Intervention Training Groningen

Transcription

1 Intervention Training Groningen

2 Evidence-based practice to reduce CVC-related infections

3 Outline Background Technology Best practice Summary

4 Outline Background Technology Best practice Summary

5 Sources of intravascular catheter infection Intraluminal from tubes and hubs Haematogen from distant sites Skin Vein Extraluminal from skin

6 Focus of prevention of infections Insertion site Skin Vein

7 Focus of prevention of infections Insertion site Hubs Tubes Catheters Skin Vein

8 A. Attachment B. Irreversible attachment, aggregation and formation of extracellular matrix C. Maturation D. Maximal thickness E. Detachment of planktonic bacteria Schachter. Nature Biotechnology 2005;21:361

9 Biofilm formation Co-factors: - Fibrinogen 1, Fibronectin 2 - Calcium 3, Magnesium 3, Iron 3,4 - Production of extracellular matrix 5,6 - DNA 7 - Stress 8* *subinhibitory concentrations of aminoglycoside on P.aeruginosa & E. coli 1. Mehall. Crit Care Med 2002;30: Vaudaux. J Infect Dis 1993;167: Banin. Appl Environ Microbiol 2006;72: Rhodes. J Med Microbiol 2007;56: Falcieri. J Infect Dis 1987;155: Sheth. Lancet 1985; 2: Qin. Microbiology 2007;153: Hoffman. Nature 2005;436:1171

10 Incidence densities Central venous catheter (CVC) 2.7/1000 catheter-days PICCs 2.1/1000 catheter-days Risk for CRBSI Tunneled CVCs 1.6/1000 catheter-days Peripheral venous catheters 0.5/1000 catheter-days Implantable port systems 0.1/1000 catheter-days Maki. Mayo Clin Proc 2006;81:1159

11 Intensive care units

12 Germany KISS per 1000 catheter-days (309 ICUs) 1 KISS: Krankenhaus Infektions Surveillance System 2.1 / catheter-days Gastmeier. J Hosp Infect 2006;64:16

13 US - National healthcare safety network 2.0 / catheter-days Edwards. Am J Infect Control 2009;37:783

14 International infection control consortium 173 ICUs from: Latin America, Asia, Africa, and Europe 7.6 / catheter-days Rosenthal. Am J Infect Control 2010;38:95

15 Regular units

16 University of Geneva Hospitals Zingg. J Hosp Infect 2009;73:41

17 USA - Missouri Central Venous Catheter (CVC) Utilization and Catheter-Associated Bloodstream Infection (CA-BSI) Rates for 4 General Medicine Wards at a Teaching Hospital in St. Louis, Missouri Marschall. Infect Control Hosp Epidemiol 2007;28:905

18 Catheter use Numbers of reasons Types of indication Zingg. J Hosp Infect 2011;77:304

19 Outline Background Technology Best practice Summary

20 Catheter colonization CRBSI 1 Coating n CVC RR (95% CI) n CVC RR (95% CI) CHG/silver-sulfadiazine ( ) ( ) (external) CHG/silver-sulfadiazine ( ) ( ) (external/internal) Silver, platinum, carbon ( ) ( ) Minocycline/rifampicin ( ) ( ) Chlorhexidine alone ( ) ( ) Cefazolin ( ) NA Vancomycin ( ) NA Ramritu. Am J Infect Control 2008;36:104

21 Chlorhexidine-impregnated sponge Control Sponge n/1 000 CVC-days n/1 000 CVC-days p=0.02 Dwell-times: 15.8 (controls), 16.6 (sponge) patients; Triple-lumen Ag/CHG-coated catheters for 5 days - Chemotherapy for haematological malignancies Ruschulte. Ann Hematol 2008;88:267

22 Chlorhexidine-impregnated sponge Control Sponge n/1 000 CVC-days n/1 000 CVC-days p=0.004 Dwell-times: 6 (controls), 6 (sponge) Timsit. JAMA 2009;301:1231

23 Lock solutions Taurolidine In vitro studies: 6 In vivo studies: 11 (2 case reports; 7-70 included patients in cohort or randomized studies 7/11 used taurolidine-citrate 4%

24 Lock solutions Controls TauroLock TM Patients Age (median) Port-days Tunneled CVC-days Simon. BMC Infect Dis 2008;8:102

25 Lock solutions Controls TauroLock TM Bacteraemia ns Bacteraemia with CoNS* ID all bacteraemia ns ID CoNS* More infections with Gram-negatives! Results not conclusive! Simon. BMC Infect Dis 2008;8:102 *CoNS: coagulase negative Staphylococcus

26 Lock solutions Ethanol N=64; many infections among controls Sanders. J Antimicrob Chemother 2008;62:809

27 Lock solutions Ethanol Ethanol 40-80% efficient in vitro but results were disappointing in a large randomized controlled trial (359 catheters*; 4 vs. 5 CLABSI) *PICCs (249), Haemodialysis catheters (63), Hickman catheters (47) Crnich. 49th ICAAC 2009; San Francisco

28 Lock solutions Citrate - Methylene blue Paraben* Sodium-citrate: 7% Methylene blue: 0.05% + paraben 408 patients with 49,565 catheter-days (207 controls [heparin]; 201 in C-MB-P group) C-MB-P* Controls 0.24/1000 catheter-days 0.82/1000 catheter-days (p=0.005) 0 patency failure 4 patency failure (p=0.120) Maki. ICAAC 2009;K-1235

29 Peripherally inserted central catheters 638 central venous catheters (4917 device-days) compared to 622 peripherally inserted central catheters (5703 device-days) 2.4/1000 vs. 2.3/1000 device-days Only difference: time-to-infection significantly longer: 23 vs 13 days; P=0.03) % CLABSI: 1.9 % vs. 2.1 %; mean device-days: 7.7 vs. 9.2 days Raiy. Am J Infect Control 2010;38:149

30 Outline Background Technology Best practice Summary

31 Procedures - Hand hygiene - Maximal sterile barrier precautions - Chlorhexidine rather than povidone-iodine for skin antisepsis - Avoiding femoral access - Single lumen if possible - Remove catheter as soon as possible - Good work organization - No guidewire exchange - No routine catheter change

32 Multimodal strategy Multimodal Intervention: - Education - Chlorhexidine - Standardized - Hand hygiene Processes - CVC care - MSB Eggimann. Lancet 2000;355:1864

33 Multimodal strategy - Single centre patients at baseline patients at intervention patient days Eggimann. Lancet 2000;355:1864

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36 Eggimann. Lancet 2000;355:1864 Multimodal strategy

37 Multimodal strategy Sustainability? 1995/ CLABSI Central line-associated bloodstream infections; incidence density (events per 1000 device-days) Eggimann. Ann Intern Med 2005;142:875

38 Bundle - Hand hygiene - MSB - Skin antisepsis with chlorhexidine - Avoiding femoral access - Remove of needless CVC Pronovost. New Engl J Med 2006;355:2725

39 Multimodal strategy Intensive care units in Michigan - 18 Months follow-up Months cumulated CVC days Pronovost. New Engl J Med 2006;355:2725

40 median/1 000 CVC days Pronovost. New Engl J Med 2006;355:2725

41 median/1 000 CVC days mean/1 000 CVC days: 7.7 Pronovost. New Engl J Med 2006;355:2725

42 median/1 000 CVC days mean/1 000 CVC days: 7.7 mean/1 000 CVC days: 1.3 Pronovost. New Engl J Med 2006;355:2725

43 Bundle Sustainability? Data from 90 out of 103 participating ICUs Baseline Implementation CLABSI Central line-associated bloodstream infections; mean incidence densities (events per 1000 device-days) Pronovost. BMJ 2010;340:c309

44 Catheter care Interventions: - Hand hygiene - Catheter care Zingg. Crit Care Med 2009;37:2167

45 Catheter care - 5 Intensive care units - Cohort study - Baseline and intervention CVC days Zingg. Crit Care Med 2009;37:2167

46 Project adoption Education of head nurses and teaching nurses Ex-cathedra teaching Bedside teaching

47 Baseline Intervention Incidence density (n/1 000 CVC-days) Time to infection 6.52 ± ±6.63 (mean ±SD) Zingg. Crit Care Med 2009;37:2167

48 Zingg. Crit Care Med 2009;37:2167 Catheter care

49 Zingg. Curr Opin Infect Dis; in press

50 Outline Background Technology Best practice Summary

51 Summary Reducing complications from central lines has a long tradition and the efforts in preventing complications exemplify not only the complexity of the problem but also the creativity and most recently success

52 Summary Although zero tolerance for central line-associated bloodstream infection may not seem a realistic goal, the number of hospitals approaching this idealistic threshold is growing

53 Summary Recent literature suggests that most success in the prevention of central line-associated bloodstream infection does not come from a magical device, but simply by complying with practice recommendations, which have been available for many years

54 Summary Today, the question hospitals should ask about catheter-associated bloodstream infection is not what to do, but rather how to do it

55 Walter Zingg Infection Control Programme University of Geneva Hospitals Rue Gabrielle Perret-Gentil Geneva, Switzerland walter.zingg@hcuge.ch P F Fabricio Jantarada Infection Control Programme University of Geneva Hospitals Rue Gabrielle Perret-Gentil Geneva, Switzerland fabricio.daliberdadejantarada@hcuge.ch P F