© 2009 csts: the cardiovascular surgical translational study the role of technology in clabsi...
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CSTS: The Cardiovascular Surgical Translational CSTS: The Cardiovascular Surgical Translational Study Study
The Role of Technology in CLABSI The Role of Technology in CLABSI PreventionPrevention
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Learning ObjectivesLearning Objectives
• To review considerations for picking new technology to reduce CLABSI
• To review currently available data regarding the efficacy of several technologies in reducing CLABSI– Chlorhexidine bathing– Chlorhexidine impregnated sponges– Antiseptic-coated catheters
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Considerations When Picking Considerations When Picking New TechnologyNew Technology
• Is technology needed to reduce CLABSI in your units?
– Has best practice been fully adopted?• CDC guidelines recommend consideration if rates
remain high after implementation of basic prevention strategies
• Risk of overreliance on technology
– Exercise caution in implementing new technology if rates rise after implementing best practice
• First go back and make sure they are doing what they are supposed to be doing
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Considerations When Picking Considerations When Picking New TechnologyNew Technology
• When are CLA-BSIs occurring?– < ~10 days often associated with extraluminal
contamination of the exit site– > ~10 days often associated with intraluminal
contamination via hub or connector– Best approach is prevention of both extraluminal and
intraluminal contamination
• What are central line use patterns in the unit?– Removed within 24-72 hours or in for long periods of
time?• May need patient-level protocol to direct technology to
those at higher risk for CLABSI
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Chlorhexidine BathingChlorhexidine Bathing
• Theory: decolonization of skin decreases organisms that might contaminate the insertion site at the time of placement and while the line is in situ
– May also reduce hub colonization if reduce overall microbial burden
– May offer the additional advantages of• Decreasing rate of blood culture contamination• Decreasing rates of other organisms (MRSA, VRE, etc.)
Moro ML et al. Infect Control Hosp Epidemiol. 1994;15:253-64.Vernon MO et al. Arch Intern Med. 2006;166:306-12.
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Chlorhexidine Bathing: Chlorhexidine Bathing: EvidenceEvidence
• 52 week crossover study in 2 MICUs in one center
• Chlorhexidine (CHG) washcloths vs. soap & water bath daily
• Primary BSI rate– CHG: 4.1 infections/1000
patient days– Soap & water: 10.4
infections/1000 patient days
– Incidence difference 6.3 (95% CI 1.2-11.0)
Bleasdale SC et al. Arch Intern Med. 2007;167:2073.
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CHG Impregnated Sponge CHG Impregnated Sponge (Biopatch)(Biopatch)
• Theory: decolonization of the catheter insertion site decreases chance of extraluminal catheter infection
• Considerations– Learning curve for optimal application—may initially have
extra manipulation of insertion site; incorrect application, etc.
– Insertion site not visible– No effect on hub
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CHG Impregnated SpongeCHG Impregnated Sponge
• RCT comparing Biopatch to standard dressings• Lines included: arterial catheters and central venous
catheters; none antiseptic or antimicrobial coated• Outcome: Catheter-related infection
– Catheter-related bloodstream infection• ≥ 1 positive peripheral blood culture, a quantitative
catheter tip culture growing the same organism or differential time to positivity of blood cultures ≥ 2 hours, and no other source
– Catheter-related clinical sepsis without bloodstream infection
• Fever, positive cath tip, pus at line site, and no other source
Timsit JF et al. JAMA. 2009;301:1231-41.
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CHG Impregnated Sponge CHG Impregnated Sponge
• 1636 catheters• Median duration of insertion:
6 days• Major catheter-related
infection rate– CHG sponge: 0.6
infections/1000 catheter days– Standard dressing: 1.4
infections/1000 catheter days– Hazard ratio 0.39 (95% CI
0.16-0.93)
• 8 episodes of contact dermatitis in sponge group
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Coated CathetersCoated Catheters
• Theory: decrease extraluminal catheter colonization and intraluminal colonization if interior surface of catheter also coated
• Types– Heparin + benzalkonium bonded
(activity on inner and outer surface)– Silver + platinum coating on inner & outer surface– Chlorhexidine and silver sulphadiazine
• Outer ± inner coating
– Antibiotic coating on outer & inner surface: minocycline and rifampin
Casey AL et al. Lancet Infect Dis. 2008;8:763-76Gilbert RE and Harden M. Curr Opin Infect Dis. 2008;21:235
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11stst Generation Chlorhexidine and Silver Generation Chlorhexidine and Silver Sulphadiazine vs. StandardSulphadiazine vs. Standard
RR 0.68 (0.47-0.98)
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22ndnd Generation Chlorhexidine and Generation Chlorhexidine and Silver Sulphadiazine vs. StandardSilver Sulphadiazine vs. Standard
• No additional benefit of outer and inner coating
OR 0.47 (0.20-1.10)
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Minocycline/Rifampin vs. StandardMinocycline/Rifampin vs. Standard
Minocycline/Rifampin vs. ChlorhexidineMinocycline/Rifampin vs. Chlorhexidine
RR 0.12 (0.02-0.67)
RR 0.29 (0.16-0.52)
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Coated Catheters: ConsiderationsCoated Catheters: Considerations
• Heparin and Minocycline/Rifampin coatings appear to be more effective than other coatings
• Limited data regarding:– Risk of development of minocycline or rifampin resistance– Risk of selection of fungal organisms
• In a different pooled analysis:– Treatment effect seen with catheters in place for 5-12
days but not 13-20 days– Treatment effect seen for femoral and internal jugular
insertion sites but not in studies using exclusively subclavian insertion sites
Hockenhull JC et al. Health Technol Assess. 2008;12(12).
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Coated Catheters: ConsiderationsCoated Catheters: Considerations
• Decision to use coated catheters depends on local factors– Extent of adoption of best practice– Duration of catheterization
• May need to make protocol based on expectations of duration of catheterization at individual patient level rather than unit level
– Usual sites of catheters – Concerns about rifampin resistance
• May choose not to use catheters with rifampin coating in patients with endovascular hardware
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Other TechnologiesOther Technologies
• Antiseptic hubs– No published clinical data supporting efficacy
• Dressings containing chlorhexidine (e.g. Tegaderm™ CHG dressing)– No published clinical data supporting efficacy
• Antimicrobial lock solutions– Not recommended for routine use– Could be considered in individual patients with limited
venous access & history of recurrent CLABSI or in patients at risk for severe sequelae of CLABSI (e.g. new prosthetic heart valve)
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Needleless Intravenous Needleless Intravenous Access DevicesAccess Devices
• “Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assessment of risk, benefits, and education regarding proper use (B-II)
– Routine use of the currently marketed devices that are associated with an increased risk of CLABSI is not recommended”
Marschall J et al, Infect Control Hosp Epidemiol 2008;29:S22-S30
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Action ItemsAction Items
• Assess compliance with best practice for CLABSI prevention in your institution
• If new technologies are desired, evaluate which ones are most appropriate for your patients
• Monitor for any unexpected effects associated with adoption of new technologies