Evidance Based:

Prevention of
Catheter Related
Bacteremia

Bernadetta Indah Mustikawati

HIPPII JAWA TIMUR
OVERVIEW
• Definitions
• Pathogenesis
• Epidemiology/Risk factors
• Prevention strategies of catheter-related bacteremia
 Definitions

Central line-associated bloodstream infection (CLABSI):

• Laboratory-confirmed bloodstream infection where central line was in
Place for >2 days on the date of event (day of device placement being
Day 1)
AND
• The line was in place on the date of event or the day before
Definitions
For surveillance purposes the CDC has introduced the term laboratory-
Confirmed bloodstream infection (LCBSI):
One of the following criteria:
• Patient has a recognized pathogen cultured from one or more blood cultures, and
the pathogen is not related to an infection at another site
• Patient has at least one of the following signs or symptoms: fever (>38.0°C), chills,
or hypotension, and the pathogen is not related to an infection at another site or,
if the organism is a common commensal, it must be presentFrom two or more
blood cultures drawn on separate occasions.
• Patient <1 year of age has at least one of the following signs or symptoms: fever,
hypothermia, apnea, or bradycardia (in addition to above criteria).
Pathogenesis/Contamination of catheters

Intraluminal
From tubes and hubs
Extraluminal
From the Skin

Haematogenous
From different sites

MermelL. Ann Intern Med2000;132:391

Pathogenesis/Biofilm formation
Epidemiology
Types of infection/United States

Magill SS, et al. N EnglJ Med, 2014;370:1198-208

Types of infection/Europe

v
v
v

ECDC, Point prevalence survey of healthcare-associated infections and antimicrobial use

In European acutecare hospitals,2013
 International Nosocomial Infection Control Consortium (INICC)
Surveillance study from January 2010-December 2015 in 703
Intensive care units (ICUs) in Latin America, Europe, Eastern
Mediterranean, Southeast Asia, and Western Pacific

Rosenthal Vetal. Am J Infect Control 2016,inpress

Rosenthal Vet al.AmJ Infect Control 2016, in press
Rosenthal V etal.Am JInfect Control 2016, in press
Rosenthal V et al. Am J Infect Control 2016, in press
Ling et al. ClinInfect Dis 2015:1690-9
 Comparisons between high and low-to
middle-income countries
High-income countries Low-to middle-income countries

17.0 42.7
23.9
7.9

4.1
12.2 8.8
3.5

• Incidence ofICU -acquired infections2-to -Fold higher

3 than in high income countries
(particularly in neonatal and pediatric ICUs)
• Device -Associated infections up to 13 times higher than in high income countries

WHO,Report on theburden of endemic healthcare-associated infections 2011

Riskfactors
• Typeof catheter
• Location of catheter placement
• Duration of catheter placement
 Risk for BSI in dependence of catheter type

Point incidencerate

Centralvenous catheters 4.4% 2.7/1000 catheter-days

Peripherallyinserted central 2.4% 2.1/1000 catheter-days
venous catheters
(hospitalized patients)
Arterial catheters 0.8% 1.7/1000catheter-days
Implanted long-term central 22.5% 1.6/1000 catheter-days
Venous catheters(tunneled)
Peripheral intravenous 0.1% 0.5/1000 catheter-days
catheters
Centralvenous ports 3.6% 0.1/1000 catheter-days

Maki D et al. Mayo ClinProc 2006;81:1159-71

 Insertion site

Gill RT et al Arch InternMed 1989;149:1139-43

 Duration of catheterization

Gill RT et al Arch InternMed 1989;149:1139-43

Grady N et al. ClinInfect Dis 2011;52:e1-32
Grady N et al. ClinInfect Dis 2011;52:e1-32
Prevention strategies
• Education and training IA
• Staffing IA/IB
• Selection of catheters and sights IA-II
• Hand hygiene and aseptic technique IB-II
• Maximal sterile barrier precautions IB
• Skin preparation IA-u.i.
• Catheter site dressing regimens IA-u.i.
• Patient cleansing II
• Antimicrobial/antiseptic impregnated cathetersandcuffs IA
• Antibiotic/antiseptic ointments IB
• Antibiotic lock prophylaxis II
Strategies which are not recommended

• Systemic antibiotic prophylaxis IB

• Anticoagulants II
• Replacement of peripheral catheters IB-u.i.
• Replacement of central venous catheters IB-ii

Grady N et al. ClinInfect Dis 2011;52:e1-32

Education and training
• Education regarding (IA)
• Indications
• Proper procedures for insertion and maintenance
• Appropriate infection control measures

• Periodic knowledge assessment (IA)

 • 10-page,self-study module on the prevention of catheter-associated
Bloodstream infections
• Lectures
• Posters

Warren D et al. CritCare 2003;31:1959-63

Warren D et al.CritCare 2003;31:1959-63
Staffing
• Designate only trained personnel for insertion and maintenance of
Peripheral and central catheters (IA).

• Ensure appropriate staff levels in ICUs (IB).

• Third-year medical students and physicians completing their first
Post graduate year.
• A 1-day course on infection control practices and procedures given in
June 1996 and June 1997.

SherertzR et al, Ann Intern Med 2000;132:641-8

SherertzR et al, Ann Intern Med 2000;132:641-8
Selection of catheters and sights

• Use central venous catheters with the minimum number of ports or

lumens essential for management (IB)
• Use of ultrasound guidance for central venous catheter placement to
reduce the number of cannulation attempts and mechanical
complications (IB)
• Replace catheters inserted during medical emergencies (when
adherence to aseptic technique cannot be ensured) as soon as
possible (IB)
• Promptly remove any intravascular catheter that is no longer
essential (IA)
Hilton E et al. Am J Med 1988;84: 667-72
Selection of catheters and sights

• Avoid using the femoral vein for central venous access in adult
patients (IA).
• Use the subclavian site rather than a jugular or a femoral site in
adult patients to minimize the risk of infection for non tunnelled
central venous catheterplacement (IB).
Parienti J et al.N Engl J Med 2015;373:1220-9
Parienti J et al. N EnglJ Med 2015;373:1220-9
Parienti J et al.N EnglJ Med 2015;373:1220-9
Hand hygiene and aseptic technique

• Hand hygiene before and after palpating insertion sites, before and
after inserting, replacing, accessing or dressing intravascular
catheters (IB).
• Maintain aseptic technique for the insertion and care of intravascular
catheters (IB).
• Sterile gloves for insertion of central venous catheters (IA).
Maximal sterile barrier precautions

• For insertion of central venous catheters or guidewire exchange:

• Cap
• Mask
• Sterile gown
• Sterile gloves
• Sterile full body drape
Patients randomized to having their central catheters inserted under
maximal barrier precautions, including:
• Sterile gloves
• Mask
• Cap
• Gown
• Large drape
or control precautions, including:
• Sterile gloves
• Small sterile drapes
RaadI et al. Infect Control Hosp Epidemiol1994; 15:231-8
RaadI et al. Infect Control Hosp Epidemiol 1994;15:231-8
RaadI et al. Infect Control HospEpidemiol 1994; 15:231-8
Skin preparation

• Skin preparation with a>0.5% chlorhexidine preparation withalcohol

before catheter insertion (IA)
• Antiseptics should be allowedto dry prior to placing the catheter (IB)
MimozO et al.Lancet 2015;386: 2069-77
MimozO et al. Lancet 2015; 386: 2069-77
“Chlorhexidine-alcohol provides greater protection against
short-term catheter-related infections than povidone iodine-
alcohol and should be included in all bundels for prevention
Of intravascular catheter-related infections.”

MimozO et al.Lancet 2015;386: 2069-77

Catheter site dressing regimens
• Sterile gauze or sterile, transparent, semipermeable dressing to cover
the catheter site (IA).
• Use gauze dressing if the catheter site is bleeding (II).
• Replace catheter dressing if damp,loosened or soiled (IB).
• Monitor the catheter insertion site and examine if patients have
tenderness,fever without an obvious source (IB)
• Use of chlorhexidine-impregnated sponge dressing for temporary
shortterm catheters if infection rates is not decreasing despite
adherence to basic interventions (IB).
TimsitJF et al. JAMA 2009;301:1231-1241
TimsitJF et al. JAMA 2009;301:1231-1241
Of note: the observed incidence of infection may have been influenced by several factors, such as:
• Inclusion of arterial catheters (46%)
• Exclusion of antimicrobial-impregnated factors

“Use of CHGIS dressings with intravascular catheters in the intensive care unit reduced risk of
infection even when background infection rates were low. Reducing the frequency of changing
unsoiled adherent dressings from every 3 days to every 7 days modestly reduces the total number
of dressing changes and appears safe.”

TimsitJF et al.JAMA 2009;301:1231-1241

Patient cleansing
• Use a 2% chlorhexidine wash for daily skin cleansing (II)
Climo MW et al. N EnglJ Med 2013;368:533-42
Climo MW et al. N EnglJ Med 2013;368:533-42

ClimoMW et al. N Engl J Med
“Daily bathing with
chlorhexidine-impregnated
washcloths significantly
reduced the risks of
acquisition of MDROs and
development of hospital-
acquired bloodstream
infections.”
2013;368:533-42
Further measures…

• Antibiotic lock prophylaxis (II) “Recommended in patients with long

term catheters and a history of multiple catheter-related blood stream
infections despite optimal adherence to aseptic technique” “Need to
be balanced by side effects, such as Toxicity, allergic reactions and
emergence of resistance…”

Grady N et al. Clin Infect Dis 2011;52:e1-32

Further measures…

Antimicrobial/antiseptic impregnated catheters and cuffs. IA

“Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin

impregnated CVC in patients whose catheter is expected to remain in
place >5 days if, after successful implementation of a comprehensive
strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing”
“Central venous catheters impregnated with a combination of chlorhexidine and silver sulfadiazine appear to
Be effective in reducing the incidence of both catheter colonization and catheter-related bloodstream infection in
patients at high risk for catheter-related infections.”

VeenstraDL et al. JAMA 1999;281:261-7

Darouiche RO et al. N EnglJ Med 1999;340:1-8
„The use of central venous catheters impregnated with minocycline and rifampin
Isassociated with alower rate of infection than the use of catheters
Impregnated with chlorhexidine and silversulfadiazine. „

Darouiche RO et al. N EnglJ Med 1999;340:1-8

Impact of infection control…
Multimodal approach, including:

• Surveillance
• Education
• Standardized processes
• Maximal sterile barrier precautions
• Catheter care
• Hand hygiene

etc.

EggimannP et al. Lancet 2000;355:1864-8

 Incidence density of exit-site catheter infection:
• Before intervention: 9.2/1000 patient-days
• After intervention: 3.3/1000 patient-days
• Relative risk: 0.36 (95% CI 0.20–0.63).
Rates for bloodstream infection:
• Before intervention: 11 . 3 / 1 0 0 0 p a t i e n t -days
• After intervention: 3.8/1000 patient-days
• Relative risk: 0.33 (95%CI 0.20–0.56)

“A multiple-approach prevention strategy, targeted at the insertion and maintenance of vascular access, can
decrease rates of vascular-access infections and can have a substantial impact on the overall incidence
Of ICU-acquired infections.”

Eggimann P et al.Lancet2000;355:1864-8
 • Hand washing
• Full barrier precautions during insertion of central venous catheters
• Cleaning skin with chlorhexidine
• Avoidance of the femoral site
• Removing unnecessary catheters

Pronovost P et al. N EnglJ Med 2006;355:2725-32

“An evidence-based intervention resulted in a large and sustained reduction (up to
66%) in rates of catheter-related bloodstream infection that was maintained
throughout the18 month study period.”

Pronovost P et al. N EnglJ Med 2006;355:2725-32

“The reduced rates of catheter related bloodstream infection achieved in the initial 18 month
post Implementation period were sustained for an additional 18 months as participating
intensive care units integrated the intervention into practice. Broad use of this intervention with
achievement of similar results could substantially reduce the morbidity and costsassociated
with catheter related bloodstream infections.”

Pronovost P et al. British Med J 2010;340:c309

Thank you for your attention!