infectious Disease Society of America (SHEA/IDSA) Compendium has synthesized basic practices for prevention and monitoring of CLABSI prevention efforts. In addition, several recent studies provide strong evidence for several additional measures to prevent CLABSI and are included below.
1. Before insertion:
a. Educate healthcare personnel who insert, care for, and maintain CVCs about risk factors for developing CLABSIs, prevention strategies, indication for CVC use, evidence based insertion and maintenance practices, and general infection prevention strategies.
b. Verify that personnel involved the insertion and care of CVCs has been educated as defined above.
c. Assess the knowledge of personnel periodically and develop programs to measure compliance with best practices.
2. While inserting the catheter:
a. Provide all supplies in one place such as in an all-inclusive catheter tray or in a line cart.
b. Avoid placing the catheter in the femoral vein (adults).
c. Use a checklist to promote evidence-based infection prevention practices.
d. Perform hand hygiene before beginning the procedure or manipulating the catheter.
e. Use maximal sterile barrier precautions during CVC insertion—both the inserter and assistant.
f. Use a chlorhexidine and alcohol-based antiseptic to cleanse the skin in patients more than 2 months of age.
3. After the catheter is inserted and while it is maintained:
a. Remove any catheter that is not needed.
b. Clean catheter hubs, connectors, and injection ports with a disinfectant before they are accessed.
c. Change transparent dressing and clean the site with a chlorhexidine-based antiseptic every 5-7 days. When the dressing is damp, bloody, or loose, additional cleaning and dressing changes are needed. When gauze dressings are used, they should be changed at least every 2 days if damp, bloodied, or loose.
d. Replace all administration sets that are used for blood, blood products, or lipids at least every 96 hours.
e. Do not use topical antimicrobial ointments except for hemodialysis lines.
f. Consider using chlorhexidine impregnated patches or implement daily bathing of all ICU patients with CVCs.
a. Assure senior leadership and hospital’s management team is accountable for providing support and visibility for the infection prevention program and campaign to reduce CLABSI.
b. Support an infection prevention program(s) with the needed clinical informatics, trained personnel and other resources to prevent CLABSIs. Such a program should identify and feedback CLABSIs data regularly to clinical care teams and leadership.
c. Assure that healthcare providers follow appropriate infection prevention and control practices are used at all times and that they are accountable for their actions.
d. Ensure that appropriate training and educational programs to prevent CLABSIs are developed and provided to healthcare personnel, patients and families.
5. The prevention bundle:
1. Clean hands prior to insertion
2. Use a chlorhexidine based product to clean the patient skin
3. Use maximal barrier precautions while inserting the catheter
4. Avoid the femoral site and use subclavian preferentially
5. Remove the catheter when no longer needed
6. Clean the hub or injection ports prior to accessing them
What are the conclusions of clinical trials and meta-analyses regarding bloodstream infections?
Some of the following measures have been combined into a “prevention bundle” that focuses on catheter insertion. We review some of the strategies used to prevent central line associated bloodstream infections from well-designed clinical trials and meta-analyses.
a. At insertion
Hand hygiene and aseptic technique are the key elements of prevention efforts for CLABSIs. Other measures may confer additional and incremental benefits.
Site of catheter insertion:
CLABSIs rates vary depending on the site of catheter insertion. Several studies found that rate of CLABSIs is highest with femoral, then jugular, and finally subclavian venous access. Emergency insertion increases the risk of catheter contamination, but not clinical infection. A meta-analysis further demonstrated that femoral venous access had higher rates of gram-positive and gram-negative organisms compared with subclavian access. However, one clinical study found that femoral and jugular venous access CLABSI rates did not differ except among adults with a high body mass index over 28.4.
Maximal sterile barrier (MSB):
The use of maximal sterile barrier protection includes head caps, facemasks, sterile body gowns, sterile gloves in the catheter inserter and others directly involved in the procedure, and full-size sterile drapes for the patient has been shown to reduce the rate of CLABSIs. One large randomized clinical trial found that MSB decreased the rate of CLABSIs by about 65% in oncology patients. Another prospective study found that the use of MSB was independent risk factor that lowered the risk of acquiring CLABSIs. The use of MSB has not been shown to prevent infections associated with arterial access.
Several studies have compared chlorhexidine-based to povidone-iodine based solutions in lowering the incidence of catheter colonization and/or infections. The povidone-iodine based solutions used in these evaluation includes 10% povidone-iodine in aqueous solution or 5% povidone-iodine in 70% alcohol. Chlorhexidine-based solutions have been used in form of 0.25% chlorhexidine gluconate, 0.025% benzakonium chloride, and 4% benzylic alcohol, so called Biseptine, 0.5% chlorhexidine in 70% alcohol, or 1% chlorhexidine in 75% alcohol.
Because of the variety of solutions studied and the small sample sizes in these studies a meta-analysis of studies was performed and demonstrated that chlorhexidine-based solutions as skin antisepsis insertion decrease the incidence of CLABSIs by 50%. Although chlorhexidine-based solutions are more expensive than previously used solutions, cost-benefit analyses using data from randomized, controlled, clinical trials support the use of these products.
Currently, the United States Food and Drug Administration (FDA) does not recommend using chlorhexidine antisepsis in infants less than 2 months of age, because safety data in this particular patient group is lacking. However, limited data from clinical trials or meta-analyses support the use of these compounds in children. One prospective clinical study in the NICU patients demonstrated a significant reduction in rate of catheter colonization and catheter-related bacteremia. Importantly, recent large well-designed clinical studies do not report serious adverse events associated with chlorhexidine use in neonates.
b. After insertion (maintenance)
Standard guidelines for non-tunneled catheter recommend changing transparent dressings site care with a chlorhexidine-based antiseptic. Soiled, loose or damp dressings should be changed more frequently. These recommendations are based on a clinical study that compared outcome in adult patients with dressing changes two and five days. However, in adults, the colonization and CLABSI rate increased if the interval between changes increased. A clinical study in pediatric patients found no difference in CLABSI rate between dressing changes every 4 or 15-days.
Replace administration set:
Intravenous fluid administration sets, not used for blood, blood products or lipids should be replaced every 96 hours. Clinical studies and a meta-analysis demonstrate that replacing administration sets more frequently than every 96 hours does not decrease catheter colonization and catheter-related infection rates.
Antibiotic ointment for hemodialysis patients:
Topical antibiotic ointments or creams should not be used to decrease the risk of CLABSIs. However, among patients on hemodialysis, topical antibiotic ointments do reduce the risk of CLABSIs, however, their use does not impact patient mortality. Among these patients, the use of topical antibiotics can decrease rate of catheter removal due to infection and episodes of hospitalization. In addition, a recent meta-analysis showed that topical ointment containing honey as the main ingredient are more effective than topical antibiotic ointments and significantly decrease the rate of catheter-related bloodstream infection/100,000 catheter-days. Topical antibiotic ointments that have been studied include mupirocin, povidone-iodine, and polysporin. High-level mupirocin resistance has been reported with its long-term local use, but polysporin resistance has not been reported even when used long-term.
Coagulation factors can promote bacterial adherence and increase risk of CLABSIs in both in-vitro studies and animal models. Many clinical studies demonstrate a relationship between developing a central vein-related thrombosis and catheter-related bacteremia or sepsis. Based on these findings, low-dose unfractionated continuous infusion or heparin coated non-tunneled central venous catheter are used to prevent catheter-related colonization and bloodstream infection and have not increased heparin-induced thrombocytopenia. Other anticoagulants and thrombolytics, including very low dose of warfarin and urokinase, have been used without inducing hemorrhagic complications. One meta-analysis showed that a urokinase lock or flush solution might reduce risk of CLABSIs.
c. Special approaches for CLABSI prevention
After implementing all the elements of the CLABSIs prevention bundle previously mentioned, other strategies can be implemented if the CLABSIs rates remain unacceptably high. The other strategies that can be used are listed below.
The daily use of 2% chlorhexidine gluconate solution or impregnated to bath patients in medical and surgical ICUs, reduce CLABSIs rates when compared to soap-and-water bathing. These have also been shown to reduce transmission of resistant organisms especially in MRSA. Similar data is forthcoming in pediatric intensive care unit patients. One study found that bathing twice weekly was sufficient but these findings have not been confirmed. Again, the FDA does not approve the use of chlorhexidine products among children younger than 2 month-old.
Chlorhexidine impregnated sponges or dressings for CVC insertion sites:
Using chlorhexidine-containing sponge dressings for CVCs in patients older than 2 months of age reduces the rate of catheter colonization. A recent randomized controlled trial found that these dressing can decrease risk of catheter-related infections in critically ill adults, but not in patients undergoing hemodialysis using nontunneled catheters. It is not known if there is an incremental benefit to the use of these dressings/sponges in the setting of chlorhexidine bathing or if bathing is superior to sponges or vice versa.
Antiseptic- or antimicrobial-impregnated coated catheters:
Coating of short-term catheters with either antiseptics or antimicrobials has been of interest of the years. Early generation catheters were coated extraluminally and more recently companies has introduced coating on the intra and extraluminal catheter surfaces or even materials that are impregnated. Both antiseptic- and antimicrobial-impregnated catheters have been shown to decrease rates of CLABSIs compared with standard catheters. Antiseptic-coated CVCs in the forms of silver-coated and chlorhexidine-silver sulfadiaxine (CH/SS) – coated catheters have been studied. Other agents used include 5-fluorourecil and benzalconium-chloride.
Both clinical studies and meta-analyses demonstrate that minocycline/rifampicin-coated (MR) CVCs were associated with lower catheter-related infectious complications than first generation antiseptic-coated catheters, defined as catheters coated with CH-SS on the external surface. Second generation catheters, or those catheters CH/SS-coated on internal and external surfaces, reduce CLABSIs more than standard catheters and first generation CH-SS coated catheters. However, no head-to-head comparison between the CH-SS catheters and antimicrobial-impregnated catheters has been published. An uncontrolled observational study demonstrated that using MR-impregnated CVCs reduces overall nosocomial bloodstream infections in the ICUs. For long-term catheters, there are very limited clinical trials and their results are varied.
At this point, the FDA has not approved the use of these catheters in children. While, clinical studies demonstrate that coated catheters decrease the rate of central venous catheter colonization and delay CLABSIs, one randomized clinical trial noted unexpected consequences in very low birth weight infants.
Although antimicrobial- and antiseptic-impregnated catheters are both efficacious and cost-effective, they are not routinely recommended. Current guidelines promote their use only in 1) hospital units or patient populations have a CLABSI rate higher than the institutional goal, in the settings of good compliance with other prevention strategies and bundled practices, 2) patients who have limited venous access with a history of recurrent CLABSIs or 3) patients who are at heightened risk for severe sequelae from a CLABSI.
Antimicrobial/anti-infective lock solutions:
To decrease the rate of catheter-related bloodstream infections in patients with long-term central intravenous devices some experts promote the use of antimicrobial lock solutions. Compounds that have been used include heparin, alcohol and antibiotics. Four meta-analyses confirmed that antibiotic containing locks are superior to heparin containing locks in reducing CLABSIs; one focused on vancomycin-containing lock only. Tested antimicrobials include gentamicin, minocycline, ciprofloxacin, vancomycin and fusidic acid, mainly aimed at preventing gram-positive bacterial infections. Limited data are available for alcohol lock solutions but small clinical trials show promising results. A newer agent, that is not an antimcirobial, taurolidine has antimicrobial activities and resistance has not been observed in vitro. Only two clinical trials evaluated short-term catheters.
Despite their advantages, antimicrobial locks are not routinely recommended because of concerns about emergence of antimicrobial resistance and systemic adverse events in case of leakage into blood circulation. Current guidelines suggested that this strategy be used in the same setting as antiseptic- and antimicrobial-impregnated catheters.
The ethanol lock technique sterilizes the intra-catheter lumen and has been studied in persons with long-term catheters. Clinical studies about this method reported tolerable adverse events and trend of benefit. Because these studies contained many variables such as ethanol concentrations, luminal dwell times, catheter type, their results are not easily comparable and requires a large outcome study or meta-analysis.
Closed infusion systems:
One source of CLABSIs is from contaminated infusates. This source of infection is more common in developing countries where resources to mix intravenous medications are more limited. Four large time-sequence clinical trials carried out in four countries demonstrated that a close infusion system, when compared with an open system, reduces CLABSI rates significantly. A recent meta-analysis confirmed this finding, and the meta-analysis also found that a closed infusion system can decrease overall ICU mortality. Because guidelines commonly are developed in regions of the world with access to more sophisticated and expensive technologies, this important technical finding is not included in any guidelines.
d. Approaches that should NOT be used routinely to prevent CLABSIs.
Systemic antimicrobial prophylaxis:
Administration of systemic antimicrobial administration to prevent CLABSIs especially coagulase-negative staphylococci, does not decrease the risk of CLABSIs significantly. Cochrane reviews concluded that there is no role for using systemic antimicrobials routinely to prevent CLABSIs in adults and neonates. While flushing the central venous catheter with a combination of an antibiotic and heparin has been used in very high-risk adult patients, including those patients with hematological malignancies receiving induction chemotherapy, who are neutropenic at the time of CVC insertion and whom are undergoing a bone-marrow transplant, none of the CLABSIs prevention guidelines recommend using systemic antimicrobial prophylaxis.
Routinely CVC change:
Scheduled and routine replacement of CVCs is not recommended. Clinical trials have not demonstrated a benefit. Furthermore, exchanging over a guide-wire increases risk of bloodstream infections, and replacement by insertion at new sites increases risk of mechanical complications. Prevention efforts should focus on catheter removal as soon as medically indicated.
What are the consequences of ignoring bloodstream infections?
CLABSIs are associated with high mortality, prolonged hospitalization, and higher healthcare costs. CLABSI prevention bundle has been demonstrated that it can significantly decrease CLABSI rate and down to zero; as a result, CLABSIs are defined as one of preventable conditions.
The Department of Health and Human Services (HHS) targeting CLABSI as part of their response to the 2005 Deficit Reduction Act. Because CLABSIs are associated with (1) high costs and high volume, (2) result in cases being assigned to a diagnosis-related group that receives a higher payment when presented as a secondary diagnosis, and (3) can reasonably have been prevented through the use of evidence-based guidelines, the Centers for Medicare and Medicaid Services (CMS) and some health maintenance organizations, promulgated regulations that will limit or no longer reimburse costs related to CLABSIs. Beginning on January 2011, CMS is requiring that hospitals use the CDC’s National Healthcare Safety Network, or NHSN, to report their incidences of CLABSIs, in order to receive a full Medicare payment update for 2013.
CLABSIs are included in patient safety indicators in many settings. To be accredited and/or certificated by accreditation organization, such as The Joint Commission (TJC), hospitals have to use evidence-based strategies to prevent CLABSIs. Furthermore, evidence that checklists or strategies to enforce basic principles must be available and analyzed within an institution.
Interest in healthcare-associated infections is increasing among the public. Because these infections are preventable and prevention strategies are well developed and agreed upon, there is an increasing focus on associated poor outcomes from the legal community. Failure to adhere infection prevention and control protocols, CLABSIs prevention bundle in particular, may be interpreted as medical negligence. Although legal systems in different countries have their own perspective, adequate infection control practices and procedures can ensure patient safety and protect healthcare providers and hospitals from lawsuits.
What other information supports the studies about bloodstream infections, e.g., case-control studies and case series?
Based on clinical studies other than randomized clinical trials and meta-analyses, we review some of the strategies used to prevent central line associated bloodstream infections from well-designed case control, cohort and observational studies.
a. Before insertion:
The impact of educational interventions to prevent catheter-associated bloodstream infection has been established in two elegant studies. Education may take the form of study modules including self-study, infection control short courses, lectures, bedside teaching, interactive educational videotape, and hands on training such as in simulation centers but they should have pre- and post-test evaluation. To magnify the impact of education, performance feedback should be performed. Healthcare personnel who take care of critically ill patients must be included in a mandatory education program. Clinical studies showed significant decrease in rate of central line associated bloodstream infection if frontline staff, including ICU nurses, intensivists, physicians-in-training complete education in some form. One study showed impact by training patients receiving long-term home parenteral nutrition. Most studies did not provide effect of education alone; nevertheless, education is a critical part of implementing the CLABSI prevention bundle.
b. At insertion:
Although benefit of checklist alone is not clearly known, checklists are tools that ensure micro- and macro-strategies are implemented. They facilitate “best practices” and improve culture within units and ultimately support CLABSI elimination programs. Compliance with processes as captured by checklists should be provided at multiple levels including hospital board, executive/senior leader and infection preventionists.
Using all-inclusive catheter cart facilitates standard of care for central line insertion by making available needed equipment. They can improve healthcare providers compliance with the central line prevention bundle.
c. After insertion
Remove nonessential vascular catheters:
Daily the need for any central venous catheters should be considered. Unnecessary central lines should be removed.
Disinfectant before using catheter hub or needleless connector:
A potential portion of entry of microorganisms into bloodstream is from contaminated vascular-catheter hubs or needleless connectors. In vitro data reveal that both 70% and 95% alcohol significantly decreased microbial contamination of catheter hubs and was superior to 1% chlorhexidine. Another clinical study found that 70% alcohol, 0.5% chlorhexidine or 10% povidone-iodine was equivalent.
Healthcare associated infections surveillance and data feedback, together with appropriate infection prevention and control strategies, have been demonstrated to reduce infection rates, and can be sustained. The incidence of CLABSIs should be reported regularly to unit-level to healthcare providers including physicians and nurses, and the data should be compared with institutional historical data and national rates. Data that includes units other than ICUs is still required.
d. Approaches that do not need to be considered
Routine use of needleless connectors:
While clinical trials demonstrate that needleless hub devices decrease the rate of device and skin contamination, but they do not significantly decrease clinical infections. In fact, several studies suggest that the use of devices with positive pressure increase CLABSI rates. More recently, an in-vitro study demonstrated that if the membranous septum of a needleless luer-cap connector is heavily contaminated, an antiseptic barrier cap provided was superior to 70% alcohol for decontamination. A randomized, controlled trial showed that using disinfectable needle-free connectors can decrease rate of catheter colonization and bloodstream infections. Given the controversies, the routine use of positive-pressure needleless connectors with mechanical valves is not recommended without a thorough assessment of risks, benefits, and education regarding their proper use.
Summary of current controversies
Patient density and understaffing, mainly examining registered nurses are associated with increased CLABSI rates. A case-control study suggested that nurse-to-patient ratio should be at least 2:1. However, these studies cannot control all nurse related factors that may be play role in CLABSI infection such as the composition of the nursing skill mix, nurse overtime and other assigned duties. Results of clinical trials are still required to establish a strong recommendation.
Phlebotomy and intravenous team:
Phlebotomy and intravenous therapy teams commonly insert and maintain vascular catheters (peripheral lines primarily) and reduce vascular catheter-related infectious complications including bloodstream infections. Two observational studies have shown a reduction of the CLABSI rate after implementation of an intravenous therapy team. The data from clinical studies do not support a recommendation for CLABSIs prevention at this point.
Surveillance systems and surveillance that includes other types of catheters:
As CMS and other agencies implement strategies to enhance performance in healthcare settings, strategies to identify events of interest will be increasingly important. In addition, institutions will be interested in a level playing field to assure that events are identified in a similar way. Most of current surveillance systems do not include all types of catheters that play role in CLABSIs (e.g., arterial catheters) or catheter related infections. Future surveillance systems including all kinds of high-risk VADs are needed.
Surveillance of non-ICU setting:
Very limited surveillance data and information about prevention strategies exist in non-ICU settings. Because of the number of beds in non-ICU settings, high-risk settings like dialysis, the CLABSI rate is significant. It is difficult to perform surveillance for infections and implement current CLABSI prevention bundle in these settings.
Current gold standard to evaluate the CLABSI rate is by using central line-day as the denominator. This risk-adjusted measurement is, however, burdensome especially in resource-limited settings. While one report found that this method has more impact than the less-sophisticated method (the patient-day rate), another study found that a sample-based method to estimate CLABSI rate can provide acceptable surveillance data.
The appropriate denominator has been a source of controversy and a recent study demonstrated the variation in rates depending on whether the traditional method of counting catheters was used or a novel method that counted the total number of catheters in a patient.
What is the impact of bloodstream infections, and how can they be controlled relative to infections at other sites or from other specific pathogens?
Central line-associated bloodstream infections (CLABSI) are healthcare-associated infections (HAIs) that contribute to morbidity and mortality despite often being preventable. CLABSI-induced mortality varies. The International Nosocomial Infection Control Consortium (INICC) reported crude mortality of the patients was 38.1% compared with 14.4% in patients who did not have HAIs. In the United States the mortality is estimated to be 12.3% and accounts for almost 31,000 deaths. These are the second most common cause of HAI associated death. CLABSIs increase length of stay and hospital cost. The cost of one CLABSI has been estimated to be as high as $45,000 (mean cost was $23,242). Cost estimates per episode of other HAIS were $25,072 per VAP, $10,443 per SSI, and $758 per CA-UTI.
CLABSI rates vary also and depend on the country, type of unit and surveillance strategy. The pooled rate of CLABSI in developing countries is higher than in the United States and Europe. INICC ICUs report a pooled rate of 7.6 per 1,000 CVC-day while in US ICUs the CDC NHSN (National Healthcare Safety Network) pooled mean rate was 2.0 per 1,000 CVC-day.
Prevention of CLABSIs and strategies used overlap with those for other healthcare associated infections. Many of the basic tenets impact other types of infections or transmission of epidemiologically significant organisms. Improved hand hygiene compliance decreases the overall HAIs rate that includes CLABSIs, VAP, UTIs and SSIs. Moreover, feedback of data also impacts rates for all HAIs. However, implementation of CLABSIs prevention bundle does not impact VAP or UTI rates. Staphylococcus aureus decolonization with chlorhexidine bathing reduces CLABSI, MRSA colonization and MRSA VAP. The use of rifampicin/minocycline-impregnated CVCs can reduce nosocomial BSIs, including VRE bacteremia.
Recommended prevention strategies for all acute care hospitals
The recommended prevention strategies for all acute care hospitals are listed in Table III, Table IV, and Table V.
a. Before insertion.
See Table III for Educational program.
b. At insertion
See Table IV Avoid using the femoral vein for central venous access in adult patients
See Table V Use maximal sterile barrier precautions during CVC insertion.
Table VI describes the use of a chlorhexidine-based antiseptic for skin preparations in patients older than 2 months.
c. After insertion
See Table VII, Table VIII, Table IX, and Table X for information about after insertion strategies.
II. Special approaches for CLABSIs prevention
See Table XI for special approaches for bloodstream infection prevention.
See Table XII, Table XIII, Table XIV, Table XV, Table XVI, and Table XVII for information about the use of antiseptic- or antimicrobial-impregnated CVCs for adults.
III. Prevention strategies not recommended:
These are described in Table XVIII and Table XIX.
Controversies in detail.
1. Routine use of antimicrobial/antiseptic-impregnated catheters
CDC/HICPAC (2002) and IDSA/SHEA (2009) guidelines do not recommend antimicrobial/antiseptic-impregnated catheters routinely. Some organizations recommended their use.
Pros: As we discussed above, both of antiseptic-coated, silver and chlorhexidine-silver sulfadiazine (CH-SS), and antimicrobial-coated catheters, minocycline-rifampicin, prevent CLABSIs. Cost-effectiveness studies confirm the benefit of these catheters in preventing patient harm. While the emergence of antimicrobial resistance and toxicity should be considered, no large longitudinal study reports antimicrobial resistance when these catheters have been used. In vitro studies demonstrated significance increase of the MICs of minocycline and rifampicin in S. epidermidis both in antiseptic-, and antimicrobial-impregnated catheters after being in place for 7 days.
Cons: The use of CLABSI bundles has resulted in dramatic reductions of CLABSIs in many settings. The incremental role of coated catheters has not been studied and may not be cost beneficial in the setting where best practices have been implemented and complied with. Emergence of antimicrobial and chlorhexidine, resistant organisms argues for caution. There are several reports of rifampicin- and minocycline-resistance among S. aureus and S. epidermidis isolates. Chlorhexidine-resistant organisms from both intra- and extraluminal sources are reported so the efficacy of CH-SS-coated catheters may be limited.
2. ‘Zero tolerance’ target of CLABSIs
CLABSI are significant healthcare-associated infections and their rate should be minimized. It is one of hospital-acquired conditions that Medicare has targeted to encourage hospitals to improve performance by reducing reimbursement.
Pros: A pound of cure is penny wise. Successful CLABSI prevention bundle implementation reduces CLABSI rates significantly and dramatically down to zero, so it is reasonable for healthcare institutions to put more effort to assure compliance with bundled interventions. Implementation of these strategies not only reduces patient harm but is cost effective for institutions.
Cons: Risk of healthcare-associated conditions depends on many factors (e.g., host factors, severity of illness) and most of them are not preventable. While we can implement care bundles based on evidence-based practices, we cannot change or alter the patient’s impaired immunity or underlying disease. Hence, there will always be some nosocomial infections that cannot be prevented. Moreover, the push to zero and the zero tolerance is creating a climate of fear and healthcare workers are fearful of the reprisals associated with infectious complications of healthcare. This has lead to providers not obtaining blood cultures and other diagnostic tests that are in the patient’s best interest. Furthermore, some institutions because of financial pressures or worries about their reputations are gaming the system and not reporting infections. This leads to a ‘questionable zero’ because surveillance data does not reflect the reality of the situation.
What national and international guidelines exist related to bloodstream infections?
We included international and national guidelines to prevent CLABSIs. Level of recommendation is listed in Table XX.
What other consensus group statements exist, and what do key leaders advise?
Table XXI describes the consensus group statements.
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- Bloodstream infections
- What are the key guidelines and principles of preventing bloodstream infections?
- What are the conclusions of clinical trials and meta-analyses regarding bloodstream infections?
- What are the consequences of ignoring bloodstream infections?
- What other information supports the studies about bloodstream infections, e.g., case-control studies and case series?
- Summary of current controversies
- What is the impact of bloodstream infections, and how can they be controlled relative to infections at other sites or from other specific pathogens?
- Controversies in detail.
- What national and international guidelines exist related to bloodstream infections?
- What other consensus group statements exist, and what do key leaders advise?