CVC Infection (SUDAN)

Management of Catheter-Related
Bloodstream infections (CRBSI)
Nabil Abouchala, MD, FACP, FCCP
Consultant, Pulmonary & ICU
King Faisal hospital and Research Center
It is what we think we
know already that often
prevents us from
learning.
--Claude Bernard
Hospital course
64 YM with previous complicated history


Gastric outlet obstruction secondary to gastric
neoplasm.
TPN due to malnutrition and inability to feed orally
June 8, 2010 at of 04:00:

Hypotension, tachycardia and tachypnea
Hospital course
June 8, 2010 at of 04:00:


Hypotension BP 77/50, tachycardia and tachypnea
Assessment:

Dehydration versus sepsis versus cardiac causes. Blood cultures were
obtained. No antibiotic was administered.

2 boluses of IV fluid
The patient BP picked up to 105/70

Cardiology at 5:30 AM:
 ST-T changes unchanged from baseline.
Hospital course
At 9:30 a.m.



Patient developed cardiopulmonary arrest with asystole
25 minutes of CPR after which he had return of spontaneous
circulation.
Transferred to the ICU
Working
diagnosis
Severe
shock
Septic vs.
cardiogenic
Admission KFSH- MSICU





Mechanical ventilation, new central line in the
right IJ, the PICC line was removed and cultured.
Patient was started on inotropic support using high
dose Levophed, phenylephrine, and dopamine.
The patient had severe refractory shock with
maximum systolic pressure of 70, anuria, lactic
acidosis (10), DIC.
Empiric antibiotic were started in ICU, using
imipenem, vancomycin and Flagyl which were
administered at 10:30 a.m.
Patient died from refractory shock at 17:50
Septic shock
4:00 AM
CPR
9:30 AM
Antibiotic
10:30 AM
Death
5:50 PM
Blood Culture
Do Central Lines Cause
Bloodstream Infections?
Maki DG. Infections due to infusion therapy. In: Hospital Infections, Third Edition,
Bennett JV, Brachman PS (eds), Little, Brown, Boston 1992.
Incidence and Risk
 48% of ICU patients have CVCs, accounting for 15
million CVC-days per year in ICUs.
 The case fatality rate for catheter-related
bloodstream infections approaches …20%
 Between 500-4,000 U.S. patients die annually due
to bloodstream infections
 Cost per infection $3,700 to $29,000.
 BSIs prolong hospitalization by a mean of 7 days.
Mermel LA. Ann Int Med. 2000;132: 391-402.
Soufir L et al. Infect Control Hosp Epidemiol. 1999 Jun;20(6):396-401.
CR sepsis with  blood culture
Probable CR sepsis
Catheter contamination
Catheter colonization
Independent Risk
Factors for CLBSI
Prolonged
hospitalization
Duration of
catheterization
Site of
catheterization
Femoral
Neutropenia
TPN
Colonization
at the insertion
site
of the catheter
hub
Substandard care
of the catheter:
excessive
manipulation
reduced nurse-topatient ratio
Infection control and hospital epidemiology; October 2008
GPC
Fungi
GNR
Micro organisms responsible for
CR-BSI according to catheter site
45%
40%
17%
Central Line Bundle
Elements
1.
2.
3.
4.
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with
subclavian vein as the preferred site for
non-tunneled catheters in adults
5. Daily review of line necessity with prompt
removal of unnecessary lines
Central Line Bundle
Elements
1.
2.
3.
4.
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with
subclavian vein as the preferred site for
non-tunneled catheters in adults
5. Daily review of line necessity with prompt
removal of unnecessary lines
Hand Hygiene
O’Grady NP. MMWR. Aug 9, 2002; 51: RR10, 1-29.
Central Line Bundle
Elements
1.
2.
3.
4.
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with
subclavian vein as the preferred site for
non-tunneled catheters in adults
5. Daily review of line necessity with prompt
removal of unnecessary lines
Maximal Barrier
Precautions (MBP)
• For the Provider:
– Hand hygiene
– Non-sterile cap and mask
• All hair should be under cap
• Mask should cover nose
and mouth tightly
– Sterile gown and gloves
• For the Patient:
– Cover patient’s head and
body with a large sterile
drape
Why Not MBP?
More cumbersome
Time-consuming
More expensive
Supplies and not always
readily available
Impact of Maximal Barrier
Precautions (MBR)
Author/date Design
Catheter
Odds Ratio
for infection
w/o MBR
Mermel
1991
Prospective
Swan Ganz
Cross-sectional
2.2 (p<0.03)
Raad
1994
Prospective
Randomized
6.3 (p<0.03)
Central
OR=odds ratio MBR= inserter washes hands and wears mask, sterile gown, sterile gloves
and patient’s head & body are covered with a large, sterile drape.
Mermel LA, Am J Med. Sep 16 1991;91(3B):197S-205S.
Raad, Infect Control Hosp Epidemiol. Apr 1994;15(4 Pt 1):231-238.
MBP: Cost analysis
• Additional cost $40
– Additional material cost $15
– Additional time needed 20 minutes for $25
•
•
•
•
Decrease BSI 5.3%  2.8%
Catheter colonization 5.5%  2.9%
Death from 0.8%  0.4%
Use of MBP lowered cost
– $621  $369 = $250
Compliance
30%
Central Line Bundle
Elements
1.
2.
3.
4.
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with
subclavian vein as the preferred site for
non-tunneled catheters in adults
5. Daily review of line necessity with prompt
removal of unnecessary lines
Chlorhexidine Skin Antisepsis
Chlorhexidine Skin Antisepsis
Povidence
Iodine
Chlorhexidine
Lowers BSI
50%
Central Line Bundle
Elements
1.
2.
3.
4.
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with
subclavian vein as the preferred site for
non-tunneled catheters in adults
5. Daily review of line necessity with prompt
removal of unnecessary lines
CDC Recommendation
Regarding Site Selection
O’Grady NP. MMWR. Aug 9, 2002; 51: RR10, 6.
What About
SC vs. IJ vs. Femoral?
• N= 2018 patients
– SC
– IJ
– Femoral
917
1390
288
What About
SC vs. IJ vs. Femoral?
• CRLI• CRBSI –
any signs of local inflammation + catheter tip > 15 CFU
CRLI + positive blood cultures
Distribution of Internal Jugular Vein According to Quadrant
Reade M et al. N Engl J Med 2007;357:943-945
US-guided placement vs. landmark
technique for insertion of IJ CVC
Outcome measures in the ultrasound group
versus the landmark group of patients
Outcome measures
Ultrasound group
(n = 450)
Landmark group
(n = 450)
Access time (seconds)
17.1 ± 16.5
44 ± 95.4
Success rate
450 (100%)a
425 (94.4%)
5 (1.1%)a
48 (10.6%)
2 (0.4%)a
38 (8.4%)
0 (0%)
11 (2.4%)
1.1 ± 0.6 (1.1 to 1.9)a
2.6 ± 2.9 (1.5 to 6.3)
47 (10.4%)a
72 (16%)
Carotid puncture
Hematoma
Pneumothorax
Average number of
attempts
CVC-BSI
Karakitsos et al. Critical Care 2006 10:R162
Summary
• IJ site:
– low rate of severe mechanical complications
– preferred for short-term access < 7 days
• SC site:
– lower risk of infection
– route of choice, in experienced hands, if for long-term
access > 7 days
• Femoral site:
– higher rate of infections and thrombosis
– should be restricted to patients in whom the
mechanical complications of SC access, i.e.
pneumothorax or hemorrhage would be unacceptable
Central Line Bundle
Elements
1.
2.
3.
4.
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with
subclavian vein as the preferred site for
non-tunneled catheters in adults
5. Daily review of line necessity with prompt
removal of unnecessary lines
Do You Still Need a CVC?
If Not Remove It!
What Else Reduces CVC infections?
Dressing
impregnated
with CHD
Needle
connector
system
Scrubbing
the hub
Chlorhexidine
Impregnated Dressing
Scrub the HUB!
American Journal Infection Control 2008
Recommendation for Implementing
Prevention and Monitoring Strategies
Before insertion
At insertion
After insertion
• Education
• Indications, appropriate
insertions and
maintenance
• Complete an
educational program
• Credentialing process
• Catheter checklists
• Hand hygiene
• Avoid using femoral vein
• Subclavian site if no increased
risk
• Use all-inclusive catheter cart
• Use MBP
• Use chlorhexidine antiseptic
• Disinfect catheter hubs
• Remove nonessential
catheters
• Change transparent
dressing every 5 -7 days
Infection control and hospital epidemiology; October 200
Special Approach for the
Prevention of CLBSI
Units/patient
population
BSI > Goal
Patients with
limited venous
access
Patient with
high-risk for
sequelae BSI
Use of antibioticcoated catheters
Chlorhexidinecontaining
dressing
Antimicrobial
locks for CVCs
Infection control and hospital epidemiology; October 200
“If you don’t prevent
You will create an event”