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L’antisepsi della cute nella
prevenzione delle CLABSI
GIANCARLO SCOPPETTUOLO
FONDAZIONE POLICLINICO UNIVERSITARIO A. GEMELLI, ROMA
Targeting Zero
Targeting Zero is the philosophy that every
healthcare institution should be working toward a
goal of zero healthcare-associated infections
(HAIs). While HAI prevention is challenging and
complex, APIC believes that all organizations
should set the aspirational goal of elimination and
strive for zero infections. Every HAI impacts the
life of
VAD SELECTION
AND HEALTHCARE WORKERS
EDUCATION AND TRAINING
INSERTION
CARE OF EXITE SITEDISINFECTION OF CATHETER HUBS, CONNECTORS AND
INJECTION PORTS
CRBSI Prevention
Prevention of extra and intraluminal
colonization
CHG Eluting
Disk
(applied after catheter
insertion and with every
dressing change)
CHG Skin Preparation(applied before catheter insertion and with every dressing change)
Swabable Needleless Connector
Intraluminal
colonization
Extraluminal
colonization
Modified, Courtesy of R. Garcia, MD
Why Proper CL Maintenance is
Critical
Average Central Line Days
0 1 2 3 4 5 6 7
Insertion
Period
= 30 min
= 0.3%
Maintenance Period = 167.5h = 99.7%
Modified, courtesy of J. LeDonne, MD
WHICH ANTISEPTIC?
Advantages of chlorhexidine
Bactericidal
Broad activity against Gram positive and Gram negative bacteria, facultative anaerobes, yeasts and some lipid-enveloped viruses, including HIV (but not sporicidal)
Rapid onset of activity
Prolonged antimicrobial effect
Synergistic effect with alcohol
Lack of inactivation when exposed to blood and serum
5
Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients.Mimoz, Olivier; Pieroni, Laurence; Lawrence, Christine; Edouard, Alain; Costa, Yannick; Samii, Kamran; Brun-Buisson, Christian
Critical Care Medicine. 24(11):1818-1823, November 1996.
Figure 1 . Time to occurrence of catheter colonization in the chlorhexidine group (closed squares) and the povidone iodine group (open squares). The risk of catheter colonization was significantly greater in the povidone iodine group than in the chlorhexidine group (p < .01, Log-rank test).
2010-2016
BUNDLES
Bundle GAVeCeLT per la prevenzione delle infezioni
associate a cateteri venosi centrali
non tunnellizzati a breve e medio termine
• Igiene delle mani e Massime precauzioni di barriera durante l’impianto del catetere
venoso
• Scelta appropriata del sito di inserzione (in ordine di preferenza: metà braccio, zona
sottoclaveare, zona sopraclaveare, collo, inguine)
• Impianto ecoguidato, ovunque possibile, sia per i cateteri a inserzione centrale che
per i cateteri a inserzione periferica
• Utilizzo di clorexidina al 2% per la disinfezione cutanea prima dell’inserzione nonché
per la disinfezione continua o discontinua dell’exit site
• Impiego di “sutureless devices” per il fissaggio del catetere, ovunque possibile
• Impiego di medicazioni semipermeabili trasparenti, ovunque possibile
• Rimozione immediata del catetere venoso centrale non più indispensabile
Premature Infant Skin
“Shaping the Future of Pediatric Vascular Access 2012”
• Stratum corneumpoorly developed orabsent
• Thin epidermis
• Dermis not fully
formed and deficientof structural proteins
Full Term Infant Skin
“Shaping the Future of Pediatric Vascular Access 2012”
Healthy infants
• Well-formed stratumcorneum…..notemultiple layers
• Thick epidermis
• Structural proteinspresent in the dermis
CHG Safety in Premature Infants
• Issues: systemic absorption, skin toxicity• Concern: hexachlorophene caused neurotoxicity• Hexachlorophene:
– Bacteriostatic– disrupts bacterial cell wall– slow onset efficacy
• CHG:–
–
–
–
Bacteriocidalincreases cell membrane permeabilityrapid onsetbinds to SC proteins
Chapman A, et al. J Perinatol (2012); 32(1):4-9
“Shaping the Future of Pediatric Vascular Access 2012”
CHG versus PI in Neonates
• Pilot parallel comparison: 2% CHG (alcohol) vs. 10% PovidoneIodine
• 48 neonates ≥ 1500 g (~ 30wks GA) and ≥ 7 days
• No catheter related BSIs in either group
• No dermatitis - CHG or PI (i.e., ≥ 2,no pink-red all area)
• CHG absorption occurred:
• 7 of 10 had blood CHG between 13 – 100 ng/ml• No neurotoxicity
Studies needed in younger preterms
“Shaping the Future of Pediatric Vascular Access 2012”
Garland J, et al. J Perinatol (2009); 29:808-813
CHG Use in NICUs
• A survey of 90 NICU training units found:
55
27
28
28
55
Used CHG, central venous catheter care
No restrictions
Restrictions: GA, actual age or birth weight
Reported adverse reactions, all skin related17 burns, 2 erosions, 9 erythema
Had concerns: Off label use, Immature skin, Limited
safety data
Tamma P, et al. Infect Control Hosp
Epidemiol (2010);31(3):846-849
“Shaping the Future of Pediatric Vascular Access 2012”
Summary
Chlorhexidine gluconate’s broad spectum of
antimicrobial activity makes it an ideal agent for many
infection prevention applications
The rapid antimicrobial activity of CHG with alcohol in
addition to persistent and residual antibacterial effect on
the skin has led to strong recommendations for its use as
a cutaneous antiseptic and cathetr hub disinfectant
More research is needed to evaluate the clinical
significance of CHG resistance
