Title: New Highlights in Central Line- Associated Bloodstream Infection and Surgical-Site Infection Prevention
1New Highlights in Central Line-Associated
Bloodstream Infectionand Surgical-Site Infection
Prevention
- Rabih O. Darouiche, MD
- VA Distinguished Service Professor
- Director, Center of Prostheses Infectionat
Baylor College of Medicine - Safe Practices Webinar
- February 18, 2010
2Disclosure Statement
- Co-invented antimicrobial-coated catheters that
are licensed by Baylor College of Medicine to
Cook Inc - Received educational and research grants from
CareFusion - Do not plan to discuss off-label and
investigational use of devices or drugs
3Overview of Presentation
- Address similarities and differences between
CLABSI and SSI - Assess the impact of these two infections
- Analyze potentially protective approaches
4Similarities Between CLABSI and SSI
- Both infections result primarily from breaking
skin integrity - Both infections are caused mostly by skin
organisms - Both infections occur at unacceptably high rates,
can be difficult to manage, may require future
intervention(s), and are expensive to treat
5Differences Between CLABSI and SSI
- CLABSI manifests while the catheter is still in
place, whereas SSI can manifest at any time after
surgery, usually by 30 days post-op - Microbiologic cause of CLABSI is almost always
identified, whereas the microbiologic cause of
SSI is unknown in many patients - Occurrence of CLABSI can be attributed to
various healthcare providers, whereas SSI is
typically linked to the surgeon
6Clinical Manifestations of infected CVC
- Exit site infection
- Tunnel infection
- Thrombophlebitis
- BSI
7Impact of CLABSI
- Incidence of the 6 million CVC inserted annually
in the U.S., 250,000 result in BSI - Management cure often requires removal of the
infected catheter and long antibiotic therapy - Medical sequelae attributable mortality 5-25
- Economic burden cost of treatment is 10K-56K
annual cost in U.S., 3 billion16.8 billion
8Annual Death Rates in the U.S. for Selected
Infectious Diseases
9Nosocomial Infections in the ICU
95 Urinary Catheters
86 Mechanical Ventilation
87 central lines
lt 55 33 55 70 32 gt70 35
N 14,177
National Nosocomial Infections Surveillance
(NNIS) (97 hospitals)
10Gram-Positive Bacteremia in Cancer Patients Role
of the CVC
80
70
70
56
60
44
50
of Bacteremia with CVC as the source
40
30
30
20
10
0
Non-CRBSI
CRBSI
Non-CRBSI
CRBSI
Solid Tumor Malignancy
Hematologic Malignancy
11Difference between Surveillance Definition (by
National Healthcare Safety Network NHSN) and
Clinical/Microbiologic Definition of CLABSI
- Surveillance definition includes all cases of
BSI in patients with CVC in whom other sites of
infection are excluded (catheter-associated BSI
varies from from 1.3/1000 cath-days in medical
surgical wards to 5.6/1000 cath-days in burn ICU) - Clinical/microbiologic definition includes only
cases of BSI in patients with CVC in whom other
sites of infection are excluded and microbiologic
relationship of catheter to BSI exists
(catheter-related BSI)
12Relationship between Catheter Colonization and
Bloodstream Infection
- Principle catheter colonization is a prelude to
catheter-related bloodstream infection - Objective to prevent infection by inhibiting
catheter colonization
13IA Recommendations in Upcoming CDC Guidelines for
Prevention of CLABSI
- Staff education and training
- Insert CVC in subclavian catheters
- Place hemodialysis catheters in jugular or
femoral veins - Promptly remove CVC when no longer essential
- Hand wash with soap/water or alcohol-based hand
rubs - Utilize 2 chlorhexidine-based preparation for
skin cleansing before inserting CVC, during
dressing changes, and wiping access ports of
needleless catheter systems - Use sterile gauze or transparent semi-permeable
dressings - Use antimicrobial-impregnated CVC if expected
duration of placement gt5 days and CLABSI remains
higher than goal set by institutions despite
comprehensive strategy - Guidelines for the Prevention of Intravascular
Catheter-related Infections. Atlanta (GA)
Centers for Disease Control and Prevention 2010.
draft -
-
14NQF CLABSI Prevention Safe Practice
Specifications 2010 Update
- Before insertion
- Educate healthcare personnel involved in the
insertion, care, and maintenance of central
venous catheters (CVCs). - At insertion
- Use a catheter checklist at the time of CVC
insertion. - Perform hand hygiene prior to catheter insertion
or manipulation. - Avoid using the femoral vein for central venous
access in adult patients. - Use a catheter cart or kit with components for
aseptic catheter insertion. - Use maximal sterile barrier precautions.
- Use chlorhexidine gluconate 2 and isopropyl
alcohol solution as skin antiseptic preparation
in patients over two months of age and allow
appropriate drying time per product guidelines. - After insertion
- Use a standardized protocol to disinfect catheter
hubs, needleless connectors, and injection ports
before accessing the ports. - Remove nonessential catheters.
- Use a standardized protocol for non-tunneled CVCs
in adults and adolescents for dressing care. - Perform surveillance for CLABSI and report the
data on a regular basis.
15Comprehensive Protective StrategyInfection
Control Bundle
- Hand washing
- Maximal barrier precautions
- 2 chlorhexidine-based skin antisepsis
- Avoiding femoral site if possible
- Removing unnecessary catheters
16Potential Limitations of Traditional Infection
Control Measures
- Although very essential, they
- Are not easily enforceable
- Are not very durable
- Do not completely prevent infection
- Save some, but not enough, lives
17Reasons to Optimize Prevention of SSI
- Unacceptably high incidence the 30 million
annual surgical procedures in the U.S. result in
300,000-500,000 cases of SSI - Difficult management may require repeated
surgical interventions - Serious medical consequences tremendous
morbidity and occasional mortality - Soaring economic burden annual cost of treatment
in the U.S. is gt7 billion
18Perioperative Approaches for Preventing SSI
- Non-antimicrobial approaches
- Normothermia
- Adequate oxygenation
- Tight glucose control
- Antimicrobial approaches
- Systemic antibiotic prophylaxis
- Nasal application of mupirocin
- Skin antisepsis
19Impact of Timing of Systemic Antibiotic
Prophylaxis on SSI
20A Prospective Randomized Trial of Nasal Mupirocin
Plus Chlorhexidine Wash
- Rapid identification of nasal carriage by S.
aureus followed by a 5-day course of nasal
mupirocin plus chlorhexidine wash - Reduces S. aureus infection (3.4 vs. 7.7)
- Decreases S. aureus SSI by almost 60
- Bode, et al. N Engl J Med 20103629-17
21Importance of the Skin
- Largest bodily organ
- Protective barrier
- Skin flora most common cause of SSI (and CLABSI)
- 80 of bacteria reside in epidermis
22Factors that Support the Need for Optimal Skin
Antisepsis
- Most pathogens that cause SSI are skin flora
- At least 2/3 of cases of SSI are incisional
- Most SSI are considered preventable
- Other preventive measures reduce but do not
eliminate SSI
23Commonly used Preoperative Antiseptics
- Povidone-iodine (Iodophor)
- Chlorhexidine gluconate
- Alcohol
- Combination products gt2 active agents
24Comparison of Antimicrobial Activity of
Antiseptic Preparations
- Chlorhexidine-based preparations are better
than alcohol or iodine-based products in - Reducing colonization of vascular catheters
- Preventing contamination of blood cultures
- Decreasing contamination of surgical tissues
25Pressing Need to Compare Clinical Efficacy of
Antiseptic Preparations in Preventing SSI
- CDC guidelines for prevention of infections
related to vascular catheters recommend
antiseptic cleansing of the skin with 2
chlorhexidine-containing products - OGrady, et al. Centers for Disease Control
and Prevention. MMWR Morb Mortal Wkly Rep
200251(RR-10)1-29 - CDC has not previously issued a preference as to
type of preoperative skin antiseptics
26Prospective, Randomized, 6-Center Clinical Trial
of 849 Patients
- Population adult patients scheduled for
abdominal or non-abdominal clean-contaminated
surgery - Randomization hospital-stratified
- Intervention preoperative skin cleansing with
- ChloraPrep (2 chlorhexidine gluconate-70
isopropyl alcohol CA) 26-ml applicators OR - 10 povidone-iodine (PI) scrub and paint
- Evaluation SSI was assessed by blinded
evaluators - Darouiche, et al. N Engl J Med
201036218-26
27Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population).
Type of Infection Chlorhexidine-Alcohol (N409) no. () Povidone- Iodine (N440) no. () Relative Risk (95 CI) P-Value
Any surgical-site infection 39 (9.5) 71 (16.1) 0.59 (0.41-0.85) 0.004
Superficial incisional infection 17 (4.2) 38 (8.6) 0.48 (0.28-0.84) 0.008
Deep incisional infection 4 (1.0) 13 (3.0) 0.33 (0.11-1.01) 0.05
Organ-space infection 18 (4.4) 20 (4.6) 0.97 (0.52-1.80) gt0.99
Sepsis from surgical-site infection 11 (2.7) 19 (4.3) 0.62 (0.30-1.29) 0.26
28Kaplan-Meier Curves for Freedom from
Surgical-Site Infection (Intention-to-Treat
Population)
29Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population). Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population).
Chlorhexidine-Alcohol Chlorhexidine-Alcohol Chlorhexidine-Alcohol Povidone-Iodine Povidone-Iodine Povidone-Iodine
Type of Surgery N no. Infected () Infected N no. Infected () Infected
Abdominal 297 37 (12.5) 308 63 (20.5)
Colorectal 186 28 (15.1) 191 42 (22.0)
Biliary 44 2 (4.6) 54 5 (9.3)
Small intestinal 41 4 (9.8) 34 10 (29.4)
Gastroesophageal 26 3 (11.5) 29 6 (20.7)
Non-abdominal 112 2 (1.8) 132 8 (6.1)
Thoracic 44 2 (4.5) 57 4 (7.0)
Gynecologic 42 0 (0.0) 40 1 (2.5)
Urologic 26 0 (0.0) 35 3 (8.6)
30Chlorhexidine-Alcohol (CA) vs. Povidone-Iodine
(PI) for Prevention of SSI
- CA significantly reduces SSI
- Number of patients needed to receive CA instead
of PI to prevent one case of SSI 17 - Delays onset of SSI
- CA and PI have similar rates of adverse events
(including events related to study medication in
0.7 in each group) and serious adverse events
31New CMS Regulations (effective 10/08) Changes to
Inpatient Prospective Payment System
- 10 non-reimbursable conditions met these
criteria - High cost
- High volume
- Triggers a high-paying MS-DRG
- May be considered reasonably preventable through
application of evidence-based guidelines - Federal Register, Volume 73, No. 161 08/19/08
32Non-reimbursable Infectious Conditions
- Catheter-associated urinary tract infection
- Vascular catheter-associated infection
- Surgical-site infection-mediastinitis after CABG
- Surgery on various joints, including shoulder,
elbow, and spine
33Perspective
- Optimal prevention of CLABSI and SSI can
- Improve patient care
- Incur cost-savings
- Enhance infection control measures