Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection

Reducing the degree of colonisation of venous access catheters by continuous passive disinfection

Introduction

The advent of Luer-type needleless venous access catheters has been accompanied by a growing number of catheter-related bloodstream infections. Our main objective was to compare rates of colonisation and phlebitis between our standard of care and the new passive disinfection system, using a Luer SwabCap bearing a sponge impregnated with 70% isopropyl alcohol.

Methods

We performed a prospective experimental study involving patients attending our day hospital oncology unit, with central venous (CV) or peripheral venous (PV) access lines with needleless connectors for antineoplastic treatment delivery. We assessed the colonisation rate by culture of the inside of the hubs (qualitative culture) and also assessed the possible appearance of phlebitis and the extra cost of introducing the new system in our oncology day hospital; nurse satisfaction was evaluated by a questionnaire. The effectiveness of the isopropyl alcohol disinfection cap was evaluated by analysing rates of catheter colonisation and phlebitis between two groups: group 1 comprised of patients receiving the standard disinfection method and group 2 comprised of patients receiving SwabCaps on any venous access connectors. Samples were taken from the catheter lumen through a sterile swab seeded in Luria Bertani-rich broth and cultivated for at least 48 h at 37°C. We also assessed the extra cost of introducing the new system in our oncology day hospital, and nurse satisfaction was evaluated by a questionnaire.

Results

29 patients were included (13 in group 1 and 16 in group 2). In group 1, 56% of the samples were taken from CV access connectors versus 40% in group 2. Bacterial growth was detected in 43.7% of group 1 samples versus 0% in group 2 (p=0.006). No differences in the degree of contamination were found between CV and PV access connectors. No cases of phlebitis were observed. Nurse satisfaction with the new system was 9.2 out of a maximum score of 10. The incremental cost of incorporating the new system in our oncology unit was estimated at €1.87 836.

Conclusion

Passive disinfection systems help reduce colonisation of venous access catheters without requiring large economic investment or special training of health personnel.

Use of Disinfection Cap to Reduce Central-Line-Associated Bloodstream Infection and Blood Culture Contamination Among Hematology-Oncology Patients

OBJECTIVE

In this study, we examined the impact of routine use of a passive disinfection cap for catheter hub decontamination in hematology-oncology patients.

SETTING

A tertiary care cancer center in New York City.

METHODS

In this multiphase prospective study, we used 2 preintervention phases (P1 and P2) to establish surveillance and baseline rates followed by sequential introduction of disinfection caps on high-risk units (HRUs: hematologic malignancy wards, hematopoietic stem cell transplant units and intensive care units) (P3) and general oncology units (P4). Unit-specific and hospital-wide hospital-acquired central-line-associated bloodstream infection (HA-CLABSI) rates and blood culture contamination (BCC) with coagulase negative staphylococci (CONS) were measured.

RESULTS

Implementation of a passive disinfection cap resulted in a 34% decrease in hospital-wide HA-CLABSI rates (combined P1 and P2 baseline rate of 2.66-1.75 per 1,000 catheter days at the end of the study period). This reduction occurred only among high-risk patients and not among general oncology patients. In addition, the use of the passive disinfection cap resulted in decreases of 63% (HRUs) and 51% (general oncology units) in blood culture contamination, with an estimated reduction of 242 BCCs with CONS. The reductions in HA-CLABSI and BCC correspond to an estimated annual savings of $3.2 million in direct medical costs.

CONCLUSION

Routine use of disinfection caps is associated with decreased HA-CLABSI rates among high-risk hematology oncology patients and a reduction in blood culture contamination among all oncology patients.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review

Background. Needleless connectors (NC) are used on virtually all intravascular devices, providing an easy access point for infusion connection. Colonization of NC is considered the cause of 50% of postinsertion catheter-related infections. Breaks in aseptic technique, from failure to disinfect, result in contamination and subsequent biofilm formation within NC and catheters increasing the potential for infection of central and peripheral catheters. Methods. This systematic review evaluated 140 studies and 34 abstracts on NC disinfection practices, the impact of hub contamination on infection, and measures of education and compliance. Results. The greatest risk for contamination of the catheter after insertion is the NC with 33-45% contaminated, and compliance with disinfection as low as 10%. The optimal technique or disinfection time has not been identified, although scrubbing with 70% alcohol for 5-60 seconds is recommended. Studies have reported statistically significant results in infection reduction when passive alcohol disinfection caps are used (48-86% reduction). Clinical Implications. It is critical for healthcare facilities and clinicians to take responsibility for compliance with basic principles of asepsis compliance, to involve frontline staff in strategies, to facilitate education that promotes understanding of the consequences of failure, and to comply with the standard of care for hub disinfection.

The prevention, diagnosis and management of central venous line infections in children

With advancing paediatric healthcare, the use of central venous lines has become a fundamental part of management of neonates and children. Uses include haemodynamic monitoring and the delivery of lifesaving treatments such as intravenous fluids, blood products, antibiotics, chemotherapy, haemodialysis and total parenteral nutrition (TPN). Despite preventative measures, central venous catheter-related infections are common, with rates of 0.5-2.8/1000 catheter days in children and 0.6-2.5/1000 catheter days in neonates. Central line infections in children are associated with increased mortality, increased length of hospital and intensive care unit stay, treatment interruptions, and increased complications. Prevention is paramount, using a variety of measures including tunnelling of long-term devices, chlorhexidine antisepsis, maximum sterile barriers, aseptic non-touch technique, minimal line accessing, and evidence-based care bundles. Diagnosis of central line infections in children is challenging. Available samples are often limited to a single central line blood culture, as clinicians are reluctant to perform painful venepuncture on children with a central, pain-free, access device. With the advancing evidence basis for antibiotic lock therapy for treatment, paediatricians are pushing the boundaries of line retention if safe to do so, due to among other reasons, often limited venous access sites. This review evaluates the available paediatric studies on management of central venous line infections and refers to consensus guidelines such as those of the Infectious Diseases Society of America (IDSA).

Scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec reduced neonatal sepsis

AIM

The aim of this study was to investigate whether scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec could reduce the incidence of neonatal sepsis in a level-three neonatal intensive care unit.

METHODS

We studied the incidence of neonatal sepsis caused by coagulase-negative staphylococci (CoNS) for 16.5 months before the initiative was launched on May 15, 2012 and then for a further 8.5 months after it was introduced. The hub routine was applied to all intravenous catheters.

RESULTS

During the control period before the initiative was launched, there were nine cases of CoNS sepsis compared with no cases after it was introduced, resulting in a decrease in sepsis incidence from 1.5% to 0% with a risk reduction of 1.5% (0.53-2.58%) (p = 0.06). In the preterm infant population, the incidence of sepsis decreased from 3.6% to 0% (1.1-6.0%) (p = 0.11).

CONCLUSION

Scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec seemed to be an efficient way of preventing sepsis caused by CoNS in newborn infants. However, the evidence for the benefits will remain weak until a large randomised trial has been completed.

Impact of universal disinfectant cap implementation on central line-associated bloodstream infections

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) result in increased length of stay, cost, and patient morbidity and mortality. One CLABSI prevention method is disinfection of intravenous access points. The literature suggests that placing disinfectant caps over needleless connectors decreases CLABSI risk.

METHODS

A quasi-experimental intervention study was conducted in a >430-bed trauma I center. In addition to an existing standard central line bundle, a new intervention consisting of a luer-lock disinfectant cap with 70% alcohol was implemented in all intravenous (IV) needleless connectors on patients with peripheral and central lines. Compliance to the disinfectant cap was monitored weekly. A generalized linear model using a Poisson distribution was fit to determine if there were significant relationships between CLABSIs and disinfectant cap use. Impacts on costs were also examined.

RESULTS

The rate of CLABSI decreased following implementation of the disinfectant cap. The incidence rate ratios (.577, P = .004) for implementing the disinfectant caps was statistically significant, indicating that the rate of patient infections decreased by >40%. Increased compliance rates were associated with lower infection rates. Disinfectant cap use was associated with an estimated savings of almost $300,000 per year in the hospital studied.

CONCLUSIONS

Use of a disinfectant cap on IV needleless connectors in addition to an existing standard central line bundle was associated with decreased CLABSI and costs.

Reducing Bloodstream Infection Risk in Central and Peripheral Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection

Background: Although few facilities focus on it, bloodstream infection (BSI) risk from peripheral intravenous catheters (PIVs) may exceed central line-related risk. Over a 6-year period, Methodist Hospitals substantially reduced BSIs in patients with central lines but not in patients with PIVs. A practice audit revealed deficiencies in manual disinfection of intravenous connectors, thereby increasing BSI risk. Methodist thus sought an engineered approach to hub disinfection that would compensate for variations in scrubbing technique.

Methods: Our institution involved bedside nurses in choosing new hub disinfection technology. They selected 2 devices to trial: a disinfection cap that passively disinfects hubs with isopropyl alcohol and a device that friction-scrubs with isopropyl alcohol. After trying both, nurses selected the cap for use in the facility's 3 intensive care units. After no BSIs occurred during a 3-month span, we implemented the cap throughout the hospital for use on central venous catheters; peripherally inserted central catheters; and peripheral lines, including tubing and Y-sites.

Results: Comparing the postintervention period (December 2011-August 2013) to the preintervention span (September 2009–May 2011), the BSI rate dropped 43% for PIVs, 50% for central lines, and 45% overall (PIVs + central lines). The central line and overall results are statistically significant. The PIV BSI rate drop is attributable to cap use alone because the cap was the only new intervention during the postimplementation period. The other infection reductions appear to be at least partly due to cap use.

Conclusions: Our institution achieved substantial BSI reductions, some statistically significant, by applying a disinfection cap to both PIVs and central lines.

Itemizing the bundle: achieving and maintaining "zero" central line-associated bloodstream infection for over a year in a tertiary care hospital in Saudi Arabia

BACKGROUND

"Zero" central line-associated bloodstream infections (CLABSI) have not been reported from Asian countries, which usually have predominance of difficult to curtail gram negative infections. It also remains unclear whether lowering CLABSI rates below National Healthcare Safety Network (NHSN) benchmarks in such countries is even possible. In this study, we evaluated effects of a quality improvement initiative to achieve "Zero CLABSI" in our intensive care unit.

METHODS

A root cause analysis in February 2010 identified problems with clinical practice, environment, and products. Extensive education sessions were followed by implementation of strategies in the form of "itemized" bundles derived from practice guidelines, with complete enforcement starting August 2010. Results were benchmarked against NHSN data. Data were analyzed in a preintervention (1 year) and postintervention (2 years) fashion, using Poisson regression analysis to generate incidence-rate ratio (IRR).

RESULTS

In the preintervention period, CLABSI rate was 6.9/1,000 catheter-days (CDs) (35 CLABSI/5,083 CDs). In the postintervention year 1, rate was 1.06/1,000 CDs (4 CLABSI/3,787 CDs) with IRR of 0.15 (95% confidence interval: 0.04-0.44, P < .001) and reduction of 85%. In postintervention year 2, rate was 0.35/1,000 CDs (1/2,860 CDs) with IRR of 0.05 (95% confidence interval: 0.001-0.31, P < .001). There was a period of "Zero CLABSI" for 15 consecutive months, surpassing NHSN benchmarks.

CONCLUSION

CLABSIs can be eliminated in any intensive care unit regardless of the location and type of organism. NHSN data should be a realistic CLABSI benchmarking target for developing countries.