Infection Control Craig M Coopersmith, MD Professor of Surgery Director, Surgical Intensive Care Unit Associate Director Emory Center for Critical Care
Financial disclosure I have received grant support from the CDC, NIH, and James S. McDonnell Foundation
Notes of a Surgeon On Washing Hands In the operating room today, no one pretends that even 90 percent compliance with scrubbing is good enough. If a single doctor or nurse fails to wash up before coming to the operating table, we are horrified and certainly not shocked if an infection develops in the patient a week or two later Gawande NEJM 350:1283, 2004
CLABSI The person who places the central line rarely even knows it gets infected. It is an invisible complication The person who takes care of the central line rarely sees a direct correlation between their actions and the ultimate infection. It is a blameless complication The person who diagnoses the infection can rarely point to a reason it occurred. It is an inevitable complication Nonetheless, a huge proportion (maybe all) are preventable
And now a few hot topics
Is it possible to get to a 0 CLABSI rate?
Show of hands: In the last 6 months, my ICU has had: More than 2 line infections 1 line infection 0 line infections I have no idea
Target audience -- all surgical Intervention ICU staff 1) Implementing an educational intervention to increase provider awareness of evidence-based infection control practices (2/99) 2) Creating a CVC insertion cart (6/99) 3) Asking providers daily whether catheters can be removed (6/01) 4) Implementing a checklist to be completed by bedside nurse (11/01) 5) Empowering nurses to stop procedures if guidelines were not followed (12/01) Berenholtz et al Crit Care Med 32:2014, 2004
Results -- intervention aimed at all surgical ICU staff Over 17,000 catheter days and 21,000 patient days in both study and control ICU Bloodstream infections decreased from 11.3/1000 catheter days in first quarter 1998 to 0/1000 catheter days in fourth quarter 2002 in study ICU Bloodstream infections decreased from 5.7/1000 catheter days in first quarter 1998 to 1.6/1000 catheter days in fourth quarter 2002 in control ICU Berenholtz et al. Crit Care Med 32:2014, 2004
Holding the gain? The SICU at Johns Hopkins has published follow-up data for 16 months following the conclusion of their study 2 CLABSIs, leading to rate of 0.54/1000 catheter days No CLABSIs for > 9 months
Can this be successfully performed on a large scale? 108 ICUs (103 with data) in Michigan 85% of all ICU beds in Michigan 1981 ICU months 375,757 catheter-days Pronovost et al. NEJM 355: 2725, 2006
Intervention Unit-based safety program to improve the safety culture Daily goal sheets Intervention to reduce CLABSI Intervention to reduce VAP
CLABSI Intervention Hand washing Full barrier precautions Chlorhexidine Avoiding femoral lines Removing unnecessary lines Central line cart Checklist Providers stopped if practices not adhered to CVC removal discussed daily
Results Median CLABSI decreased from 2.7/1000 catheter days at baseline to 0 at 3 months Mean CLABSI decreased from 7.7/1000 catheter days at baseline to 1.4/1000 catheter days at 16-18 months of follow-up
If you can t get to zero, what should you do? Is there a role for impregnated catheters?
Antibiotic impregnated catheters Chlorhexidine/silver sulfadiazine Minocycline/rifampin Both decrease infection rates in prospective, randomized trials
When do you need antiseptic or antimicrobial-impregnated catheters? On behalf of the CDC in collaboration with SCCM, IDSA, SHEA, SIS, ACCP, ATS, ASCCA, APIC, INS, ONS, SCVIR, and AAP, the following recommendation was made: O Grady et al MMWR 51:1, 2002
When do you need more? Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion. O Grady et al Clin Infect Disease 2011
What is the data on antiseptic or antimicrobial-impregnated catheters? 38 randomized, controlled trials At least 4 meta-analyses 2 cost-benefit analyses The majority show a benefit to these catheters leading the authors to title their recent review: Are antimicrobial catheters effective? When does repetition reach the point of exhaustion? Crnich CJ et al. CID 2005 Casey et al Lancet Infectious Diseases 2008 Hockenhull et al. CCM, 2009
Trying to get to zero What is the impact of antiseptic or antimicrobial-impregnated catheters in an ICU where there is an education program, where full barrier precautions are used, where chlorhexidine is used, and where rates are low, but not zero?
Study design Pre/post study on all patients requiring CVCs in SICU at (18 beds at beginning of study, increased to 24 beds in 5/03) Pre-intervention period 9/02 2/04 (17 months) began at end of our previous published data on the effects of behavioral intervention on CLABSI Post-intervention period 3/04 8/05 (18 months) All patients in post-intervention period had chlorhexidine/silver sulfadiazine-impregnated catheters placed in SICU (second generation Arrow-gard blue plus, external coating and internal impregnation) Study powered to detect 50% decrease in CLABSI rate Schuerer et al. Surg Infect, 2007
Pre-hoc study design Primary outcome CLABSI rate in lines placed in SICU in preand post-intervention group Secondary outcome CLABSI rate in all lines. This includes CVCs placed in the OR, ED, interventional radiology, hospital ward, other hospitals. These were not antiseptic-impregnated in either pre or postintervention groups.
Patients 4630 patients over 35 months CVCs were a marker of illness severity. Comparing those with a CVC (regardless of where it was placed) to those without a CVC Higher APACHE II score (18.2 vs. 15.6) Longer length of stay (6.9 vs. 4.3 days)
Effect of antiseptic-impregnated catheters on CLABSI rate in the SICU Average 49 CVCs placed per month (range 15 to 64) 9/02 -- 2/04 23 CLABSIs out of 6960 catheter days 3.3/1000 catheter days 3/04 -- 8/05 16 CLABSIs out of 7732 catheter days 2.1/1000 catheter days P=0.16
Are antiseptic and antibiotic impregnated catheters equivalent? No prospective randomized trials compares second generation chlorhexidine/silver sulfadiazine-impregnated catheters to minocycline/rifampin-impregnated catheters It is questionable whether this study will ever be done. With tremendous public pressure and CMS declaring CLABSI a never event, rates for the complication have halved over the past decade The number of patients needed to perform this study is significant
The next best thing
Study design Pre/post study on all patients requiring CVCs in 24-bed SICU All patients who needed a CVC placed between 3/04 and 8/05 had chlorhexidine/silver sulfadiazine-impregnated catheters placed. (Note: this is the post-intervention phase of the previous study) All patients who needed a CVC placed between 4/06 and 7/08 had minocyline/rifampin-impregnated catheters placed.
Pre-hoc study design Primary outcome CLABSI rate in all lines. This includes impregnated CVCs placed in the SICU and CVCs placed in the OR, ED, interventional radiology, hospital ward, other hospitals.
Comparison of impregnated catheters on CLABSI rate Chlorhexidine/silver sulfadiazine-impregnated 3/04 -- 8/05 22 CLABSIs out of 7732 catheter days 2.7/1000 catheter days Minocycline/rifampin-impregnated 22 CLABSIs out of 15,722 catheter days 1.4/1000 catheter days P<0.05
How do we define VAP?
CDC/NHSN definition Ventilator in place or within 48 hours of placement Two or more serial chest radiographs with at least one of the following: New or progressive and persistent infiltrate Consolidation Cavitation
CDC/NHSN definition PLUS At least one of the following: Fever (>38.4 C or >100.4 F) with no other recognized cause Leukopenia (<4000 WBC/mm 3 ) or leukocytosis (>12,000 WBC/mm 3 ) Altered mental status with no other recognized cause in adults >70 years of age
CDC/NHSN definition PLUS At least two of the following: New onset of purulent sputum or change in character of sputum or increased respiratory secretions, or increased suctioning requirement New onset or worsening cough or dyspnea or tachypnea Rales or bronchial breath sounds Worsening gas exchange (O2 desaturations, PaO2/FiO2,240), increased oxygen requirements or increased ventilation demand
But Prospective, observational cohort study of 2060 patients 4% had VAP by ACCP criteria 0.6% had VAP per NHSN criteria Agreement between two was marginal (k statistic 0.26) Skrupky et al Crit Care Med, 2012
New Algorithm to Define Ventilator-Associated Events Joint effort of CDC and Critical Care Societies Collaborative (disclosure: I am secretary of SCCM, but was not involved in their making) Detects ventilator-associated conditions, including but not limited to VAP Requires a minimum period on ventilator Focuses on readily available, objective clinical data Does not include chest x-ray findings