Dr. Shafiq A.Alimad MD

Head of medical department at USTH

YICID workshop , 15-12-2014

1. Define a bundle 2. Describe Central venous catheters

types and its risk factors 3. Define source of infection and its types 4. Apply appropriate prevention

measures.

At the end of this lecture you should be able to :

What is a bundle?

A bundle is a structured way of improving processes of care and patient outcomes.

It is a small straightforward set of practices - generally three to five - that, when performed collectively, reliably and continuously, have been proven to improve patient outcomes.

Who can use the bundles?

Anyone in the clinical setting with the agreement of the clinical team and Quality Improvement Leads can use the bundles.

INTRODUCTION

Central venous catheters (CVCs) are increasingly used in the inpatient and outpatient setting to provide long-term venous access. Infection of CVCs remains a major problem. It is estimated, for example, that approximately 90 percent of the 50,000 to 100,000 annual catheter-related bloodstream infections in the United States occur with CVCs

EPIDEMIOLOGY

• Catheter-related bloodstream infections (CR-BSI) are an important cause of morbidity and mortality worldwide.

the incidence of CR-BSI associated with central lines among (ICUs) Patients

ICUPts exposed to more medical devices and are more severely ill than other patients

EPIDEMIOLOGY

• Indwelling catheters are also a frequent source of infection in many populations who required long term venous access, including hemodialysis and oncology patients as well as those receiving total parenteral nutrition.

RISK FACTORS

Its associated with nosocomial bloodstream infections (BSIs) include the following

1. Chronic illness 2. Bone marrow transplantation 3. Immune deficiency, especially neutropenia

4. Malnutrition 5. TPN administration 6. Previous BSI 7. Extremes of age 8. Loss of skin integrity, as with burns

Host factors

RISK FACTORS

The type and location of the catheter, the most important extrinsic risk factors associated with intravascular catheter-associated bloodstream infections include: 1. Duration of catheterization 2. Type of catheter material 3. Conditions of insertion 4. Catheter-site care. 5. Skill of the catheter inserter.

Catheter factors

RISK FACTORS

The importance of these factors varies with the site and type of IV catheter . the risk of CR-BSI is comparatively elevated in the following circumstances:

1. Femoral or internal jugular placement compared with subclavian

2. Use for hyperalimentation or hemodialysis compared with other indications

3. Submaximal compared with maximal (mask, cap, sterile gloves, gown, large drape) barrier precautions during insertion .

4. Nontunneled compared with tunneled insertion 5. Tunneled insertion compared with a totally

implantable device 6. Bare compared with antibiotic impregnated catheter

Catheter factors

RISK FACTORS

Other factors that may increase the risk of infection include : 1. thrombosis of the catheter, 2. Repeated catheterization, 3. Increased manipulation of the

catheter (including catheter repair), 4. Presence of septic foci elsewhere

Catheter factors

Sources of infection

Bloodstream infection associated with (CVCs) can be to four major sources:

1. Colonization from the skin, 2. intraluminal or hub contamination, 3. secondary seeding from a

bloodstream infection, 4. contamination of the infusate

Sources of infection

The most common source of CVC-related infections is colonization of the intracutaneous and intravascular portions of the catheter by microorganisms from the patient's skin and occasionally the hands of healthcare workers .

1- Skin colonization

Sources of infection

Intraluminal and/or hub contamination is an important source of bloodstream infection in patients with centrally-inserted CVCs that are in place for more than two weeks or in patients with a surgically implanted device .

2- Intraluminal contamination

Sources of infection

Administration of contaminated infusate or additives, such as a contaminated heparin flush, can result in a bloodstream infection. Organisms may contaminate infusate by several mechanisms: during manufacture, during solution preparation, via retrograde contamination from a contaminated catheter, or handling by healthcare workers.

3- Infusate contamination

MICROBIOLOGY

Coagulase-negative staphylococci – 31 % ●Staphylococcus aureus – 20 % ●Enterococci – 9 % ●Candida species – 9 % ●Escherichia coli – 6 % ●Klebsiella species – 5 % ●Pseudomonas species – 4 % ●Enterobacter species – 4 % ●Serratia species – 2 % ●Acinetobacter baumannii – 1 %

Special populations Certain patient populations have a different

to microbial etiology: Among burn patients, Pseudomonas

aeruginosa is the most frequently isolated gram-negative pathogen

In patients with hematologic and non-hematologic malignancies, gram-negative pathogens predominate

In hemodialysis patients, gram-positive organisms reflecting skin flora are responsible for most catheter-related infections.

CVC Catheter Care Bundles

INSERTION

MAINTANANCE

About half of nosocomial bloodstream infections (BSIs) occur in intensive care units, and the majority are associated with the presence of an intravascular device. Catheter-related bloodstream infections (CR-BSI) are an important cause of morbidity and mortality worldwide, including resource-limited settings.

All types of intravascular catheters pose

significant but varying risk of infection.

Duration of catheterization, catheter

material, insertion conditions, and site

care also impact the risk of catheter-

associated infections .

The skin flora is probably the most important source of intravascular catheter infection.