New Highlights in Central Line- Associated Bloodstream Infection and Surgical-Site Infection Prevention - PowerPoint PPT Presentation

1 / 33
About This Presentation
Title:

New Highlights in Central Line- Associated Bloodstream Infection and Surgical-Site Infection Prevention

Description:

New Highlights in Central Line-Associated Bloodstream Infection and Surgical-Site Infection Prevention Rabih O. Darouiche, MD VA Distinguished Service Professor – PowerPoint PPT presentation

Number of Views:244
Avg rating:3.0/5.0
Slides: 34
Provided by: Rodr62
Category:

less

Transcript and Presenter's Notes

Title: New Highlights in Central Line- Associated Bloodstream Infection and Surgical-Site Infection Prevention


1
New 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

2
Disclosure 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

3
Overview of Presentation
  • Address similarities and differences between
    CLABSI and SSI
  • Assess the impact of these two infections
  • Analyze potentially protective approaches

4
Similarities 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

5
Differences 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

6
Clinical Manifestations of infected CVC
  • Exit site infection
  • Tunnel infection
  • Thrombophlebitis
  • BSI

7
Impact 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

8
Annual Death Rates in the U.S. for Selected
Infectious Diseases
9
Nosocomial 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)
10
Gram-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
11
Difference 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)

12
Relationship 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

13
IA 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

14
NQF 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.

15
Comprehensive Protective StrategyInfection
Control Bundle
  • Hand washing
  • Maximal barrier precautions
  • 2 chlorhexidine-based skin antisepsis
  • Avoiding femoral site if possible
  • Removing unnecessary catheters

16
Potential 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


17
Reasons 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

18
Perioperative Approaches for Preventing SSI
  • Non-antimicrobial approaches
  • Normothermia
  • Adequate oxygenation
  • Tight glucose control
  • Antimicrobial approaches
  • Systemic antibiotic prophylaxis
  • Nasal application of mupirocin
  • Skin antisepsis

19
Impact of Timing of Systemic Antibiotic
Prophylaxis on SSI
20
A 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

21
Importance of the Skin
  • Largest bodily organ
  • Protective barrier
  • Skin flora most common cause of SSI (and CLABSI)
  • 80 of bacteria reside in epidermis

22
Factors 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

23
Commonly used Preoperative Antiseptics
  • Povidone-iodine (Iodophor)
  • Chlorhexidine gluconate
  • Alcohol
  • Combination products gt2 active agents

24
Comparison 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

25
Pressing 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

26
Prospective, 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

27
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). 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
28
Kaplan-Meier Curves for Freedom from
Surgical-Site Infection (Intention-to-Treat
Population)
29
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). 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)
30
Chlorhexidine-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

31
New 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

32
Non-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

33
Perspective
  • Optimal prevention of CLABSI and SSI can
  • Improve patient care
  • Incur cost-savings
  • Enhance infection control measures
Write a Comment
User Comments (0)
About PowerShow.com