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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