APSA Central Venous Catheter presentation.ppt
- 1. Strategies for the Treatment Strategies for the Treatment and Prevention of Central and Prevention of Central Venous Catheter Infections Venous Catheter Infections Eunice Huang, MD, MS APSA Education Day Palm Desert, CA May 22, 2011 OUTCOMES AND CLINICAL TRIALS COMITTTEE
- 2. Objectives Objectives 1) To define central venous catheter (CVC) infection and strategies for treatment. 2) To discuss available evidence addressing strategies for prevention of central venous catheter infection during insertion. 3) To discuss available evidence addressing strategies for prevention of central venous catheter infection during catheter care. 4) To discuss combination strategies (“bundling”) used by some institutions to minimize risk of central venous catheter infections.
- 3. Case discussion Case discussion 24 month old with short bowel syndrome, on long-term TPN. Infant admitted for 3rd line infection over past 8 months…
- 4. Diagnosing CVC infection Diagnosing CVC infection CVC cultures should be performed only when bloodstream infection is suspected. Blood samples should be obtained prior to initiation of antibiotic therapy. Skin preparation should be performed (alcohol, iodine, chlorhexidine) prior to blood draw. Two samples should be obtained: Blood sample should be obtained through catheter (if catheter salvage planned) or catheter tip should be cultured (if removed) Peripheral blood culture (blood sample through a second catheter lumen if not able to obtain peripheral sample) Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45.
- 5. Definition of CVC infection Definition of CVC infection CRBSI (catheter-related bloodstream infection) = growth of the same organism from the catheter and the peripheral blood, meeting criteria for quantitative blood cultures or differential time to positivity Quantitative blood cultures = a catheter hub blood microbe colony count that is at least 3-fold greater then that generated from the peripheral blood Differential time to positivity = growth of microbes from catheter hub blood at least 2 hours before growth is detected from the peripheral blood Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45.
- 6. Common organisms Common organisms Most CRBSI among children are caused by coagulase- negative staphylococci (CNS) (34%), followed by S. aureus (25%) In neonates, CNS (51%) is the most common, followed by Candida species, enterococci, and gram-negative bacilli Infants with short-gut syndrome are more likely to have CRBSI secondary to gram-negative bacilli Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45.
- 7. Empiric antibiotic coverage Empiric antibiotic coverage Gram positive and gram negative organisms should be covered in pediatric patients Consider an institution’s commonly isolated organisms and susceptibility patterns Vancomycin is recommended for empiric therapy Empiric coverage for gram-negative bacilli can be a third or fourth generation cephalosporin, carbapenem, or -lactam/- lactamase combination, with or without aminoglycoside In neutropenic patients, gram negative coverage should included P. aeruginosa Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45. Flynn, Diagnosis and Management of Central Venous Catheter-Related Bloodstream Infections in Pediatric Patients, Pediatr Infect Dis J 2009;28:1016-17.
- 8. General treatment guidelines General treatment guidelines Remove CVC except in patients with uncomplicated coagulase- negative staphylococci or enterococci bacteremia Catheter salvage is an option in patients with uncomplicated CVC infection Uncomplicated - defined as: Resolution of bloodstream infection and fever within 72 hours in a patient who: Has no intravascular hardware No endocarditis No suppurative thrombophlebitis Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45.
- 9. Length of treatment Length of treatment Length of antimicrobial therapy: CNS: may retain and treat 10 to 14 days Enterococcus: may retain and treat 7 to 14 days S. aureus: remove and treat 4 to 6 weeks Gram negative bacilli: remove and treat 7 to 14 days; if salvaged, treat 10 to 14 days Candida species: remove and treated for 14 days; difficult to eradicate without catheter removal Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45.
- 10. Antibiotic lock therapy Antibiotic lock therapy Indicated in patients when catheter salvage is the goal Use in conjunction with systemic antimicrobial therapy Dwell times for antibiotic lock solutions should not exceed 48 hours Antibiotic concentrations must be increased (100 to 1000 times) to kill bacteria within a biofilm S. aureus and Candida species are less likely to respond to lock therapy Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45.
- 11. Treatment failure Treatment failure No clearance of bacteremia 72 hours after start of antimicrobial therapy or clinical deterioration If persistent fever or clinical signs of sepsis, consider work up for: Endocarditis Supprative thrombophlebitis Other metastatic infection Mermel et al., Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infections: 2009 Update by the Infection Disease Society of America, CID 2009;49:1-45.
- 12. Prevention of CVC infection Prevention of CVC infection 1. Cutaneous antisepsis for CVC insertion and care 2. Chlorhexidine impregnated catheter dressing 3. Lock therapy
- 14. Is chlorhexidine (CH) a more effective cutaneous antiseptic agent than povidone-iodine (PI) for CVC insertion and care? Study, Year Design Population N Treatment Outcome Results (95% CI) P value Mimoz, 2007 RCT Adult 481 catheters Biseptine CC CRBSI IR: Bs 11.6%, PI 22.2% IR: Bs 1.7%, PI 4.2% P=0.002 P=0.09 Langgartner 2004 RCT Adult 140 catheters Skinsept + PI vs Skinsept vs PI CC IR: Sk+PI 4.7%, Sk 24.4%, PI 30.8% P=0.006 Chaiyakun- apruk, 2002 Meta- analysis 8 RCTs, adult 4143 catheters ChloraPrep, 0.5% CH, Biseptine CC CRBSI RR: 0.49 (0.31-0.71) RR: 0.49 (0.28-0.88) -- Humar, 2000 RCT Adult 242 patients 0.5% CH CC CRBSI RR: 1.33 (0.87-2.04) RR: 0.75 (0.20-2.75) -- Mimoz, 1996 RCT Adult 158 catheters Biseptine CC CRBSI RR: 0.3 (0.1-1.0) RR: 0.3 (0.1-1.0) P=0.03 P=0.02 Maki, 1991 RCT Adult 144 catheters 2% CH CC CRBSI OR: 0.26 (0.07-0.91) OR: 0.23 (0.03-1.80) P=0.02 P=0.18 Garland, 1995 PNT Pediatric, NICU, PICC 826 catheters 0.5% CH + 70% isopropyl alcohol CC IR: CH 4.7%, PI 9.3% P=0.01 Biseptine (Bs): 0.25% chlorhexidine, 0.025% benzalkonium chloride, 4% benzyl alcohol Skinsept (Sk): 0.5% chlorhexidine, 70% isopropyl alcohol ChloraPrep: 2% chlorhexidine, 70% isopropyl alcohol
- 15. Does the placement of a chlorhexidine-impregnated sponge (Biopatch ) at the CVC insertion site decrease the risk of CC and/or CRBSI? Study, Year Design Population N Treatment Outcome Results (95% C.I.) P value Timsit, 2009 RCT Adult 1636 patients. 3778 catheters CC CRBSI HR: 0.36 (0.28-0.46) HR: 0.24 (0.09-0.65) P<0.001 P=0.005 Ruschulte, 2009 RCT Adult 601 patients CRBSI RR: 0.54 (0.31-0.94) P=0.016 Ho, 2006 Meta- analysis 6 RCTs (2 pediatric) 2446 catheters CC CRBSI OR: 0.47 (0.34-0.65) OR: 0.61 (0.30-1.26) P<0.00001 P=0.19 Chambers, 2005 RCT Adult, tunneled CVC 112 catheters Exit- site/tunnel/tip infections OR: 0.13 (0.04-0.37) P<0.001 Levy, 2005 RCT Age 0-18 145 patients CC CRBSI RR: 0.61 (0.37-1.0) Infection Rate: CH 5.4%, control 4.2% P=0.04 P=1.0 Garland, 2001 RCT NICU, PICC and tunneled CVC 705 neonates chlorhexidine -impregnated sponge (BiopatchØ) CC CRBSI RR: 0.6 (0.5-0.9) RR: 1.2 (0.5-2.7) P=0.004 P=0.65
- 16. Are antibiotic or ethanol lock therapies effective in decreasing CC and/or CRBSI? Study, Year Design Population N Treatment Outcome Results P value Cober, 2011 Retrospec- tive review Patients <25 years old, >5 kg, silicone CVC 15 70% ethanol Bloodstream infection Pre-EtOH lock: 8.0 + 5.4 Post-EtOH lock: 1.3 + 3.0 P<0.001 Jones, 2010 Retrospec- tive review 3 moŠ18 years, >5 kg, silicone CVC & PICC 23 70% ethanol Median CVC infection rate Pre-EtOH lock: 9.9 (IQR 4.4-16.0) Post-EtOH lock: 2.1 (IQR 0.0-7.6) P=0.03 Kayton, 2010 Prospective Phase I single-armed Pediatric, neuroblastoma, mediport 12 70% ethanol (+) cultures 1/12 patients (8%)- Strep pneumoniae 3 cases of catheter thrombosis Sanders, 2008 RCT Adult, cancer, tunneled CVC 64 70% ethanol CABSI OR: 0.18 (95% CI: 0.05-0.65) P=0.008
- 17. Are antibiotic or ethanol lock therapies effective in decreasing CC and/or CRBSI? Study, Year Design Population N Treatment Outcome Results P value Garland, 2005 RCT NICU, PICC 85 Vancomy cin -heparinized saline Combined definite and probable CRBSI RR 0.16 (95% CI 0.04-0.66) P=0.002
- 18. Recommendations Recommendations Based on adult data, use of chlorhexidine with alcohol as cutaneous antisepsis decreases the risk of CC and CRBSI when compared to 10% povidone-iodine. (Care should be taken in neonates and premature infants.) Use of a chlorhexidine-impregnated sponge (Biopatch® ) at the CVC insertion site decreases the risk of catheter related infections. (Sponge should not be used in premature infants.) Ethanol lock therapy for silicone CVCs can be administered safely and may reduce the incidence of catheter related infections. Vancomycin lock solution can reduce the incidence of CABSI.
- 19. Process improvement Process improvement “Bundle” – a collection of evidence-based care processes Allows for implementation of a collective set of quality improvement processes in a consistent, organized manner Examples: CVC insertion bundle: hand washing, prep description, standard catheters, prepackaged instruments, checklist, training video CVC maintenance bundle: daily assessment, site care instructions, hub care instructions, prepackaged kit, training video Shown to decrease frequency of CVC infections Miller et al., Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI’s Quality Transformation Efforts, Pediatrics, 2010.
- 20. Case discussion Case discussion 24 month old with short bowel syndrome, on long-term TPN. Infant admitted for 3rd line infection over past 8 months… Plan: • Obtain peripheral and catheter blood culture • Start empiric therapy, i.e., Vancomycin & Meropenem • Sequential blood cultures until negative, change to target therapy • Complete appropriate length of target therapy with concurrent antibiotic lock therapy • Start ethanol lock therapy to prevent recurrent infection