What’s New in the 2011 Guideline for Preventing Catheter Related BSI? Naomi P. O’Grady, MD Critical Care Medicine Department National Institutes of Health

What’s New in the 2011 Guideline What’s New in the 2011 Guideline for Preventing Catheter Related for Preventing Catheter Related

BSI?BSI?

Naomi P. O’Grady, MDNaomi P. O’Grady, MD

Critical Care Medicine DepartmentCritical Care Medicine Department

National Institutes of HealthNational Institutes of Health

I have no disclosures.I have no disclosures.

ObjectivesObjectives

Highlight some areas of controversy, Highlight some areas of controversy, including catheter site selection, including catheter site selection, antimicrobial locks, and chlorhexidine antimicrobial locks, and chlorhexidine impregnated sponge dressings impregnated sponge dressings

Discuss the recommendations in the Discuss the recommendations in the updated guidelineupdated guideline

Outline some of the data to support the Outline some of the data to support the new recommendationsnew recommendations

Clinical Infectious Diseases 2011; 52(9) e162-e193Clinical Infectious Diseases 2011; 52(9) e162-e193

Site SelectionSite Selection

Old RecommendationOld Recommendation

Use a subclavian site (rather than Use a subclavian site (rather than a jugular or a femoral site) in a jugular or a femoral site) in adult patients to minimize adult patients to minimize infection risk for non-tunneled infection risk for non-tunneled CVC placementCVC placement

Site SelectionSite Selection

Rather than focus on one specific site Rather than focus on one specific site to select, we now focus on one specific to select, we now focus on one specific site to avoid.site to avoid.

Avoid the femoral vein for central Avoid the femoral vein for central venous access in adultsvenous access in adults

Femoral site associated with greater Femoral site associated with greater risk of infection and DVTrisk of infection and DVT

Merrer; JAMA, 2001Parienti; JAMA, 2008

JAMA, 2001; 286:700-07

Catheter ComplicationsCatheter Complications

Randomized patients to femoral (145) vs Randomized patients to femoral (145) vs subclavian (144)subclavian (144)

8 ICU’s; 3 years8 ICU’s; 3 years Mechanical complications similar in both Mechanical complications similar in both groupsgroups

Infection and thrombosis higher in Infection and thrombosis higher in femoral groupfemoral group



* Thrombotic complications were 21% in femoral group Thrombotic complications were 21% in femoral group and 1.9% in subclavian group ( p<0.001) with 2 PE’sand 1.9% in subclavian group ( p<0.001) with 2 PE’s

JAMA 2008JAMA 2008

Femoral vs Jugular Femoral vs Jugular CatheterizationCatheterization

375 patients in each arm over a 3 year 375 patients in each arm over a 3 year periodperiod

Primary endpoint was colonization on Primary endpoint was colonization on removalremoval

Insertion complications, CR-BSI, and Insertion complications, CR-BSI, and thrombosis were secondary endpointsthrombosis were secondary endpoints

Mechanical ComplicationsMechanical Complications

Jugular catheters: longer insertion times, Jugular catheters: longer insertion times, more failed attempts and more crossovermore failed attempts and more crossover

Arterial punctures no different (5.1% vs Arterial punctures no different (5.1% vs 3.6%), although hematoma formation higher in 3.6%), although hematoma formation higher in jugularjugular

2 patients required intubation in jugular 2 patients required intubation in jugular groupgroup

1 patient required vascular surgery for 1 patient required vascular surgery for carotid artery insertioncarotid artery insertion

1 patient with acute leg ischemia required 1 patient with acute leg ischemia required limb amputationlimb amputation

Infectious ComplicationsInfectious Complications

JAMA 2008JAMA 2008

Controversy. . .Controversy. . .

JAMA 2008JAMA 2008

Skin AntisepsisSkin Antisepsis

Old RecommendationOld Recommendation

Disinfect clean skin with an Disinfect clean skin with an appropriate antiseptic. A appropriate antiseptic. A chlorhexidine-based preparation chlorhexidine-based preparation with >2% is preferred. with >2% is preferred. Alternatively, tincture of Alternatively, tincture of iodine, an iodophor, or 70% iodine, an iodophor, or 70% alcohol could be used.alcohol could be used.

New RecommendationNew Recommendation

Disinfect clean skin with an Disinfect clean skin with an appropriate antiseptic. A appropriate antiseptic. A chlorhexidine-based preparation chlorhexidine-based preparation with >0.5% is preferred. with >0.5% is preferred. Alternatively, tincture of Alternatively, tincture of iodine, an iodophor, or 70% iodine, an iodophor, or 70% alcohol could be used.alcohol could be used.

Annals of Internal Medicine 2002

Chlorhexidine significantly reduces risk of colonization and BSIChlorhexidine significantly reduces risk of colonization and BSI

Catheter Site Dressing Catheter Site Dressing RegimensRegimens

Old Recommendation: Old Recommendation: No recommendationNo recommendation

Efficacy of Chlorhexidine Efficacy of Chlorhexidine Impregnated Sponges for Impregnated Sponges for

Prevention of Intravascular Prevention of Intravascular Catheter Related InfectionsCatheter Related Infections

Catheter ColonizationCatheter Colonization

Blood Stream InfectionBlood Stream Infection

109 109

(16%)(16%)

8 (1.2%)8 (1.2%)

216 (29%)216 (29%)

24 (3.3%)24 (3.3%)

0.62 (0.49-0.78)0.62 (0.49-0.78)

0.38 (0.16-0.29)0.38 (0.16-0.29)

ChlorhexidineChlorhexidineSpongeSpongeN = 665N = 665

ControlControlN = 736N = 736

RRRR

ICAAC 2000ICAAC 2000

Timsit JF et al. JAMA 2009

Chlorhexidine sponge dressings reduce Chlorhexidine sponge dressings reduce risk of infection and colonizationrisk of infection and colonization

2 x 2 factorial RCT to evaluate chx 2 x 2 factorial RCT to evaluate chx dressing vs standard and to evaluate 3 dressing vs standard and to evaluate 3 day vs 7 day dressing changesday vs 7 day dressing changes

1653 patients1653 patients 3778 catheters3778 catheters 28,931 catheter days28,931 catheter days

Timsit JF et al. JAMA 2009

Chlorhexidine sponge dressings reduce risk of infection and colonizationChlorhexidine sponge dressings reduce risk of infection and colonization

Catheter Site Catheter Site Dressing RegimensDressing Regimens

Use a chlorhexidine sponge Use a chlorhexidine sponge dressing in adult patients with dressing in adult patients with short-term catheters to reduce short-term catheters to reduce the incidence of infection the incidence of infection catheter-related infection.catheter-related infection.

Antimicrobial Lock SolutionsAntimicrobial Lock Solutions

Use prophylactic antimicrobial Use prophylactic antimicrobial lock solution in patients with lock solution in patients with long term catheters who have a long term catheters who have a history of multiple CRBSI despite history of multiple CRBSI despite optimal maximal adherence to optimal maximal adherence to aseptic technique. aseptic technique.

Catheter LocksCatheter Locks

Technique by which an antimicrobial solution is Technique by which an antimicrobial solution is used to fill a catheter lumen and then allowed used to fill a catheter lumen and then allowed to dwell for a period of time while the to dwell for a period of time while the catheter is idle.catheter is idle.

Antibiotics of various concentrations that have Antibiotics of various concentrations that have been used either alone (when directed at a been used either alone (when directed at a specific organism) or in combination (to specific organism) or in combination (to achieve broad empiric coverage)achieve broad empiric coverage)

Formulations made in-houseFormulations made in-house Studies are limited; populations are Studies are limited; populations are hemodialysis, neonates, patients with hemodialysis, neonates, patients with neutropenianeutropenia

Needleless ConnectorsNeedleless Connectors

Mechanical ValveMechanical Valve

Split SeptumSplit Septum

RecommendationRecommendation

When needleless systems are used, a When needleless systems are used, a split septum valve may be preferred over split septum valve may be preferred over a mechanical valve due to increased risk a mechanical valve due to increased risk of infection with some mechanical of infection with some mechanical valves. Category IIvalves. Category II

Bundles and ChecklistsBundles and Checklists

Eliminating Catheter Related Eliminating Catheter Related InfectionsInfections

Crit Care Med; October 2004Crit Care Med; October 2004


Educational intervention to increase Educational intervention to increase provider awarenessprovider awareness

Created CVC insertion cartCreated CVC insertion cart Asking providers daily if the CVC is Asking providers daily if the CVC is neededneeded

Checklist at bedside for nursesChecklist at bedside for nurses Empowering nurses to stop the procedureEmpowering nurses to stop the procedure Did not include tunneled of PA cathetersDid not include tunneled of PA catheters

Eliminating Catheter Related Eliminating Catheter Related Infections Infections

Implemented simple strategiesImplemented simple strategies No impregnated cathetersNo impregnated catheters Reduced infection rate from 11.3/1000 Reduced infection rate from 11.3/1000 catheter days to 0/1000 catheter days catheter days to 0/1000 catheter days during study periodduring study period

Performance sustainedPerformance sustained Jan-April 2003 only 2 infections Jan-April 2003 only 2 infections (0.54/1000 catheter days)(0.54/1000 catheter days)

Eliminating Catheter Related InfectionsEliminating Catheter Related Infections


Excluded PICCSExcluded PICCS Implemented teaching programImplemented teaching program CVC cartsCVC carts Checklist for compliance with Checklist for compliance with handwashing and barrier precautionshandwashing and barrier precautions


Antibiotic/Antiseptic CathetersAntibiotic/Antiseptic Catheters

Antibiotic/Antiseptic CathetersAntibiotic/Antiseptic Catheters

Use an antimicrobial or antiseptic-Use an antimicrobial or antiseptic-impregnated CVC in adults whose catheter impregnated CVC in adults whose catheter is expected to remain in place >5 days if, is expected to remain in place >5 days if, after implementing a comprehensive after implementing a comprehensive strategy to reduce rates of CR-BSI, the strategy to reduce rates of CR-BSI, the rate has not sufficiently decreased. The rate has not sufficiently decreased. The comprehensive strategy should include the comprehensive strategy should include the following 3 components: educating persons following 3 components: educating persons who insert and maintain catheters, use of who insert and maintain catheters, use of maximal barrier precautions, and a 0.5% maximal barrier precautions, and a 0.5% chlorhexidine preparation for skin chlorhexidine preparation for skin antisepsis during central venous catheter antisepsis during central venous catheter insertion.insertion.

Efficacy of Chlorhexidine-Silver Efficacy of Chlorhexidine-Silver Sulfadiazine Catheters for Prevention Sulfadiazine Catheters for Prevention

of Catheter Colonizationof Catheter Colonization

Collin, 1999Collin, 1999

George, 1999George, 1999

van Heerden, 1997van Heerden, 1997

Maki, 1997Maki, 1997

Heard, 1998Heard, 1998

Bach, 1996Bach, 1996

-0.2-0.2 00 0.20.2 0.40.4 0.60.6 0.80.8 11 1.21.2

Odds ratio, 95% CIOdds ratio, 95% CI Decreasing risk Increasing riskDecreasing risk Increasing risk

Risk of Bloodstream Infections Risk of Bloodstream Infections Using Two Types of Impregnated Using Two Types of Impregnated

CathetersCatheters

00

1.01.0

0.90.9

0.80.8

0.70.7

0.60.6

0.50.5

0.40.4

0.30.3

0.10.1

0.00.055 1010 1515 2020 2525 3030

Minocycline-rifampin Minocycline-rifampin catheterscatheters

Chlorhexidine-silver Chlorhexidine-silver sulfadiazine catheterssulfadiazine catheters

Proportion of Catheters

Proportion of Catheters

without Infection

without Infection

Duration of Catheterization (Days)Duration of Catheterization (Days)

M/RM/RC/SSC/SS

365365382382

214214246246

93939696

48483939

20201818

9955

4422

No. at RiskNo. at Risk

Darouiche Darouiche NEJM 1999NEJM 1999

CatheterCatheter

Annals of Internal Med 2005Annals of Internal Med 2005



SummarySummary

Educate healthcare workers and provide Educate healthcare workers and provide training for the insertion and training for the insertion and maintenance of cathetersmaintenance of catheters

Use chlorhexidine preferentially for skin Use chlorhexidine preferentially for skin antisepsisantisepsis

Use maximal barrier precautionsUse maximal barrier precautions Use a chlorhexidine sponge dressing in Use a chlorhexidine sponge dressing in adults with short-term cathetersadults with short-term catheters

Use an antibiotic/antiseptic catheters if Use an antibiotic/antiseptic catheters if CRI rates have not sufficiently declinedCRI rates have not sufficiently declined

Use a bundled strategy for simplicityUse a bundled strategy for simplicity

ConclusionsConclusions

Prevention strategies have measurable Prevention strategies have measurable impactimpact

Multiple interventions may be neededMultiple interventions may be needed Performance improvement programs will Performance improvement programs will be focused on moving toward be focused on moving toward elimination of CA-BSIs rather than elimination of CA-BSIs rather than “benchmark goals”“benchmark goals”

Focus of prevention moving away from Focus of prevention moving away from insertion phase and into maintenance insertion phase and into maintenance phasephase

Thank you.Thank you.

Documents

What’s New in the 2011 Guideline for Preventing Catheter Related BSI? Naomi P. O’Grady, MD Critical Care Medicine Department National Institutes of Health