crbsi bundle
TRANSCRIPT
The presentation is solely meant for Academic purpose
Vascular access by the central route epitomizes ICU care
In the US more than 5 million catheters are inserted every year
In the United States15 million CVC days (ie the total number of days of exposure to CVCs by all patients in the selected population during the selected time period) occur in ICUs each year
These vascular devices become a important source of nosocomial blood stream infection
Almost 250000 cases of nosocomial BSI occur per year in US
Almost 65 of nosocomial BSI are Primary and are associated with Vascular access
90 are due to central venous catheters Second leading cause of Nosocomial sepsis in
the ICU
If the average rate of CVC-associated BSIs is 53 per 1000 catheter days in the ICU approximately 80000 CVC-associated BSIs occur in ICUs each year
The attributable mortality for these BSIs has ranged from no increase in mortality in studies that controlled for severity of illness to 35 increase in mortality in prospective studies that did not use this control
The attributable cost per infection is an estimated $34508ndash$56000 and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $23 billion
Terminology
Microbiologic criteria for diagnosis Concordant growth of the same organism from peripheral blood and
one of the following
quantitative catheter blood culture (CP ratio of 31 to 51)
quantitative catheter segment ( 103 CFU) or
semiquantitative catheter segment (gt5 CFU) regardless
of pathogen
culture of inner catheter hub ( 103 CFU for skin
colonizers any growth for other pathogens)
culture of catheter entry site exudate (regardless of
pathogen)
culture of infusate (regardless of pathogen)
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Vascular access by the central route epitomizes ICU care
In the US more than 5 million catheters are inserted every year
In the United States15 million CVC days (ie the total number of days of exposure to CVCs by all patients in the selected population during the selected time period) occur in ICUs each year
These vascular devices become a important source of nosocomial blood stream infection
Almost 250000 cases of nosocomial BSI occur per year in US
Almost 65 of nosocomial BSI are Primary and are associated with Vascular access
90 are due to central venous catheters Second leading cause of Nosocomial sepsis in
the ICU
If the average rate of CVC-associated BSIs is 53 per 1000 catheter days in the ICU approximately 80000 CVC-associated BSIs occur in ICUs each year
The attributable mortality for these BSIs has ranged from no increase in mortality in studies that controlled for severity of illness to 35 increase in mortality in prospective studies that did not use this control
The attributable cost per infection is an estimated $34508ndash$56000 and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $23 billion
Terminology
Microbiologic criteria for diagnosis Concordant growth of the same organism from peripheral blood and
one of the following
quantitative catheter blood culture (CP ratio of 31 to 51)
quantitative catheter segment ( 103 CFU) or
semiquantitative catheter segment (gt5 CFU) regardless
of pathogen
culture of inner catheter hub ( 103 CFU for skin
colonizers any growth for other pathogens)
culture of catheter entry site exudate (regardless of
pathogen)
culture of infusate (regardless of pathogen)
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
These vascular devices become a important source of nosocomial blood stream infection
Almost 250000 cases of nosocomial BSI occur per year in US
Almost 65 of nosocomial BSI are Primary and are associated with Vascular access
90 are due to central venous catheters Second leading cause of Nosocomial sepsis in
the ICU
If the average rate of CVC-associated BSIs is 53 per 1000 catheter days in the ICU approximately 80000 CVC-associated BSIs occur in ICUs each year
The attributable mortality for these BSIs has ranged from no increase in mortality in studies that controlled for severity of illness to 35 increase in mortality in prospective studies that did not use this control
The attributable cost per infection is an estimated $34508ndash$56000 and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $23 billion
Terminology
Microbiologic criteria for diagnosis Concordant growth of the same organism from peripheral blood and
one of the following
quantitative catheter blood culture (CP ratio of 31 to 51)
quantitative catheter segment ( 103 CFU) or
semiquantitative catheter segment (gt5 CFU) regardless
of pathogen
culture of inner catheter hub ( 103 CFU for skin
colonizers any growth for other pathogens)
culture of catheter entry site exudate (regardless of
pathogen)
culture of infusate (regardless of pathogen)
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
If the average rate of CVC-associated BSIs is 53 per 1000 catheter days in the ICU approximately 80000 CVC-associated BSIs occur in ICUs each year
The attributable mortality for these BSIs has ranged from no increase in mortality in studies that controlled for severity of illness to 35 increase in mortality in prospective studies that did not use this control
The attributable cost per infection is an estimated $34508ndash$56000 and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $23 billion
Terminology
Microbiologic criteria for diagnosis Concordant growth of the same organism from peripheral blood and
one of the following
quantitative catheter blood culture (CP ratio of 31 to 51)
quantitative catheter segment ( 103 CFU) or
semiquantitative catheter segment (gt5 CFU) regardless
of pathogen
culture of inner catheter hub ( 103 CFU for skin
colonizers any growth for other pathogens)
culture of catheter entry site exudate (regardless of
pathogen)
culture of infusate (regardless of pathogen)
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
The attributable cost per infection is an estimated $34508ndash$56000 and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $23 billion
Terminology
Microbiologic criteria for diagnosis Concordant growth of the same organism from peripheral blood and
one of the following
quantitative catheter blood culture (CP ratio of 31 to 51)
quantitative catheter segment ( 103 CFU) or
semiquantitative catheter segment (gt5 CFU) regardless
of pathogen
culture of inner catheter hub ( 103 CFU for skin
colonizers any growth for other pathogens)
culture of catheter entry site exudate (regardless of
pathogen)
culture of infusate (regardless of pathogen)
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Terminology
Microbiologic criteria for diagnosis Concordant growth of the same organism from peripheral blood and
one of the following
quantitative catheter blood culture (CP ratio of 31 to 51)
quantitative catheter segment ( 103 CFU) or
semiquantitative catheter segment (gt5 CFU) regardless
of pathogen
culture of inner catheter hub ( 103 CFU for skin
colonizers any growth for other pathogens)
culture of catheter entry site exudate (regardless of
pathogen)
culture of infusate (regardless of pathogen)
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Microbiologic criteria for diagnosis Concordant growth of the same organism from peripheral blood and
one of the following
quantitative catheter blood culture (CP ratio of 31 to 51)
quantitative catheter segment ( 103 CFU) or
semiquantitative catheter segment (gt5 CFU) regardless
of pathogen
culture of inner catheter hub ( 103 CFU for skin
colonizers any growth for other pathogens)
culture of catheter entry site exudate (regardless of
pathogen)
culture of infusate (regardless of pathogen)
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Catheter Maintained
quantitative blood cultures
differential time to positivity
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Differential time to positivity early studies indicated utility primarily in
immunocompromised patients with long-term or tunneled catheters
recent published study indicated utility in patients with both short- and long-term catheters (short-term defined as lt 30 days) diagnosis of CRBSI based on semiquantitative catheter tip
andor quantitative cultures)
sensitivity was lower in short-term catheters and specificity was lower in long-term catheters
Raad I et al Ann Intern Med 200414018-25
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Catheter Maintained (continued)
Problems associated with catheter-maintained diagnostics inability to aspirate blood back for culture
which lumen of the catheter should be cultured
establishment of appropriate threshold for positive result
Problems associated in particular with quantitative blood cultures not available in many institutions
long turn-around time (48-72 hours)
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Catheter removal required quantitative or semi-quantitative catheter tip or segment
cultures
Problems associated with catheter segment
diagnostics needless removal of uninfected catheters
retrospective diagnosis of CRBSI
establishment of appropriate threshold for positive result
potential inhibitory effect of antimicrobial impregnated
catheters on subsequent catheter cultures
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Do we need the catheter culture data
General consensus of the 1999 AIDAC was yes
particularly where the predominant pathogen is also
the most frequent blood culture contaminant
Alternative definitions have been proposed probable or suspected CRBSI
positive peripheral blood culture (second positive independent
blood culture for organisms associated with skin contamination -
CNS)
no other secondary source of infection identified
catheter cultures not done or no catheter versus peripheral blood
differential was demonstrated
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
CRBSI is a clinical definition used when diagnosing and treating patients that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI
A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Epidemiology of CLABSI
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
The most commonly reported causative pathogens remain coagulase-negative staphylococci Staphylococcus aureus enterococci and Candida spp
Gram negative bacilli accounted for 19 and 21 of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database respectively
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
CVCndashAssociated Bloodstream Infection
The rate of CVC-associated bloodstream infection ranged from 78 to 185 per 1000 CVC days and was 125 per 1000 CVC days overall
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care teaching hospital in Mumbai
Chopdekar K Chande C Chavan S Veer P Wabale V Vishwakarma K Joshi A
Source
Department of Microbiology Grant Medical College and Sir JJ Hospital Mumbai 400 008 India
Abstract
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI) The CRBSI rate was 926 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27021000 days) Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate Coagulase-negative Staphylococci were the predominant cause Mortality of 33 was observed in patients with CRBSI Since central venous catheters are increasingly being used in the critical care regular surveillance for
infection associated them are essential
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Organisms Isolated from Blood cultures (2010-2011)
Eschcoli 96 14
Candida sp 73 10
Staph aureus 279
41
Acinetobacter 38
5Enterococcus
faecalis 32 5
Klebsiella sp 85
12
Salmonella typhi
paratyphi A 50 7
Pseudomonas
aeruginosa 29 4
Pseudomonas sp
17 2
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1) migration of skin organisms at the insertion site into the cutaneous
catheter tract and along the surface of the catheter with colonization of the catheter tip this is the most common route of infection for short-term catheters
2)direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices
3) less commonly catheters might become hematogenously seeded from another focus of infection
4) rarely infusate contamination might lead to CRBSI
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1) the material of which the device is made
2) the host factors consisting of protein adhesions such as fibrin and fibronectin that form a sheath around the catheter and
3) the intrinsic virulence factors of the infecting organism including the extracellular polymeric substance (EPS) produced by the adherent organisms
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Microbial biofilms
develop when
microorganisms
irreversibly adhere to a
submerged surface and
produce extracellular
polymers that facilitate
adhesion and provide a
structural matrix
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Education training and staffing
Selection of catheters and sites
Hand Hygeine and aseptic techniques
Antimicrobialantiseptic impregnated catheter
Systemic antibiotics and local antibiotics
Antimicrobial lock prophylaxis
Replacement of Catheters
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
is a group of interventions related to
patients with intravascular central
catheters that when implemented
together result in better outcomes than
when implemented individually
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Hand hygiene before catheter insertion or maintenance combined
with proper aseptic technique during catheter manipulation provides
protection against infection
Proper hand hygiene can be achieved through the use of either an
alcohol-based product or with soap and water with adequate rinsing
Appropriate aseptic technique does not necessarily require sterile
gloves for insertion of peripheral catheters a new pair of disposable
nonsterile gloves can be used in conjunction with a no-touch
technique for the insertion of peripheral venous catheters
Sterile gloves must be worn for placement of central catheters since
a no-touch technique is not possible
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Maximum sterile barrier (MSB) precautions are
defined as wearing a sterile gown sterile gloves
and cap and using a full body drape (similar to the
drapes used in the operating room) during the
placement of CVC
Maximal sterile barrier precautions during insertion
of CVC were compared with sterile gloves and a
small drape in a randomized controlled trial
The MSB group had fewer episodes of both
catheter colonization and CR-BSI
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Prepare clean skin with an antiseptic (70 alcohol
tincture of iodine an iodophor or chlorhexidine
gluconate) before peripheral venous catheter insertion
Prepare clean skin with a gt05 chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion and
during dressing changes
If there is a contraindication to chlorhexidine tincture
of iodine an iodophor or 70 alcohol can be used as
alternatives
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
The density of skin flora at the catheter insertion
site is a major risk factor for CRBSI
No single trial has satisfactorily compared
infection rates for catheters placed in jugular
subclavian and femoral veins
In retrospective observational studies catheters
inserted into an internal jugular vein have usually
been associated with higher risk for colonization
andor CRBSI than those inserted into a
subclavian
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1 Hand hygiene
2 Maximal barrier precautions
3 Chlorhexidine skin antisepsis
4 Optimal catheter site selection with
subclavian vein as the preferred site
for non-tunneled catheters in adults
5 Daily review of line necessity with
prompt removal of unnecessary lines
6 Line secure and dressing clean and intact
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
1 Use either sterile gauze or sterile transparent
semipermeable dressing to cover the catheter site
2 If the patient is diaphoretic or if the site is
bleeding or oozing use gauze dressing until this is
resolved
3 Replace catheter site dressing if the dressing
becomes damp loosened or visibly soiled
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Replace dressings used on short-term CVC sites
at least every 7 days for transparent dressings
Replace dressings used on short-term CVC sites
every 2 days for gauze dressings
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis depending on the
clinical situation of the individual patient
If patients have tenderness at the insertion site
fever without obvious source or other
manifestations suggesting local or bloodstream
infection the dressing should be removed to allow
thorough examination of the site
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Use a 2 chlorhexidine wash for daily skin cleansing to
reduce CRBSI
Bleasdale SC Trick WE Gonzalez IM Lyles RD
Hayden MK Weinstein RA Effectiveness of
chlorhexidine bathing to reduce catheter-associated
bloodstream infections in medical intensive care unit
patients Arch Intern Med 2007 1672073ndash9
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Application of antibiotic ointments (eg bacitracinmupirocin neomycin and polymyxin) to catheter-insertion sites increases the rate of catheter colonization by fungi
Promotes the emergence of antibiotic-resistant bacteria and has not been shown to lower the rate of catheter-related bloodstream infections
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
Group of interventions ie bundles are the best way forward to prevent device related infections
Insertion Bundles and Maintenance bundles both are important constituents of CRBSI bundles
