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Reducing catheter-related

bloodstream infections in the


NICU

Martin Skidmore
University of Toronto
The scope of the problem
• 15 million “CVC days” per year in USA

• Average rate of CRBSI 5.3/1000 catheter


days
– 80,000 CRBSI per year in NICU’s and ICU’s
– 250,000 per year in total
• Mortality is 12-25%
• Cost estimated $25,000 per episode
» CDC, 2002
Pathogenesis
• Migration of skin organisms

• Colonization of catheter lip

• Contamination of catheter hub

• Haematogenous seeding

• Contamination of infusate
Strategies for prevention of CRBSI
• Site of catheter insertion
• Type of intravascular catheters used
• The use of a closed medication system
• Differing techniques of insertion and securement
• The use of inline filters
• Procedures for tubing changes
• Procedures for dressing changes
• Routine replacement of central catheters
• The use of systemic antibiotic prophylaxis
• The use of anticoagulants.
Site of catheter insertion

• Subclavian better than jugular?

• Avoid femorals? (?in neonates)

• u/s confirmation of placement preferred


Type of intravascular catheters
used
• Teflon, polyurethane catheters preferred over
PVC or polyethylene

• Antimicrobial/antiseptic impregnated catheters


seem cost effective

• (None approved/available for infants <3 kg)


– Chlorhexidine/silver sulphadiazine
– Minocycline/rifampicin
– Platinum/silver
– Silver cuffs
Hand hygiene, aseptic technique,
skin antisepsis

• ‘No touch’ technique (+gloves)

• Maximal sterile barrier precautions

• Povidone-iodine v. 2% aqueous
chlorhexidine gluconate
Site dressing regimens/securement

• Transparent, semipermeable polyurethane


dressings (?gauze if bleeding)

• Chlorhexidine–impregnated sponge
(Biopatch) over site

• Sutureless securement advantageous


Inline filters
• Reduce incidence of infusion related
phlebitis

• Infusate-related BSI is rare – especially if


done in pharmacy

• May become blocked by infusion of some


solutions
Systemic antibiotic prophylaxis

• No studies show oral/parental antibacterial


or antifungal drugs reduce CRBSI in
adults

• 2 studies in LBW have shown vancomycin


prophylaxis decreases CRBSI
– risk of acquiring VRE
Anticoagulants
• Prophylactic heparin
– 3 units/ml in TPN
– 5000 units q6 or q12 hour flush
– 2,500 units LMW heparin S/C

• Catheters are available with heparin


bonded coating (benzalkonium chloride)
Replacement of Catheters

• Replacement schedules have not lowered


rates of CRBSI
• Scheduled guidewire exchanges also
have not lowered rates of CRBSI
• ‘high’ vs. ‘low’ UVC placement
• Remove uac before 5 days
• Remove uvc before 14 days
– OR when no longer needed
Practical Approach To CRBSI
• Remove promptly if s.aureus or gram
negative rod infection

• CoNS infections - remove after 3 positive


blood cultures
» Benjamin, 2001

• Application of closed medication system


– showed immediate results in one study
» Aly, 2006
Suspected or proven CRBSI
Remove catheter if:

• Catheter is no longer required


• Child is haemodynamically unstable
• Metastatic foci of infection (septic
emboli/infective endocarditis) are present
• Candidaemia/mycobacterial infection
• Catheter tunnel is inflamed
Suspected or proven CRBSI

• Unrepaired congenital heart disease


• Suspected pathogen is a gram-negative
organism

Remove catheter unless replacement will be


very difficult or bacteraemia appears to be
resolving
Suspected or proven CRBSI
• Suspected pathogen is Staphylococcus
aureus:

Retain catheter only if bacteraemia resolves


within 24 h and there is no clinical or
echocardiographic evidence of infective
endocarditis
Suspected or proven CRBSI

In all other situations:

Retain catheter unless bacteraemia persists


after four days of appropriate intravenous
antibiotics or child becomes unstable.

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