64
Alice Guh, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention November 3, 2012 Epidemiology and Prevention of Catheter-Related Bloodstream Infections in Outpatient Settings National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

Epidemiology and Prevention of Catheter-Related Bloodstream Infections in Outpatient Settings

Embed Size (px)

DESCRIPTION

Epidemiology and Prevention of Catheter-Related Bloodstream Infections in Outpatient Settings. Alice Guh, MD, MPH. Division of Healthcare Quality Promotion Centers for Disease Control and Prevention November 3, 2012. National Center for Emerging and Zoonotic Infectious Diseases. - PowerPoint PPT Presentation

Citation preview

Page 1: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Alice Guh, MD, MPHDivision of Healthcare Quality Promotion

Centers for Disease Control and Prevention

November 3, 2012

Epidemiology and Prevention of Catheter-Related Bloodstream

Infections in Outpatient Settings

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

Page 2: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Overview

Epidemiology of catheter-related bloodstream infections (CRBSI) in outpatient settings

Core and supplemental measures for CRBSI prevention with focus on outpatient settings

Page 3: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Burden of Central Venous Catheter Use

>5 million CVCs inserted in US annually 93% of patients receiving home infusion therapy,

compared to 13% of hospitalized patients

Approximately 25-30% of all hemodialysis patients 80% initiate hemodialysis with CVC

Estimated 2/3 of cancer patients use long-term CVC

Moureau N et al. J Vasc Interv Radiol 2002;13:1009-1016.Herbst S et al. Infusion 1998;4(suppl):S1-132.Kallen A et al. Clin Infect Dis 2010;51(3):335-341.Van de Wetering MD et al. Cochrane Database Syst Rev 2007.

Page 4: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Outpatient Central Venous Catheter Use

Diverse indications Hemodialysis Chemotherapy administration Intravenous antimicrobial therapy Parenteral nutrition, intravenous fluids Treatment of pulmonary hypertension

Various outpatient settings Physician offices, clinics, infusion centers, home settings

(self-care, home healthcare agencies)

Page 5: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Overall Burden of Catheter-Related Bloodstream Infections (CRBSI)

~250,000 BSI cases in US annually Majority associated with central venous catheter Higher costs, crude mortality rates, and number of

hospital-days

Acute care settings (2009 NHSN data) Medical-surgical wards: 1.2 cases / 1000 catheter-days Medical-surgical ICU: 1.5-2.1 cases / 1000 catheter-days

Outpatient settings Variable rates Multiple factors: patient comorbidities, catheter type,

CVC indicationKlevens RM et al. Public Health Rep 2007;122:160-166.Edwards JR et al. Am J Infect Control 2009;37:783-805.

Page 6: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Outpatient CRBSI Rates

>50,000 patients receiving home infusion Retrospectively collected data from 37 US states 0.19 cases per 1000 catheter-days

• Highest in tunneled (0.34) and nontunneled (0.22) catheters• Lowest in midline catheters (0.09) and PICCs (0.11)• Ports and midline had lowest combined local and BSI rates (0.3)

827 patients receiving outpatient/home infusion Two study sites, prospective evaluation 0.99 cases per 1000 catheter-days

• Nonsignificantly higher risk in centrally inserted catheter versus ports

Moureau et al. J Vasc Interv Radiol 2002;13:1009-1016.Tokars J et al. Ann Intern Med. 1999;131:340-347.

Page 7: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Outpatient CRBSI Rates by Population Type

Outpatient hemodialysis facilities (NHSN data) 4.2 BSI cases per 100 pt-months (1.4 cases per 1000 catheter-

days)

Cancer patients Studies of mostly adults: 1.0 to 2.1 per 1000 catheter-days Outpatient pediatric studies: 0.1 to 7.4 per 1000 catheter-days

One study: home parenteral nutrition (n=53) 2.5 cases of “line sepsis” per 1000 catheter-days

• Adults 0.8 /1000 catheter-days vs children 6.9 / 1000 catheter-days

Klevens RM et al. Semin Dial 2008;21:24-28.Howell PB et al. Cancer 1995;75:1367-75.Groeger Js et al. Ann Inter Med 1993;119:1168-1174.Barrell C et al. AJIC 2012;40:434-439.Gillanders L et al. Clin Nutr. 2012;31:30-34.

Page 8: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Pathogens Associated with Outpatient CRBSIs

Varies by patient population type

Gram-positive organisms most common Coagulase-negative Staphylococci – 28-60%

Increasing infections by gram-negative organisms Pediatric oncology and HSCT patients

• Nonendogenous organisms during summer months

Higher risk for Candida infections in long-term parental nutrition population

20-37% polymicrobial infectionsTokars J et al. Ann Intern Med. 1999;131:340-347.Opilla M. AJIC. 2008;36(10):S173.e5-8.Smith T et al. Infect Control Hosp Epidmiol 2002;23:239-243.Barrell C et al. AJIC 2012:40:434-439.

Page 9: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Polymicrobial BSIs among Pediatric Outpatients with CVCs

Downes KJ et al. Clin Infect Dis. 2008;46:387-394

Page 10: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

General Risk Factors for Outpatient CRBSIs

Prospective study: 827 patients receiving home infusions

Tokars J et al. Ann Intern Med. 1999;131:340-347.

Page 11: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

CRBSI PREVENTION IN OUTPATIENT SETTINGS

Page 12: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Limitations of Current Recommendations

Based on studies conducted in ICU settings

Prevention of outpatient CRBSIs largely focused on hemodialysis patients

Page 13: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Surveillance

Outbreak detection

Staff feedback to improve performance

Collection of outcome and/or process measures CRBSI rates Adherence to hand hygiene

Page 14: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Value of Surveillance

Busy London dialysis unit: 112 patients

Implemented CDC dialysis surveillance; described their experience over 18 months

After initial set up, required 2 hours per month

Outcomes: Reductions in Access-related bacteremia Antibiotic usage Hospital admissions

George A et al. BMJ 2006; 332:1435-1439Slide courtesy of Dr. Priti Patel

Page 15: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Antimicrobial Starts

George A et al. BMJ 2006; 332:1435-1439Slide courtesy of Dr. Priti Patel

Page 16: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Access-Related Bacteremia

George A et al. BMJ 2006; 332:1435-1439Slide courtesy of Dr. Priti Patel

Page 17: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Observations

“Surveillance raised awareness and provided a cornerstone for improved infection control and line care involving all staff of the dialysis unit.”

“The data feedback generated unit led programmes of risk reduction and infection control.”

George A et al. BMJ 2006; 332:1435-1439Slide courtesy of Dr. Priti Patel

Page 18: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Challenges Related to Surveillance

Challenges of measuring outpatient CRBSI rates

No established surveillance system for all outpatient settings

Determining infections originating in outpatient facility or related to home infusion

Collecting appropriate denominator data, e.g., catheter days

Page 19: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Considerations for CRBSI Surveillance in Certain Outpatient Settings

Hematology/oncology patients with long-term CVC Tracking positive blood culture results: laboratory

notification, ask patients at visits Denominator data: total number of line days/month

Building line days database Determine list of patients with CVCs Designate personnel to build and

maintain database Collect initial and subsequent data

• Nurses reporting, monthly surgery list of lines placed/removed

Children’s Hospital Association Heme-Onc Collaborative for Prevention of CLABSI.

Page 20: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Pathogenesis: Mechanism for Colonization of Longer-term CVC

Intraluminal pathway most common for CVC >1 week Contamination of the hub, catheter, or other

administration device

Presence of biofilm greater on luminal surface in CVC >30 days

Emphasis on appropriate CVC maintenance and access practices

Raad I et al. J Infect Dis 1993;168:400-407.Safdar N et al. Intensive Care med 2004; 30:62-67.

Page 21: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Removal of Unnecessary CVC

Important component of interventions to decrease CRBSIs

Multisite studies of ICU settings Implementation of multifaceted interventions led to

significant decrease in CRBSI rates Interventions included: asking providers daily whether

catheters can be removed• Added to rounding form: “daily goals form”

Brenholz SM et al. Crit Care Med 2004;32:2014-2020.Pronovost P et al. N Engl J Med 2006;355:2725-2732.

Page 22: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Hand Hygiene

Perform hand hygiene before and after: Palpating catheter insertion sites Changing dressing of catheter site Accessing catheter

Outpatient facilities Ensure easy access to alcohol-based hand rub and/or

soap and water Observation of practices and “just in time” feedback as

needed

Page 23: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Skin Antisepsis for Cleansing Catheter SIte

Prospective, randomized trial (n=668 catheters: CVC, arterial catheters)

Maki D et al. Lancet 1991;388:339-343.

Page 24: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Meta-analysis: Comparison of Chlorhexidine and Povidone-Iodine

Solution

Vascular catheter-sitecare

4143 catheters (various types)

All hospital settings

Chaiyakunapruk N et al. Ann Intern Med 2002;136:792-801.

Page 25: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Meta-analysis: Results

Chaiyakunapruk N et al. Ann Intern Med 2002;136:792-801.

Chlorhexidine gluconate reduced catheter-related BSI by approximately 50% (summary risk ratio 0.49 [95% CI, 0.28-0.88])

Similar findings when only CVCs were included in the analysis (summary risk ratio, 0.51 [95% CI, 0.27-0.97])

Page 26: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Why Chlorhexidine Gluconate May be Better Antisepsis Than Povidone-Iodine

Microbicidal effect might not be affected by protein-rich biomaterials (e.g., blood, serum)

Prolonged residual effect (at least 6 hours)

Superior bactericidal effect against coagulase-negative staphylococci Disinfection of peritoneal dialysis catheter sites

Chaiyakunapruk N et al. Ann Intern Med 2002;136:792-801.Shelton DM. Adv Perit Dial. 1991;7:120-4.

Page 27: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Catheter Site Dressing: Gauze and Tape vs Transparent Polyurethane Dressing

Study of peripheral catheters (n=2000 catheters) No difference in rate of catheter colonization or phlebitis

Systematic review and meta-analysis: 8 of 23 studies included; data available from only 6 studies

• No difference in incidence of infectious complications (catheter-related sepsis, exit site infection)

Updated review in 2011• higher CRBSI rate with polyurethane dressing, but small sample

size with low quality evidence

Use either sterile gauze or sterile, transparent, semipermeable dressing to cover catheter site

Maki DG et al. JAMA 1987;258:2396-403.Gillies D et al. J Adv Nurs 2003;44:623-32.Gillies D et al. Cochrane Database Syst Rev 2011;9:CD003827.

Page 28: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Catheter Site Dressing Changes

Wear clean or sterile gloves

Replace dressing if becomes damp, loosened, or visibly soiled

Remove dressing to allow examination if: Tenderness at insertion site Other symptoms suggestion of local infection or BSI

Do not use topical antibiotic ointment or creams on insertion site (except for dialysis catheters) Potential for fungal infections Antimicrobial resistance

Page 29: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Needleless Connectors

Catheter hub is important portal of entry

Needleless connectors evolved from split septum to mechanical valves

Potential decreased microbial contamination rate compared to stopcocks/caps

Randomized controlled trial in ICU 243 patients, mean CVC duration 9.9 days CVC with needleless connectors vs 3-way stopcock/cap CRBSI incidence significantly reduced with needleless

connectors (0.7 / 1000 catheter days vs 5.0 / 1000 catheter days)

Caeey AL et al. J Hosp Infect 2003l54:288-93.Bouza E et al. J Hosp Infect 2003;54:279-87.Yebenes JC et al. Am J Infect Control 2004;32:291-5.

Page 30: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Importance of Access Port / Connector Disinfection

Appropriate disinfection must be performed

Experimental model evaluating barrier effect of 3 different needleless connectors Peripheral catheter with connector inserted in blood

culture bottle Contaminated external surfaces of connectors with

different concentrations of S. epidermidis Assigned to “correct cleaning group” (70% alcohol before

handling) vs. control group (no disinfection before handling)

Incorrect handling reduced sterility from 94.4 to 66.7% (p=0.001)

Yebenes JC et al. Crit Care Med 2008;36:2558-61.

Page 31: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Disinfection Procedure for Connectors

Mixed findings regarding alcohol vs chlorhexidine disinfectants Earlier study showing ethanol-based disinfectants most

effective Recent studies: higher microbial contamination following

alcohol (69%) than chlorhexidine (30.8%) or povidone-iodine (25%)

Role of antimicrobial impregnated connector

Wiping with 70% alcohol for 3-5 sec not effective

No difference when vigorously scrubbing 15 sec with alcohol or chlorhexidine In vitro study of various mechanical valves

Salzman MB et al. J Clin Microbil 1993;31:475.Casey AL et al. J Hosp Infect 2003;54:288-293Menyhay SZ et al. Infect Control Hosp Epidemiol 2006;27:23-7.Kaler W et al.JAVA 2007;12:3-9.

Page 32: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

CRBSI Associated with Mechanical Valves?

Several reports of increased CRBSI when switching from split septum to mechanical valves Acute care settings Large, multicenter study across 5 hospitals (16 ICUs, 1

entire hospital, 1 oncology unit)

Pediatric hematology/oncology patients receiving home infusion 182 patients, >75,000 catheter days CRBSI significantly increased when mechanical valves

introduced (0.8 to 1.4 / 1000 catheter days)

Page 33: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Mechanical Valves in Long-Term Acute Care Setting

Salgado CD et al. Infect Control Hosp Epidemiol 2007;28:684-688.

CRBSI increased from 1.79 to 5.9 / 1000 catheter days

Page 34: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Potential Explanations for Increased CRBSI with Mechanical Valves

Device-specific vs all mechanical valves?

Improper cleaning of connector surface (difficulty in adequate disinfection) Recommendations may differ by device type

Fluid flow properties and inadequate flushing (poor visualization in opaque devices)

Exposure to blood/nutritional fluids enable biofilm formation

Presence of internal corrugations could harbor organisms

Page 35: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Recommendations for Disinfecting Access Port / Connectors

Scrub access port / connects with appropriate antiseptic Chlorhexidine, povidione-iodine, 70% alchohol

Access port with only sterile devices

Split septum may be preferred over some mechanical valves Must follow manufacturer recommendations for

disinfection when using mechanical valves

Page 36: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Outbreak Related to Unsafe Injection Practices

Outpatient pediatric bone marrow transplant clinic

September 2007: Initially 6 patients with CVC had BSI, some polymicrobial

Surveillance blood cultures during outbreak period (n=30 patients) 13 patients with BSI, 17 without BSI

Cohort study looking at risk factors

Infection control assessment, including saline flush preparation

Wiersma P et al. Infect Control Hosp Epidemiol 2010;31:522-27.

Page 37: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Cohort Study Results

Wiersma P et al. Infect Control Hosp Epidemiol 2010;31:522-27.

Page 38: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Cohort Study Results

Wiersma P et al. Infect Control Hosp Epidemiol 2010;31:522-27.

Page 39: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Infection Control Assessment: Saline Flush Preparation

Outside of automated medication supply

Prepared predrawn saline and heparin syringes: Preservative-free, single-dose 50-mL saline vial Multidose 10-mL heparin vials

Vials accessed multiple times

Predrawn syringes and vials not dated

Outbreak likely due to extrinsiccontamination of saline vials

Wiersma P et al. Infect Hosp Control Epidemiol 2010;31:522-27.

Page 40: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Recommendations for Safe Injection Practices

Injection safety refers to proper use and handling of supplies for administering injections and infusions Syringes, needles, IV tubing, vials and parenteral solutions

Key injection safety recommendations include: Dedicate single dose vials for single patient use Always use new syringe and needle to access medication

vials Avoid prefilling and storing batch-prepared syringes (outside

of pharmacy setting) Whenever possible, use commercially manufactured or

pharmacy-prepared prefilled syringes (saline, heparin)

Page 41: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Education

Education of healthcare personnel Proper care/maintenance of catheter Periodically assess adherence to recommended

practices

Education of patients Do not submerge catheter or catheter site in water Report any changes in catheter site or new discomfort

Page 42: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

SUPPLEMENTAL CRBSI PREVENTION MEASURES

Page 43: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Supplemental Measures

Chlorhexidine-impregnated sponge dressings

Antimicrobial / antiseptic impregnated catheters

Antimicrobial / antiseptic catheter locks

Page 44: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Chlorhexidine-Impregnated Sponge Dressings vs Standard Dressings

Largest multicenter, randomized controlled trial

7 ICUs (mix of medical and surgical) across academic and community hospitals

Included 1636 adult patients (n=3778 catheters)

Interventions included: CHGIS dressing applied to entire insertion site under

semitransparent dressing (controls: only semitransparent dressing)

Of note: Alchohol based povodone-iodine was used for antisepsis

Outcomes included catheter-related infection (BSIs) rates, catheter colonization

Timsit JF et al. JAMA 2009;301:1231-41.

Page 45: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Results of CHGIS vs Standard Dressings: Cumulative Risk of Catheter-Related

Infections

Timsit JF et al. JAMA 2009;301:1231-41.

Major catheter-related infection rate:

1.4 / 1000 catheter-days to0.6 / 1000 catheter-days Catheter-related BSI rate*:1.3 / 1000 catheter-days to 0.4 / 1000 catheter-daysCatheter colonization rate:15.8 / 1000 catheter-days to 6.8 / 1000 catheter-days

Page 46: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Additional Findings From Same Study

Significant decrease in bacterial skin colonization with CHGIS dressings Not associated with greater resistance of bacteria

Severe contact dermatitis leading to removal of CHGIS: 8 patients (10.4 / 1000 patients) No systemic adverse reactions to chlorhexidine occurred

No difference in catheter colonization between dressing change at 3 days vs 7 days

Timsit JF et al. JAMA 2009;301:1231-41.

Page 47: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Chlorhexidine-Impregnated Sponge Dressing in Cancer Patients

Randomized controlled trial at a single hopsital

601 patients receiving chemotherapy (>9000 catheter days) Used chlorhexidine and silver sulfadiazine-impregnated CVC CVC for ≥5 days, removed when not needed or patient

discharged Intervention: CHGIS dressing (controls: sterile transparent

dressing), changed regularly after 1 wk

CRBSI was 46% less in the CHGIS dressing group

Catheter tip bacteria similar in both groups (>50% S. epidermidis)

Ruschulte H et al. Ann Hematol 2009;88:267-72.

Page 48: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Other CHGIS Studies

Meta-analysis of RCTs: CHGIS vs standard dressing (7 studies) or povidone-iodine dressing (1 study) Associated with reduction of vascular and epidural catheter

exit site colonization Trend towards reduction in CRBSI Local cutaneous reactions in 5.6% patients in 3 studies, 96%

of these in neonatal patients

Study involving 2 outpatient dialysis centers Prospective, crossover intervention trial over 1-year period:

121 patients with tunneled catheters received CHGIS dressing Use of CHGIS did not decrease CRBSI incidence

Ho KM et al. J Antimicrob Chemother 2006;58:281-7.Camins BC et al. Infect Control Hosp Epidemiol 2010;31:1118-23.

Page 49: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Current Recommendations for Chlorhexidine-Impregnated Sponge

Dressing

Limited evidence indicating CHGIS use may decrease CRBSI rates

Mainly studied short-term CVCs

May consider if CRBSI rate not decreasing despite implementation of core measures In patients >2 months of age ?Applicability to long-term CVC use

Page 50: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Antimicrobial / Antiseptic Impregnated Catheters

Several randomized studies in 1990s Chlorhexidine / silver sulfadiazine coated on external

luminal surface vs standard uncoated catheters

Meta-analysis: 11 studies for catheter

colonization 12 studies for CRBSI Mostly ICU patients Median CVC duration

5.1-11.2 days

Page 51: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Meta-Analysis Results

Summary OR 0.44 (95% CI, 0.36-0.54) Summary OR 0.56 (95% CI, 0.37-0.84)

Veenstra DL et al. JAMA 1999;281:261-7.

CVCs impregnated with chlorhexidine/silver sulfadizine effective in reducing catheter colonization and CRBSI

Page 52: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Chlorhexidine / Silver Sulfadiazine Coated Catheters

Second generation catheters Chlorhexidine on internal surface extending to hubs Higher concentration of chlorhexidine/silver sulfadizine

on external luminal surface

Prospective, randomized studies of 2nd generation catheters vs standard uncoated catheters: Significant reduction in catheter colonization Underpowered to detect difference in CRBSI

Rare reports of anaphylaxisBrun-Buisson C et al. Intensive Care Med 2004;30:837-43.Ostendorf T et al. Support Care Cancer 2005;13:993-1000.Rupp ME Ann Intern Med 2005;143:570-80.

Page 53: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Minocycline / Rifampin Impregnated Catheters

To assess long-term catheters impregnated with minocycline/rifampin in reducing CRBSI: Prospective, randomized trial in oncology hospital Mean CVC duration >60 days

Hanna H et al. J Clin Oncol. 2004;22:3163-71.

M-R catheter: 0.25/1000 catheter days

Uncoated catheters:1.28/1000 catheter days

Page 54: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Catheters Impregnated with Minocycline / Rifampin vs Chlorhexidine

/ Silver Sulfadiazine

Multicenter randomized trial (n=12 hospitals): M-R CVC vs first generation Chlorhexidine/silver

sulfadizine CVC

Darouiche RO et al. N Engl J Med 1999;340:1-8.

M-R catheters •12 times less likely to have CRBSI•3 times less likely to be colonized

Page 55: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Additional Considerations for Minocycline/Rifampin Impregnated

Catheters

No comparison with 2nd generation chlorhexidine / silver sulfadiazine catheters

Concern for increased antimicrobial resistance but not shown in clinical settings Prospective, 7-year follow-up study in cancer center

(>500,000 catheter days)

Ramos ER et al. Crit Care Med 2011;39:245-51.

Page 56: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Current Recommendations for Antimicrobial / Antiseptic Impregnated

Catheters

May consider use if CRBSI rates not decreasing: Either chlorhexidine / silver sulfadiazine or minocycline /

rifampin impregnated CVC If catheter is expected to remain in place >5 days

Additional data needed on other new catheters Platinum/silver Miconazole/rifampin M-R / Chlorhexidine / silver sulfadiazine

Page 57: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Antimicrobial / Antiseptic Catheter Lock

Filling catheter lumen with antimicrobial solution when not in use

Various concentrations and combinations Antibiotics: vancomycin, gentamicin, ciprofloxacin,

minocycline, amikacin, cefazolin, cefotaxime, ceftazidime

Antiseptics: alcohol, taurolidine*, trisodium citrate*

Usually combined with anticoagulant Heparin, EDTA

*Not approved for this use in the US

Page 58: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Antimicrobial Lock Solutions in Select Patient Populations

Several studies in higher-risk patients, longer-term CVC use Hemodialysis patients

• Study of 291 patients – significantly lower CRBSI rate using 30% trisodium citrate (1.1/1000 CVC days) vs heparin (4.1/1000 CVC days)

Oncology patients• Study of 126 patients – median CVC days 200-247 days:

o Vanc/Cipro/Heparin (0.55/1000 CVC days) vs Vanc/Heparin (0.37/1000 CVC days) vs Heparin (1.72/1000 CVC days)

Patients receiving long-term parenteral nutrition

Generally found reduction in CRBSI rates

Weijmer MC et al. J Am Soc Nephrol 2005;16:2769-77.Henrickson KJ et al. J Clin Oncol 2000;18:1269-78.

Page 59: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Use of 70% Ethanol Lock

Prospective, randomized trial of patients with hematological disease (long-term CVC): 70% ethanol lock vs heparinized saline

Sanders J et al. J Antimicrob Chemother 2008;62:809-15.

0.6 CRBSI/1000 days

3.11/1000 CVC days

Page 60: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Additional Considerations Regarding Catheter Locks

Need to balance benefits with potential side effects Toxicity, allergic reactions Emergence of antimicrobial resistance

Limitations of studies Small sample size Heterogeneity of patient populations

Wide variety of compounds for use No FDA approved formulations

Page 61: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Recommendations for Catheter Locks

Not recommended for general use

May consider in patients with long-term CVC and recurrent CRBSI despite adherence to aseptic technique

Page 62: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Summary

CRBSI in outpatient settings is an emerging issue Impacting diverse patient populations Various outpatient settings

Limited surveillance and prevention data for outpatient settings Additional research warranted for long-term CVC use,

novel technologies

Page 63: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

Summary: Key Recommendations

Similar to inpatient settings with emphasis on line care/maintenance practices: Remove unnecessary CVC Perform hand hygiene Use >0.5% chlorhexidine/alcohol for skin / CVC site

antisepsis Appropriate disinfection of connectors/ports prior to

access

Consideration of supplemental measures as needed

Page 64: Epidemiology and Prevention of  Catheter-Related Bloodstream Infections in Outpatient Settings

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion

Thank you