Guidelines to Prevent Central Line-Associated Blood Stream Infections

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Guidelines to Prevent Central Line-Associated
Blood Stream Infections
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Why do I need to complete this orientation?

• Problem
• Vascular access device-associated infections
  increase morbidity, mortality, hospital length of
  stay, and costs.
• Education of health care workers decreases
  healthcare-associated infections.
• Intervention
• Mandatory course to achieve standardization of
  infection control practices during central
  vascular access device (C-VAD) insertion.

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Why do I need to complete this orientation?
(cont.)

• Outcome
• Education in another center achieved a 28 percent
  relative reduction in central line infections and
  saved 800,000.
• Since implementing this orientation, that
  centers central line-associated related blood
  stream infection (CLABSI) rates have decreased
  below the national average.

Sherertz, et al. Ann Intern Med.
2000132(8)641-648
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Statistics for CLABSIs

• 90 percent of all blood stream infections are
  associated with C-VADs.
• 400,000 CLABSIs occur each year in the United
  States.
• CLABSIs are
• Associated with increased morbidity
• Associated with mortality rates of 10 percent to
  20 percent
• Associated with prolonged hospitalization (mean
  of 7 days) and increase in medical costs gt28,000

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National Nosocomial Infection Surveillance Rates

• In 2003, National Nosocomial Infection
  Surveillance from the Centers for Disease Control
  Prevention reported the number of CLABSIs per
  1,000 catheter days based on nationwide intensive
  care unit (ICU) surveillance.
• Table 1 compares ICUs from one academic medical
  center to national benchmark CLABSI rates.

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CLABSI Rates per 1,000 Catheter Days
  NHSN 90th Percentile NHSN 50th Percentile Pre-VAD Training Post-VAD Training
SICU 9.1 5.3 6.7 0.6
PICU 11.9 7.7 5.5 5.4
CVICU 4.9 2.8 7.6 2.7
MICU 9.8 6.1 7.8 3.3
CCU 7.9 4.6 5.0 1.2
NCCU 8.3 4.9 6.6 3.7
OncICU 9.3 4.7 N/A 1.6
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Risk Factors for CLABSI

• Site of insertion Subclavian vein poses less
  risk than internal jugular or femoral vein.
• Multiple lumen catheters
• Increased tissue trauma predisposes to CLABSI
• More manipulation and contamination of multiple
  ports/hubs
• Total parenteral nutrition and/or lipids
• Low nurse to patient ratio
• Merrer, et al. JAMA. 2001286700-7

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Risk Factors for CLABSIs (cont.)

• Infection elsewhere (remote, i.e., urinary tract
  infection or wound) secondary source
• Colonization of catheter with organisms
• IV catheterization longer than 72 hours
• Inexperience of personnel inserting the C-VAD
• Use of stopcocks

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Process of Catheter-Related Infections
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Five Evidence-Based Steps to Prevent CLABSI

• Use appropriate hand hygiene.
• Use chlorhexidine for skin preparation.
• Use full-barrier precautions during central
  venous catheter insertion.
• Avoid using the femoral vein for catheters in
  adult patients.
• Remove unnecessary catheters.

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Hand Hygiene

• Wash hands with soap and water or use a waterless
  hand sanitizer
• Before and after invasive procedures
• Between patients
• After removing gloves
• Before eating
• After using the bathroom
• If contamination is suspected

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Hand Hygiene Works!
Year Author Setting Comparison Group Results
1982 Maki ICU (U.S.) Crossover ? Nosocomial Infection
1984 Massanari ICU (U.S.) Crossover ? Nosocomial Infection
2000 Pittet Teaching Hospital, Switzerland Observational ? Nosocomial Infection? MRSA Rates
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Waterless Hand Hygiene Steps

• Coat all surfaces of your hands thoroughly with
  waterless hand sanitizer, including palms, in
  between fingers, under fingernails, backs of
  hands, and around wrists.
• Rub your hands briskly until they feel
  comfortably dry.
• It takes about 15 seconds, and no water or towels
  are needed.

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Hand Washing Steps

1. Wet hands.
2. Obtain soap.
3. Lather for 10 to 15 seconds.
4. Rinse hands.
5. Turn off faucet handles with paper towel.

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C-VAD Site Selection

• Use the subclavian site unless medically
  contraindicated (e.g., patient has an anatomic
  deformity, coagulopathy, or has renal disease
  that may require dialysis).

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C-VAD Site SelectionSpecial Considerations

• For patients on hemodialysis, the National Kidney
  Foundations 2000 guidelines recommended against
  the use of the subclavian vein for any VAD unless
  use of the internal jugular vein is absolutely
  contraindicated. This is due to the risk of
  subclavian vein stenosis.
• If the internal jugular vein is chosen, use the
  right side to reduce the risk of noninfectious
  complications.

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C-VAD Line Selection

• Use a single lumen C-VAD, unless multiple lumens
  are absolutely necessary.
• Consider a tunneled or implanted C-VAD for
  patients requiring long-term access (gt30 days) or
  a PICC or cuffed C-VAD for patients requiring
  therapy for gt1 week.
• Evaluate the need for C-VAD daily.
• Remove it when not needed or change to a single
  lumen C-VAD when possible.

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Aseptic Technique Goals

• Remove transient organisms and soil from the
  skin.
• Reduce the number of resident microbial flora and
  inhibit their rebound growth.
• Create a sterile working surface that acts as a
  barrier between the insertion site and any
  possible source of contamination.

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Aseptic Technique

• Prepare skin with antiseptic/detergentchlorhexidi
  ne 2 percent in 70 percent isopropyl alcohol.
• Pinch the wings on the ChloraPrep applicator to
  pop the ampule. Hold the applicator down to allow
  the solution to saturate the pad. Press the
  sponge against skin and apply chlorhexidine
  solution using a back-and-forth friction scrub
  for at least 30 seconds. Do not wipe or blot.
• Allow the antiseptic solution time to dry
  completely before puncturing the site. This may
  take 2 minutes.

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Evidence Supporting Chlorhexidine Use Skin
Prep-Meta Analysis
Ann Intern Med. 2002136792-801
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Maximal Barriers Required for C-VAD Insertion

• Use face mask, cap, and sterile gloves.
• Wear a sterile gown with neck snaps and
  wrap-around ties properly secured.
• Instruct anyone assisting you to wear the same
  barriers.
• Cover the patient entirely with a large sterile
  drape.

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Maximal Barrier Precautions Decrease CLABSI
Infections
Author Design Catheter Type OR for Infection Without MBR
Mermel/1990 Prospective, cross-sectional Swan-Ganz 2.2 (plt0.03)
Raad/1994 Prospective, randomized Central 6.3 (plt0.03)

• OR odds ratio
• MBR maximal barrier precautions. Inserter
  washes hands and wears mask, cap, sterile gown,
  and sterile gloves. Patients head and body are
  covered with a large, sterile drape.

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Caveats Catheter Insertion

• IV antimicrobial prophylaxis does not reduce
  CLABSI.
• Insertion of C-VADs through open techniques/cut
  down increases the risk of CLABSI.
• Adequate room is needed to perform the procedure
  without risk of contamination.

Ranson. J Hosp Infect. 199015(1)95-102.
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Post Insertion C-VAD Care

• Antimicrobial ointments do not reduce the
  incidence of CLABSI.
• A sterile dressing should be applied to the
  insertion site before the sterile barriers are
  removed.
• Transparent dressings are preferred to allow
  visualization of the site. However, if the
  insertion site is oozing, apply a gauze dressing
  instead of a transparent dressing.
• When the C-VAD dressing becomes damp, loosened,
  or soiled or after lifting the dressing to
  inspect the site, replace the dressing.

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Replacing C-VADs

• Lines should be removed as soon as possible.
• Routine C-VAD guidewire exchange or site rotation
  is not recommended.
• Guidewire exchange is acceptable for replacing a
  malfunctioning catheter or downsizing a pulmonary
  artery catheter to a central venous catheter.
• Patients who clearly have a CLABSI should not
  undergo a guidewire exchange.
• Selected patients with suspected blood stream
  infections and limited venous access may have
  their catheter exchanged over a guidewire and the
  catheter tip should be cultured. Before handling
  the new catheter, switch to a new set of sterile
  gloves.

Eyer, et al. Crit Care Med.
199018(10)1073-9 .
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Suspected C-VAD Infections

• Remove the C-VAD in a patient with proven CLABSI
  (i.e., blood culture positive for a recognized
  pathogen with no identified secondary source).
• If a blood stream infection is only suspected,
  the C-VAD is not known to be the source, or the
  C-VAD cannot be removed, clinical judgment is
  necessary. Extensive, evidence-based guidelines
  exist for the diagnosis and treatment of
  catheter-related infections.

Mermel, et al. Clin Infect Dis.
200132(9)1249-72.
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Suspected C-VAD Infections (cont.)

• Draw two sets of blood cultures from a patient
  with new episode of suspected C-VAD infection,
  preferably both sets peripherally.
• It is not always necessary to remove the C-VAD in
  a mildly ill patient with unexplained fever.
• If the catheter is the suspected source of the
  infection, it can be changed over a wire and
  cultured. If the catheter culture grows ?15
  colony forming units of organisms, remove it and
  place at a different site.
• Tailor antimicrobial therapy to the individual
  patient based on severity of illness, suspected
  pathogen, and presence of complicating factors.

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C-VAD Line Cultures Indications

• The utility of catheter cultures is
  controversial nonetheless, proper technique is
  imperative to evaluate the data.
• The catheter tip may be submitted for
  semiquantitative culture if there is clinical
  suspicion of CLABSI.
• Routinely removed catheters should not be sent
  for culture.

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C-VAD Line Cultures Method

• Remove all dressings and cap off all hubs/ports
  then paint the site with antiseptic solution and
  include within the sterile field.
• Remove C-VAD en bloc. Under no circumstance
  should catheters be cut prior to removal.
• Remove the catheter aseptically, avoiding contact
  with the patients skin and catheter tray.
• Use sterile scissors (not the scalpel used to cut
  the C-VAD sutures) to cut a 5 cm segment,
  including the tip, and place it in a culture
  container.

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C-VAD Line Cultures Interpretation

• A catheter culture yield of ³15 colony forming
  unit, accompanied by signs and/or symptoms of
  infection is consistent with a catheter-related
  infection.
• Do not give antibiotics based on a positive
  catheter culture only. Evaluate the clinical
  picture.

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Blood Cultures

• Patients with a new episode of suspected
  catheter-related infection should have two sets
  of peripheral blood samples drawn for culture.
• In rare instances where access for peripheral
  blood draws is limited, one set may be drawn from
  the line and one set may be drawn percutaneously.

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Peripheral Blood Cultures Method

• Don sterile gloves and observe standard
  precautions.
• Apply chlorhexidine 2 percent in 70 percent
  isopropyl alcohol (ChloraPrep Frepp) using a
  back-and-forth friction rub for at least 30
  seconds over a 5 cm area.
• Allow the solution time to dry completely before
  puncturing the skin.
• Do not touch the venipuncture site after skin
  prep except with sterile gloves.
• Insert the needle into the vein and withdraw 20
  cc of blood (adults).
• Distribute the blood evenly between two culture
  bottles (10 cc per bottle), taking care not to
  inject air into the anaerobic bottle.
• Always send a second set of blood cultures from a
  separate venipuncture site.

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Arterial Line Site Selection

• Radial artery is the preferred site.
• Dorsalis pedis is an alternative site.
• Femoral sites have higher infection rates and
  risk of thrombosis.
• Brachial/maxillary sites are a last resort
  because of the lack of collateral circulation.

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Arterial Lines Aseptic Technique

• As with C-VADs, always
• Clean your hands with soap and water or waterless
  hand cleaner.
• Maintain standard precautions.
• Perform thorough skin preparation.
• Use barrier protection.

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Arterial Lines Barriers

• For radial or dorsalis pedis sites, create a
  generous sterile working surface using sterile
  drapes. Wear sterile gloves and a mask with face
  shield.
• Femoral or axillary arterial catheters may
  increase the risk of infection and require
  maximum barriers as with C-VADs, including mask,
  sterile gloves, sterile gown, and large sterile
  drape.

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Special Thanks

• Sean Berenholtz, M.D.
• Roy Brower, M.D.
• Raphe Consunji, M.D.
• Sara Cosgrove, M.D.
• Pamela Lipsett, M.D.
• Trish Perl, M.D.
• Peter Pronovost, M.D.
• Lisa Cooper, R.N.