Central Line Associated Blood Stream Infections( CLABSI)

Using the Central Line Bundle
Hand Hygiene
Remove Unnecessary Lines
Use of Maximal Barrier Precautions
Chlorhexidine for Skin Antisepsis
Avoid femoral lines
Report CLABSI rates to the units
Celebrate success!!

1. CLABSI Karthik Ponnappan T MD DM Organ Transplant Anaesthesia and Critical Care

2. 46 % decrease in CLABSIs in U.S . from 2008-2013 30,100 central line-associated bloodstream infections (CLABSI) still occur in U.S . acute care facilities each year

3. Definition A pathogen isolated from a blood culture (a single culture for organisms which are not commonly present on skin and two or more blood culture for organisms which are commonly present on the skin) in a patient with signs and symptoms of infection who has a central line in place at the time of the identification or within 48 h before the infection develops Such infections cannot be related to any other source for infection that the patient may have or was incubating when the patient was admitted Centers for Disease Control and Prevention (CDC). Vital signs:central line-associated blood stream infections–United States Morb Mortal Wkly Rep .2011

4. Catheter colonization : The patient has no signs and symptoms of infection but a quantitative or semiquantitative culture of the catheter tip or catheter hub yields significant growth of a microorganism

5. Exit site infection : These infections manifest erythema, induration, and/or tenderness within 2 cm of the catheter exit site , and exudate at the exit site yields a microorganism

6. Tunnel infection : Tenderness , erythema, and/or induration are present more than 2 cm from the exit site along the subcutaneous tract of a tunneled catheter with or without concomitant bloodstream infection

7. Pathogenesis

8. Diagnosis

9. Goal: Preventing CLABSI Using the Central Line Bundle Hand Hygiene Remove Unnecessary Lines Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines Report CLABSI rates to the units Celebrate success!!

10. Hand Hygiene The single most important factor to reduce healthcare-associated infections Chlorhexidine >> soap and water, alcohol rubs Hand hygiene for every time line is accessed CLABSI rates decreased from 4.08 per 1000 central line days to 0.42 per 1000 central line days after education and implementation of proper hand hygiene practices Doebbeling BN et al. Comparative efficacy of alternative handwashing agents in reducing nosocomial infections in intensive care units. NEJM 1992 Walker JL et al. Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. Am J Infect Control . 2014 Johnson L et al. A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream infections. Am J Infect Control . 2014

11. Skin Preparation Chlorhexidine rather than povidone -iodine 1.6 % decrease in CLABSIs 0.23 % decrease in mortality saving $ 113 per catheter used Chaiyakunapruk N , Veenstra DL, Lipsky BA, Sullivan SD, Saint S.Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine. Clin Infect Dis . 2003

12. Full barrier precautions Full body drape for the patient Cap , mask, sterile gown, and sterile gloves by the care providers Lower CLABSI rate Tang H-J et al . The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis. 2014

13. Insertion Site Avoidance of the femoral site Associated with the flora of the skin in pediatrics - no difference DVT risk No RCT demonstrating a difference in the risk of CLABSI between the sites Due to strict adherence to guidelines (US, Europe) Marik PE , Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med . 2012

14. Removal of unnecessary lines Prompt removal of the central line 26.2 % of catheter days were idle, with no medical indication for continued use Risk of CLABSI 2.1 per 1000 catheter days at line days 1–5 to 10.2 per 1000 catheter days at line days 16–30 Burdeu G , Currey J, Pilcher D. Idle central venous catheter-days pose infection risk for patients after discharge from intensive care. Am J Infect Control . 2014

15. Other interventions N eedleless intravenous connectors Split septum Tabak YP , Jarvis WR, Sun X, Crosby CT, Johannes RS. Meta analysis on central line-associated bloodstream infections associated with a needleless intravenous connector with a new engineering design . Am J Infect Control. 2014

16. chlorhexidine-impregnated dressings and patches antibiotic- or chlorhexidine impregnated catheters Safdar N et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med . 2014

17. Antibiotic lock therapy for prophylaxis( salvage) Upto 48 hours

18. CLABSI in limited resource setting

19. Quality Improvement Initiatives Matching Michigan Keystone ICU Bacteremia Zero

20. Type of Catheter Non- tunneled Central Venous Catheters Multilumen catheters  higher rate of colonization and infection Choose a CVC with minimum number of ports required Gil RT , Kruse JA, Thill-Baharozian MC, et al: Triple- vs single-lumen central venous catheters: a prospective study in a critically ill population. Arch Intern Med 1989

21. Antimicrobial Impregnated CVCs If CVC needed for > 5 to 14 days and CLABSI rates high L imited venous access and a history of CLABSI Risk for severe sequelae in case of systemic infections, such as patients with recently implanted devices Casey AL , Mermel LA, Nightingale P, et al: Antimicrobial central venous catheters in adults: a systematic review and meta-analysis. Lancet Infect Dis , 2007

22. Peripherally Inserted Central Venous Catheters less infections more mechanical complications Can be left in place for weeks to months Mermel LA , Allon M, Bouza E, et al: Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009.

23. Semipermanent tunneled catheters The risk of infection appears to be low Chemotherapy those requiring long-term parenteral nutrition Crnich CJ , Maki DG: The promise of novel technology for the prevention of intravascular device-related bloodstream infection. II. Long-term devices. Clin Infect Dis , 2002

24. Pulmonary Artery Catheters The risk of low if in for less than 7 days Plastic sleeves to cover the PAC is recommended

25. Peripheral Arterial Catheters rates of complications similar to venous catheters Thrombosis  19% to 38% Infection  4 % to 23 % increasing risk of infection after day 4 of catheterization Femoral route has more infections Decreased infection with chlorhexidine impregnated dressing No study of barrier precautions O’Horo JC , Maki DG, Krupp AE, Safdar N. Arterial Catheters as a Source of Bloodstream Infection: A Systematic Review and Meta-Analysis. Critical care medicine . 2014

26. Catheter Hub Disinfection Local disinfection of the with chlorhexidine or 70% alcohol before access allow the antiseptic to dry before accessing the catheter

27. Catheter Replacement Peripheral Catheters Catheter causing phlebitis  removed and the tip cultured Recommendations to remove and change these catheters to another site every 72 hours are aimed at decreasing the risk for infection and the discomfort associated with phlebitis Central Catheters Routine rotation does not reduce rates of infections

28. Infusion-Related Issues Local Effects acidic , hypertonic, or direct irritants ( KCl , certain antibiotics, chemotherapeutic agents)  inflammatory response, thrombosis, phlebitis  infection use a central catheter Infusion Tubing Infusion tubing – change every 96 hours If blood products used- change every 24 hours

29. In-Line Devices and Filters Pressure transducers  water-associated Gram-negative bacilli, including Pseudomonas, Serratia, Enterobacter, Citrobacter , and Acinetobacter spp

30. In-Line Devices and Filters Use of a closed system rather than stopcocks has been shown to lead to less contamination All catheter hubs, needleless connectors, and injection ports should be disinfected with a chlorhexidine preparation before access

31. Contamination of Infusates Several Gram-negative bacilli in the acidic environment of intravenous fluids Candida species  total parenteral nutrition (TPN) Albumin  the growth of bacteria and fungi Lipid emulsions  corynebacteria and the yeast Malassezia furfur Centers for Disease Control and Prevention : Epidemiologic notes and reports. Nosocomial bacteremias associated with intravenous fluid therapy— USA. Morb Mortal Wkly Rep 1997.

32. Suppurative Phlebitis For peripheral catheters  needle aspiration or incision Central veins  confirmed by detection of a thrombus by CT,MRI,USG Surgical or interventional radiological procedures to remove the thrombus are technically difficult

33. Suppurative Phlebitis Most patients will respond to 3 to 4 weeks of treatment with systemic antimicrobial therapy Surgical resection if bloodstream infection persists or purulence extends beyond the vessel wall

34. Endocarditis The aortic and mitral valves are involved most often TEE  presence and size of vegetations , the valves involved and their function, and the presence of myocardial abscesses