Recognising and Preventing Intravascular Catheter- related Infections

Recognising and Recognising and Preventing Preventing

Intravascular Intravascular Catheter-related Catheter-related

InfectionsInfections

AIMAIM

To reduce the “risk” of infection To reduce the “risk” of infection caused by micro-organisms prior to caused by micro-organisms prior to commencing and during an I.V. commencing and during an I.V. therapytherapy

All Doctors and Nurses must be All Doctors and Nurses must be aware of how to minimise the risk of aware of how to minimise the risk of infection prior to the insertion of an infection prior to the insertion of an I.V. cannula and during I.V. therapyI.V. cannula and during I.V. therapy

Learning OutcomesLearning Outcomes:-:-

The participants will:The participants will: Be aware of how infection presents itselfBe aware of how infection presents itself Identify how catheter colonisation Identify how catheter colonisation

occursoccurs Be able to observe patient for signs of Be able to observe patient for signs of

infection & to use the VIP scoreinfection & to use the VIP score Identify potential sources of infectionIdentify potential sources of infection Understand how to incorporate the Understand how to incorporate the

“Saving Lives – care bundles” to prevent “Saving Lives – care bundles” to prevent infection and promote good practiceinfection and promote good practice

33rdrd National HCAI Prevalence National HCAI Prevalence Survey Feb - May 2006Survey Feb - May 2006

A total of 75,694 patients were surveyed

5743 of these had HCAIs, giving a prevalence of 7.59% (95% confidence)

HCAI prevalence: England was 8.19% Wales 6.35%, Northern Ireland 5.43% Republic of Ireland 4.89%.Primary bloodstream (7.0%). Journal of Hospital Infection (2008) 69, 230 248

Are PVCs a risk for Are PVCs a risk for BSI?BSI?

At any one time 61% of hospital patients were found At any one time 61% of hospital patients were found to have a peripheral intravenous cannula or to have a peripheral intravenous cannula or catheter in placecatheter in place11

1.9% of all hospital acquired infections in the UK are 1.9% of all hospital acquired infections in the UK are due to Peripheral Venous Cathetersdue to Peripheral Venous Catheters22

Catheters inserted in the emergency department Catheters inserted in the emergency department had higher rates of infection despite shorter dwell had higher rates of infection despite shorter dwell time compared to those inserted on hospital wardstime compared to those inserted on hospital wards33

Blood stream infections remain underestimated and Blood stream infections remain underestimated and potentially serious complications of peripheral potentially serious complications of peripheral vascular catheterisationvascular catheterisation331. 2006 HCAI prevalence survey

2 Emmerson et al, JHI, overview of Second National Prevalence survey of infections in hospitals (1996)

3 Pujol et al, Journal of Hospital Infection (2007) 67, 22-29

>250,000 central venous catheters are used >250,000 central venous catheters are used in the UK annuallyin the UK annually

30,000 are associated with infection30,000 are associated with infection

Cost approx £10 million annuallyCost approx £10 million annually

Mortality> 25%Mortality> 25%

Particular problem in haematology and Particular problem in haematology and oncologyoncology

Are CVCs a risk for Are CVCs a risk for BSI?BSI?

OrganismsOrganisms 10% of HAB were caused by more than one 10% of HAB were caused by more than one

organismorganism The most commonly isolated organisms from all The most commonly isolated organisms from all

types of intravenous cannulae are coagulase -types of intravenous cannulae are coagulase -negative staphylococci (35%), with negative staphylococci (35%), with Staphylococcus aureus Staphylococcus aureus the second most the second most commoncommon (25(25%%))11

Meticillin resistant Meticillin resistant Staphylococcus aureus Staphylococcus aureus (MRSA) (MRSA) accounted for 40–45% of accounted for 40–45% of Staphylococcus Staphylococcus aureus aureus infections in a 2006 prevalence surveyinfections in a 2006 prevalence survey22

1 Managing bloodstream infection associated with intravascular catheters. Drug Therapy Bulletin 2001,39:75–801 Managing bloodstream infection associated with intravascular catheters. Drug Therapy Bulletin 2001,39:75–80

2 Smyth ETM. Healthcare acquired infection prevalence survey 2006. Presented at 6th international conference of the Hospital 2 Smyth ETM. Healthcare acquired infection prevalence survey 2006. Presented at 6th international conference of the Hospital Infection Society, Amsterdam 2006, Preliminary data available in Hospital Infection Society: The third prevalence survey of Infection Society, Amsterdam 2006, Preliminary data available in Hospital Infection Society: The third prevalence survey of healthcare associated infections in acute hospitals, 2006healthcare associated infections in acute hospitals, 2006

Associated factorsAssociated factors

Overall, almost Overall, almost 22//33 of bacteraemias of known of bacteraemias of known source were associated with intravascular source were associated with intravascular device or were device-related e.g.device or were device-related e.g.

Catheter-associated urinary tract infectionCatheter-associated urinary tract infection Ventilator associated respiratory tract Ventilator associated respiratory tract

infectioninfection Central IV catheters were the commonest Central IV catheters were the commonest

source of hospital acquired bacteraemiasource of hospital acquired bacteraemia

Nosocomial Infection National Surveillance Service. Surveillance of hospital-acquired bacteraemia in English hospitals 1997-2002.

Sources of hospital-acquired Sources of hospital-acquired bacteraemiabacteraemia

Blood-stream infection Blood-stream infection (BSI)(BSI)

Approx. 20% ofApprox. 20% of BSIs are caused by BSIs are caused by haematogenous spread from haematogenous spread from another body site another body site

e.g. urinary tract, wound infection e.g. urinary tract, wound infection and respiratory tract (Wilson 1995)and respiratory tract (Wilson 1995)

The majority of such infections The majority of such infections originate from intravenous devicesoriginate from intravenous devices

Sources of InfectionSources of Infection

Intrinsic Sources of Infection/ContaminationIntrinsic Sources of Infection/Contamination(Present prior to use)(Present prior to use)

Extrinsic Sources of Extrinsic Sources of Infection/ContaminationInfection/Contamination(Introduced in use)(Introduced in use)

Drip Site InfectionDrip Site Infection

Identify how infection Identify how infection occursoccurs

INTRINSIC SOURCES INTRINSIC SOURCES (Present prior to (Present prior to use)use)

3 Stages in the life of infusion 3 Stages in the life of infusion products during which products during which contamination can occur :~contamination can occur :~

During Manufacture and During Manufacture and PackagingPackaging

Transport and StorageTransport and Storage UsageUsage

What errors can occur What errors can occur (1)(1)

1990: Johannesburg Death of 15 babies

Contaminated IV feeds

2000: India2000: India Death of 3 young mothers and 3 newborn babies

Contaminated IV fluids

2002: Brazil 2002: Brazil 36 n36 neonatal deaths in Brazil contaminated intravenous fluids.

Endotoxin contaminated IV medication

2004: South Africa 2004: South Africa 6 premature babies died Enterobacter cloacae

three containers one infusion set

A pharmacist's dirty hands the main reason

What errors can occur What errors can occur (2)(2)

Evans Medical in Speke (not connected with present trading company)

Tue 6th April 19715% Sterile Dextrose Solution - Lot D1192

29th Feb – 2nd Mar 19715 deaths at Devonport Hospital

6th Mar 1972 - Investigation begins

12th Jul 1972 - Clothier Report issued by Department of Health & Social

Security

Report of the Committee appointed to inquire into the circumstances, including the production, which led to the use of contaminated infusion fluids in the Devonport section of Plymouth General Hospital. (London: HMSO, 1972)

Prevention of Prevention of infectionsinfections

INTRINSIC SOURCESINTRINSIC SOURCES

ActionAction Visual Inspection ~ a vital partVisual Inspection ~ a vital part Observe for leakage:Observe for leakage:

~ Pinhole leaks in PVC bags ~ Pinhole leaks in PVC bags

~ Cracks in glass bottles~ Cracks in glass bottles

EXTRINSIC SOURCESEXTRINSIC SOURCES

HOW DO THEY HOW DO THEY OCCUR?OCCUR?

Identify how infection Identify how infection occursoccurs

EXTRINSIC SOURCES EXTRINSIC SOURCES (Introduced in use)(Introduced in use)

Bacterial migration from patient’s Bacterial migration from patient’s skin/infected sites/contaminated IV fluidskin/infected sites/contaminated IV fluid

Poor asepsis/staff’s hands/disinfectantsPoor asepsis/staff’s hands/disinfectants IV drug incompatibility/additivesIV drug incompatibility/additives Line/filter changes/insertion/manipulation Line/filter changes/insertion/manipulation

of deviceof device Reflux of micro-organisms/retrograde Reflux of micro-organisms/retrograde

contaminationcontamination

Peripheral Intravenous Cannula Peripheral Intravenous Cannula Ongoing Care Observation & Record Ongoing Care Observation & Record

Sources of Infection/ContaminationSources of Infection/Contamination

(Drip Site Infection (Drip Site Infection))Hands of medical/nursing staff Hands of medical/nursing staff Patient’s own skin and floraPatient’s own skin and floraHub contaminationHub contaminationCatheter contamination on Catheter contamination on

insertion insertion Other infected sites on patient’s Other infected sites on patient’s

own bodyown bodyContaminated skin disinfectants/ Contaminated skin disinfectants/

infusate/cannula/admin setinfusate/cannula/admin set

How infection presents How infection presents itselfitself

Local site infectionLocal site infection

Inflammation of the vein (phlebitis)Inflammation of the vein (phlebitis)

Bacteraemia and SepticaemiaBacteraemia and Septicaemia

Catheter colonisationCatheter colonisation

Patient’s signs of Patient’s signs of InfectionInfection

Deteriorating patient conditionDeteriorating patient condition PyrexiaPyrexia RigorsRigors TachycardiaTachycardia TachypnoeaTachypnoea CyanosisCyanosis HypertensionHypertension Confusion/agitationConfusion/agitation No Clinical symptomsNo Clinical symptoms

Meditech IV InterventionMeditech IV Intervention

Document Document interventionintervention

How does catheter How does catheter colonisation occur?colonisation occur?

The IV device becomes The IV device becomes covered by a film of protein covered by a film of protein such as albumin, fibrinogen such as albumin, fibrinogen and immunoglobulin mixed and immunoglobulin mixed with micro-organisms and with micro-organisms and known collectively as a known collectively as a “BIOFILM”“BIOFILM”

Biofilm FormationBiofilm Formation

Skin bacteria

At insertionpolyurethane/silicon catheter

Jeske C, et al. Anaesth Analg 97:240. 2003Livesly M, et al. Eur J Clin Micro Infect Dis 17:108.1998

Elliott T, et al. Eur J Clin Micro Infect Dis 16:210.1997

Attachment


Seconds/Minutes

Protein/Platelets/White Blood Cells

Jeske C, et al. Anaesth Analg 97:240. 2003 Livesly M, et al. Eur J Clin Micro Infect Dis 17:108.1998 Elliott T, et al. Eur J Clin Micro Infect Dis 16:210.1997

Attachment & Adhesion


1-2 Hours

Fibrin Sheath


Adhesion & Maturation


2-3 Days

Thrombus Formation


Detachment

BIOFILMBIOFILM

Biofilm helps bacteria adhere to Biofilm helps bacteria adhere to the catheter and resist anti-the catheter and resist anti-microbial agents circulating in microbial agents circulating in the bloodthe blood

It can be difficult to treat It can be difficult to treat catheter-related infections catheter-related infections without removing the devicewithout removing the device

Normal floraNormal flora

Numbers of bacteria that colonize different parts of the body

Numbers per square centimeter of skin surfaceNumbers per square centimeter of skin surface

Hair follicles

Sebaceous/Sweat glands

Temperature

Insertion site colonisation is a Insertion site colonisation is a major risk factor for CR-BSI major risk factor for CR-BSI

80% of resident and transient skin flora 80% of resident and transient skin flora reside in the reside in the first 5 cellfirst 5 cell layers layers

of the epidermisof the epidermis**

Does current application methodology Does current application methodology ensure ensure that the solution reaches into the that the solution reaches into the cracks and cracks and fissures of the fissures of the epidermal layer?epidermal layer?

*Hendley JO, Ashe KM. Antimicrob Agents Chemother 1991;35:627-31

Care of intravenous devicesCare of intravenous devices

Contaminated fluid

Hub/Port colonizationOperator’s microflora

Patient’s skin microflora

Local infection

Contaminated on insertion

Haematogenous spread

Bacteria

For Hubs/ Ports

Not for skin cleansing

Use Povidone-iodine for sensitivity

Saving Lives through Care Saving Lives through Care BundlesBundles

Saving Lives Implementation Saving Lives Implementation ProgrammeProgramme::

1) CVC Care Bundle2) Peripheral IV Care Bundle3) Preventing Surgical Site Infection4) Taking Blood Culture (Best

Practice)

Peripheral Intravenous Cannula Care Bundle Peripheral Intravenous Cannula Care Bundle High Impact InterventionHigh Impact Intervention(HII) - Elements of the care (HII) - Elements of the care

process:process:

Peripheral Intravenous Cannula Care Bundle Peripheral Intravenous Cannula Care Bundle High Impact InterventionHigh Impact Intervention(HII) - Elements of Care (HII) - Elements of Care

processprocess

Central Venous Cannula Care Bundle Central Venous Cannula Care Bundle High Impact InterventionHigh Impact Intervention(HII) - Elements of the care (HII) - Elements of the care

processprocess


processprocess


processprocess

SummarySummary

Infection Prevention GuidelinesInfection Prevention Guidelines Handwashing/ANTTHandwashing/ANTT IV Infusion/catheter site prep/careIV Infusion/catheter site prep/care Selection of :~ Catheter Type, Selection of :~ Catheter Type,

Catheter Insertion Site, Sterile Catheter Insertion Site, Sterile transparent semi-permeable film transparent semi-permeable film dressing/tapedressing/tape

Change administration set (12 or 24 Change administration set (12 or 24 or 72 hrs)or 72 hrs)

Rotate peripheral IV cannulae (72hrs)Rotate peripheral IV cannulae (72hrs)

SummarySummary

Infection Prevention GuidelinesInfection Prevention GuidelinesRecord date of insertion & removal Record date of insertion & removal

of the deviceof the deviceKeep number of lines, lumens & Keep number of lines, lumens &

stopcocks to minimumstopcocks to minimumMaintenance and inspection of I.V. Maintenance and inspection of I.V.

line/siteline/siteQuality control of Quality control of

infusion/additivesinfusion/additivesCleanliness of equipment Cleanliness of equipment

ReferencesReferences Department of Health (2003) Department of Health (2003) “Winning Ways” “Winning Ways” Working together to reduce Working together to reduce

Healthcare Associated Infection in England (Report from CMO)Healthcare Associated Infection in England (Report from CMO) Emmerson, A.M. Emmerson, A.M. et alet al. The second national prevalence survey of infection in . The second national prevalence survey of infection in

hospital: overview of results. hospital: overview of results. Journal of Hospital InfectionJournal of Hospital Infection (1996) (1996) 3232: 3, 175-: 3, 175-190.190.

HCA Control of Infection Manual HCA Control of Infection Manual www.infectioncontrolservices.co.ukwww.infectioncontrolservices.co.uk Maki, D.G. and Ringer, M. (1987) Evaluation of dressings regimens for Maki, D.G. and Ringer, M. (1987) Evaluation of dressings regimens for

prevention of infection with peripheral venous catheters. prevention of infection with peripheral venous catheters. J. Am. Med. Ass., J. Am. Med. Ass., 285, 285, 2396-4032396-403

Weightman N.C Weightman N.C et al et al (1988) Bacteraemia related to indwelling central venous (1988) Bacteraemia related to indwelling central venous catheters: prevention diagnosis and treatment. catheters: prevention diagnosis and treatment. Eur. J. of Clin. Microbiol. and Eur. J. of Clin. Microbiol. and Inf. Dis., Inf. Dis., 77, 125-129, 125-129

Little et Little et al.al. Gloves to fit the bill. Gloves to fit the bill. Nursing Times Nursing Times (1999) Vol 95 No20, 57-58(1999) Vol 95 No20, 57-58 Pratt et al. epic 2: National Evidence-Based Guidelines for Preventing Pratt et al. epic 2: National Evidence-Based Guidelines for Preventing

Healthcare-Associated infections in NHS Hospitals in England. Healthcare-Associated infections in NHS Hospitals in England. Journal of Journal of Hospital InfectionHospital Infection (2007) (2007) 65(Supplement 1): 65(Supplement 1): February 2007February 2007

Am J Infect Control 2005;33:83e87 Lobo R, Levin A, Gomes L, et al. Impact of Am J Infect Control 2005;33:83e87 Lobo R, Levin A, Gomes L, et al. Impact of an educational program and policy changes on decreasing catheter an educational program and policy changes on decreasing catheter associated bloodstream infections in a medical intensive care unit in Brazil.associated bloodstream infections in a medical intensive care unit in Brazil.

Department of Health. The Health and Social Care Act 2008: Code of Practice Department of Health. The Health and Social Care Act 2008: Code of Practice for health and social care on the prevention and control of infections and for health and social care on the prevention and control of infections and related guidance. Department of Health. London. 2009. Available related guidance. Department of Health. London. 2009. Available http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110288icyAndGuidance/DH_110288

http://www.infectioncontrolservices.co.uk/

Aseptic Non Touch Aseptic Non Touch Technique (ANTT) Technique (ANTT)

PrinciplesPrinciples

DVDDVD

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Recognising and Preventing Intravascular Catheter- related Infections