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American College of SurgeryCritical Care Review Course: 2013
Shea C. Gregg, MD FACSTrauma Attending, Division of Trauma and Surgical Critical CareAssistant Professor of Surgery, Warren Alpert School of Medicine
Rhode Island Hospital, Providence, Rhode Island
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2013 Clinical Congress 2013 Clinical Congress Presenter Disclosure SlidePresenter Disclosure Slide
Shea C. Gregg, MD FACS
American College of Surgeons ♦ Division of Education
:
Nothing To Disclose
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Pathophysiology and Infection Control of CLABSI and CA‐UTI
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Central line associated blood stream infection (CLABSI)
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The number of CLABSIs has been estimated to be >250,000 per year
Increase length of stay In ICU by an average of 2.4 days Total hospital length of stay by 7.5 days
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Mechanisms of colonization: Extraluminal Colonization‐migration▪ Ineffective neutrophils along catheter ▪ Early infection
Intra Luminal Colonization▪ Infected hub?▪ Infected infusates?▪ Later infection
Other▪ Seeding from another sourceZimmerli W et al, 1984 HICPAC. Guideline for Prevention of
Intravascular Device-Related Infections. 1996
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Extraluminal Colonization‐migration Ineffective neutrophils along catheter Zimmerli W et al, 1984
Conclusion: PMNs at foreign bodies are dysfunctional
Bacteriocidal capacity of PMN: Cage fluid (o) vs peritoneal fluid (Triangle)
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Hand hygiene/Sterile technique Site‐choice 2% chlorhexidine prep decreases catheter colonization and/or CLABSI more effectively than:▪ 10% povidone‐iodine▪ 70% alcohol solutions
Chlorhexidine dressing: Reduces CLABSI Full‐barrier precautions Antibiotic/Antiseptic impregnated catheter?
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Intra‐Luminal Colonization Infected hub? Infected infusates?
Safdar N, Maki DG 2004 DNA subtyping of organism 26% intraluminal origin
Loftus et al, 2008 Stop‐cock contamination
in anesthesia work spaceSafdar N, Maki DG 2004
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Hand hygiene/Sterile technique
Scrub the hub! Ideal duration?
Continuous disinfection cap Wright MO et al, 2013
Antibiotic flush? ? Benefit in “high‐risk patients”
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“In conclusion, both extraluminal and intraluminal routes of infection are important in the pathogenesis of central venous catheter–related infections. Soon after insertion, the extraluminal route of infection predominates, whereas the intraluminal route does so after a more extended dwell time.”
‐Leonard A. Mermel, 2011
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Catheter‐Associated Urinary Tract Infections (CA‐UTI)
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>500,000 cases of CA‐UTIs a year in United States
Accounts for 23% of nosocomial infections in ICU
Incidence of catheter associated bacteriuria: 3‐8% per day
Excess length of stay: 2‐4 days
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Once very low levels of bacteria or candida are present in a urinary catheter, the progression to levels consistent with infection is rapid
Stark RP & Maki DG, 1984
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Mechanisms of colonization: Extraluminal Colonization‐Migration and biofilm▪ Perineal florae
Intraluminal Colonization▪ Manipulation related
Maki DG, Tambyah PA. 2001
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Hand hygiene/Sterile technique
Avoid placement Alternatives to catheterization Bladder scanners
Early removal
Antimicrobial catheters?
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Hand hygiene/Sterile technique
Don’t Flush!
Maintain unobstructed drainage
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Educational programs and application of bundles are only useful if compliance is high!
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“Ventilator Associated Event” Algorithm
Review CDC algorithm for diagnosis of CA‐UTI
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Questions?