The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping

Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Catheter-related bloodstream infection

Catheter-related bloodstream infections (CR-BSIs) are a common, frequently preventable complication of central venous catheterization. CR-BSIs can be prevented by strict attention to insertion and maintenance of central venous catheters and removing unneeded catheters as soon as possible. Antiseptic- or antibiotic-impregnated catheters are also an effective tool to prevent infections. The diagnosis of CR-BSI is made largely based on culture results. CR-BSIs should always be treated with antibiotics, and except in rare circumstances the infected catheter needs to be removed.

Influence of tracheostomy on the incidence of central venous catheter-related bacteremia

Although there are many studies on catheter-related infection, there are scarce data about the influence of tracheostomy in the incidence of central venous catheter-related bacteremia (CRB). In this cohort study, we found a higher incidence of CRB in patients with tracheostomy than without (11.25 vs. 1.43 per 1,000 catheter-days; odds ratio [OR] = 7.99; 95% confidence interval [CI] = 4.38-infinite; P < 0.001). Besides, we found a higher incidence of CRB in patients with tracheostomy using the jugular access compared to subclavian access (21.64 vs. 5.11 per 1,000 catheter-days; OR = 4.23; 95% CI = 1.44-infinite; P = 0.0097).

Strategies to prevent central line-associated bloodstream infections in acute care hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. 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. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Patients at risk for CLABSIs in acute care facilities

a. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters, the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, arterial catheters), and the fact that catheters are frequently placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods.

b. Non-ICU population: Although the primary focus of attention over the past 2 decades has been the ICU setting, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, where there is a substantial risk of CLABSI.

2. Outcomes associated with hospital-acquired CLABSI

a. Increased length of hospital stay

b. Increased cost; the non-inflation-adjusted attributable cost of CLABSIs has been found to vary from $3,700 to $29,000 per episode

Prevention of catheter-related bloodstream infections

CRBSIs are expensive, prevalent, and often fatal complications. In the past few years, several preventive interventions have been applied with excellent results toward decreasing CRBSIs. Studies show that most CRBSIs are preventable; therefore, health care organizations should strive to substantially reduce if not eliminate them. In addition to being a measure of quality of care, reducing infections will soon be a bottom-line issue, given that the Centers for Medicare and Medicaid Services announced its decision to cease paying hospitals from October 2008 for some care necessitated by "preventable complications", including CRBSIs. Therefore, health care facilities that do not make the necessary adjustments to improve the quality of their patient care and avoid harm may be economically penalized. This article reviews the available evidence on and possible barriers to the widespread use of preventive strategies. The health care community has struggled to build a culture that can eliminate the barriers obstructing high-quality care. These new approaches must facilitate collaboration among caregivers. During the past few years, much effort has been dedicated to researching causes for inadequate patient care and executing interventions to improve processes of care; only now are projects beginning to focus on evaluating whether patients are safer. This article discusses the prevention of CRBSIs and shows that substantial reductions in the rate of these infections are possible. It is no longer acceptable for health care organizations to have the goal of being at the CDC mean for rate of infections; they should strive to substantially reduce or even eliminate them. Patients deserve no less.

The role of nurses working in emergency and critical care environments in the prevention of intravascular catheter-related bloodstream infections

Intravascular catheter-related infections are a major problem in healthcare. This review provides up-to-date guidance of evidence-based recommendations for the prevention of intravascular catheter-related infections with special focus on strategies relevant for nurses working in emergency and critical care environments or practitioners responsible for surveillance and control of infections. The review concludes by providing a range of approaches advocated for: (i) translating guidelines to the needs and expectations of emergency and critical care nurses, and (ii) increasing the chance of successful implementation and compliance with these recommendations.

Models for the histologic study of the skin interface with percutaneous biomaterials

Percutaneous devices are critical for health care. Access to tissue, vessels and internal organs afforded by these devices provides the means to treat and monitor many diseases. Unfortunately, such access is not restricted, and infection may compromise the usefulness of the device and even the life of the patient. New biomaterials offer the possibility of maintaining internal access while limiting microbial access, but understanding of the cutaneous/biomaterial interface and models to study this area are limited. This paper focuses on models useful for studying the morphology and biology of the intersection of skin and percutaneous biomaterials. An organ culture and a mouse model are described that offer promising possibilities for improved understanding of this critical interface.

Central venous catheterization: a prospective, randomized, double-blind study

Central venous catheters (CVCs) are extensively used worldwide. Mechanical, infectious and thrombotic complications are well described with their use and may be associated with prolonged hospitalization, increased medical costs and mortality. CVCs account for an estimated 90% of all catheter-related bloodstream infections (CRBSI) and a host of risk factors for CVC-related infections have been documented. The duration of use of CVCs remains controversial and the length of time such devices can safely be left in place has not been fully and objectively addressed in the critically ill patient. Antimicrobial-impregnated catheters have been introduced in an attempt to limit catheter-related infection (CRI) and increase the time that CVCs can safely be left in situ. Recent meta-analyses concluded that antimicrobial-impregnated CVCs appear to be effective in reducing CRI. The authors conducted a prospective, randomized, double-blind study at Johannesburg Hospital over a 4-year period. The study entailed a comparison of standard triple-lumen versus antimicrobial impregnated CVCs on the rate of CRI. Our aim was to determine whether we could safely increase the duration of catheter insertion time from our standard practice of seven days to 14 days, to assess the influence of the antimicrobial impregnated catheter on the incidence of CRI, and to elucidate the epidemiology and risks of CRI. One hundred and eighteen critically ill patients were included in the study which spanned 34 951.5 catheter hours (3.99 catheter years). It was found that antimicrobial catheters did not provide any significant benefit over standard catheters, which the authors feel can safely be left in place for up to 14 days with appropriate infection control measures. The most common source of CRI was the skin. The administration of parenteral nutrition and the site of catheter insertion (internal jugular vein vs subclavian vein) were not noted to be risk factors for CRI. There was no clinical evidence of thrombotic complication in either of the study groups. This study offers direction for the use of CVCs in critically ill patients and addresses many of the controversies that exist.

Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America

OBJECTIVE

To update the practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit, for the purpose of guiding clinical practice.

PARTICIPANTS

A task force of 11 experts in the disciplines related to critical care medicine and infectious diseases was convened from the membership of the Society of Critical Care Medicine and the Infectious Diseases Society of America. Specialties represented included critical care medicine, surgery, internal medicine, infectious diseases, neurology, and laboratory medicine/microbiology.

EVIDENCE

The task force members provided personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus was obtained. Published literature was reviewed and classified into one of four categories, according to study design and scientific value.

CONSENSUS PROCESS

The task force met twice in person, several times by teleconference, and held multiple e-mail discussions during a 2-yr period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the strength of the recommendation. Draft documents were composed and debated by the task force until consensus was reached by nominal group process.

CONCLUSIONS

The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the intensive care unit should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made.

Catheter-related bacteremia from femoral and central internal jugular venous access

The objective of this prospective observational study was to determine the influence of femoral and central internal jugular venous catheters on the incidence of catheter-related bacteremia (CRB). We included patients admitted to a 12-bed polyvalent medico-surgical intensive care unit over 4 years who received one or more femoral or central internal jugular venous catheters. We diagnosed 16 cases of CRB in 208 femoral catheters and 22 in 515 central internal jugular venous catheters. We found a higher incidence of CRB with femoral (9.52 per 1,000 catheter days) than with central internal jugular venous access (4.83 per 1,000 catheter days; risk ratio = 1.93; 95% confidence interval: 1.03-3.73; P = 0.04). Central internal jugular venous access could be considered a safer route of venous access than femoral access in minimizing the risk of central venous catheter-related bacteremia.

Comparison of complications and procedural activities of pulmonary artery catheter removal by critical care nurses versus medical doctors

BACKGROUND

None of the nursing studies on PA catheter removal pointed out any differences in complications after removal and procedural activities for removal of PA catheter by CCNs vs MDs in Turkey.

AIMS

This quasi-experimental study was conducted to determine the occurrence and type of complications and to indicate the differences between CCNs and medical doctors' (MDs) activities for removal of PA catheter.

METHODS

Totally, 60 critical care unit patients were scheduled as a sample, and they were assigned randomly to the CCN (n = 30) or to the MD (n = 30) groups. For the comparison purposes of the different activities and complications of PA catheter removal procedure between the two groups, 'Instruction Form' was followed step by step. The differences in the prevalence of variables were tested using Student's t statistics. For categorical data, Fisher's exact test was used. Significance was declared by P value of <0.05.

RESULTS

Preprocedural activities like patient positioning (P < 0.001) and instructing the patient for breathing (P = 0.001) demonstrated statistically significant differences between the two groups. The PA catheters were removed properly in both groups (P > 0.05). The majority of postprocedural activities were completed successfully. The complications of the catheter removal were documented more carefully by nurses compared with doctors (P < 0.01). Additionally, singular premature ventricular complexes were observed on electrocardiogram in both groups (P > 0.05).

CONCLUSION

Instructing CCNs to remove a PA catheter has been highlighted in keeping the number of complications associated with removal procedure of PA catheter.

Clinical Performance of a New Transparent Chlorhexidine Gluconate Central Venous Catheter Dressing

As the sciences of vascular access and infection prevention rapidly advance healthcare professionals are often faced with new technologies designed to help, but which are often so complicated to use that they cause unforeseen problems. As a vascular access team at a major mid-western hospital, we evaluated the ease-of-use and the performance characteristics of a new transparent catheter dressing, 3M Tegaderm CHG IV Securement Dressing® (3M Health Care™, St. Paul, MN) containing the antimicrobial chlorhexidine gluconate (CHG), with a variety of central venous catheters insertion sites in comparison to a standard non-antimicrobial dressing Tegaderm® (3M Health Care™, St. Paul, MN). Following IRB approval, sixty-three consenting patients were enrolled and randomized; 33 in the CHG antimicrobial dressing group and 30 in the standard dressing group. Thirty six patients had peripherally inserted central catheters (PICCs), 20 had intrajugular insertions (IJ), and 7 had subclavian insertions. The new 3M Tegaderm CHG IV Securement Dressing® (3M Health Care™, St. Paul, MN) was evaluated for its ability to permit visualization of the insertion site, ease of use, ease of using correctly, ability to secure the catheter and absorb exudates and remain transparent.

The new 3M Tegaderm CHG IV Securement Dressing® (3M Health Care™, St. Paul, MN) was found to be as easy to use in central venous catheter care clinical practice as the standard of care non-antimicrobial transparent adhesive dressing. No additional training or education was required to properly use it. This dressing was applied and removed like standard transparent adhesive dressings, but offered many advantages over standard dressings. Advantages include that it is antimicrobial, handles moderate bleeding, remains transparent and appears to offer greater catheter securement than the Tegaderm® (3M Health Care™, St. Paul, MN) standard dressing. The CHG gel pad also conformed well to the catheter.

Invasive hemodynamic monitoring the aftermath of the ESCAPE trial

The Swan-Ganz catheter was developed 35 to 40 years ago for intensive and cardiac care units to allow bedside placement and continuous monitoring and recording of right-sided heart, pulmonary artery, and wedge pressures and reasonably accurate determinations of cardiac output. Considerations for the clinical application of this balloon-tip, flow-directed, multilumen, thermodilution pulmonary artery catheter in the post-ESCAPE era are presented.

Usefulness of Groshong catheters for central venous access via the external jugular vein

This study was designed to evaluate the usefulness of central venous access via the external jugular vein (EJV) employing Groshong catheters, and to compare the complications with those of conventional internal jugular venous catheterization. Central venous access was achieved by insertion of a single-lumen 4.0 Fr Groshong catheter via the EJV or internal jugular vein (IJV) with a single puncture. Complications associated with insertion and central venous catheter-related bloodstream infection (CVC-RBSI) were evaluated from the database. Two hundred and twenty-five patients received 400 catheters for a total period of 5377 catheter-days. Ninety-six patients underwent 201 internal jugular venous catheter (IJV-C) procedures for 2381 catheter-days, and 129 patients underwent 199 external jugular venous catheter (EJV-C) procedures for 2996 catheter-days. Use of EJV-C was associated with a longer catheter insertion length (p < .01) and period (p < .01), a larger number of operations (p < .01), and more frequent use of total parenteral nutrition (TPN) (p < .01) and less frequent use of chemotherapy (p < .01) than for IJV-C. However, there were no significant differences (NS) in complications associated with insertion and CVC-RBSI between IJV-C and EJV-C. There were no significant differences such complications as malposition, oozing or hematoma formation of insertion site, arterial bleeding, nerve damage, pneumothorax, and phlebitis between IJV-C and EJV-C. Moreover, EJV-C was not associated with morbidities such as pneumothorax, arterial bleeding, and nerve damage. Thus the study concluded that EJV-C using Groshong catheters has no severe complications and has the same rates of CVC-RBSI as conventional IJV-C for central venous access.

The effectiveness of a nurse-initiated intervention to reduce catheter-associated bloodstream infections in an urban acute hospital: An intervention study with before and after comparison

BACKGROUND

Catheter care is considered to be important for prevention of catheter-associated bloodstream infections (CABSIs) although epidemiological evidence is sparse.

OBJECTIVES

To identify problems associated with catheter care and evaluate the effectiveness of nurse-initiated interventions to reduce CABSIs.

DESIGN

An intervention study with before and after comparison.

SETTINGS

CABSI surveillance was conducted in a 560-bed acute hospital located in a major urban area in Japan.

PARTICIPANTS

Patients were enrolled in this study from April 2000 to December 2002 based on the following criteria: (1) adult inpatients; and (2) those in whom central venous lines or Swan-Ganz catheters were inserted for 2 days or longer.

METHODS

In the first year, risk factors for CABSI and problems associated with catheter care were identified by inspection of the infection control nurse (ICN) or four trained link nurses, and the laboratory results. In the subsequent 2 years, the following interventions based on the surveillance results were implemented: (1) enhanced skin preparation by scrubbing with regular bathing soap and tap water; (2) a new method for stabilisation of the catheter inserted into the internal jugular vein, where additional dressing was placed over the sterilised dressing; (3) educating the staff on maximal sterile precautions by teaching staff members at their section meetings and displaying posters; (4) use of a check list and observation of catheter insertion by link nurses to monitor compliance; and (5) selection of a disinfectant that requires shorter contact time and has longer residual effect.

RESULTS

After these interventions were implemented, the overall bloodstream infection (BSI) rate declined from 4.0/1000 device-days to 1.1/1000 device-days (p<0.005).

CONCLUSIONS

We identified four problems-those related to skin preparation, dressing, sterile precautions and disinfectant. We implemented a series of interventions to reduce CABSIs; the overall CABSI rate decreased significantly.

Intravascular catheter-related infections: advances in diagnosis, prevention, and management

Indwelling vascular catheters are a leading source of bloodstream infections in critically ill patients and cancer patients. Because clinical diagnostic criteria are either insensitive or non-specific, such infections are often overdiagnosed, resulting in unnecessary and wasteful removal of the catheter. Catheter-sparing diagnostic methods, such as differential quantitative blood cultures and time to positivity have emerged as reliable diagnostic techniques. Novel preventive strategies include cutaneous antisepsis, maximum sterile barrier, use of antimicrobial catheters, and antimicrobial catheter lock solution. Management of catheter-related bloodstream infections involves deciding on catheter removal, antimicrobial catheter lock solution, and the type and duration of systemic antimicrobial therapy. Such decisions depend on the identity of the organism causing the bloodstream infection, the clinical and radiographical manifestations suggesting a complicated course, the underlying condition of the host (neutropenia, thrombocytopenia), and the availability of other vascular access sites.

Guidelines on the insertion and management of central venous access devices in adults

Central venous access devices are used in many branched of medicine where venous access is required for either long-term or a short-term care. These guidelines review the types of access devices available and make a number of major recommendations. Their respective advantages and disadvantages in various clinical settings are outlined. Patient care prior to, and immediately following insertion is discussed in the context of possible complications and how these are best avoided. There is a section addressing long-term care of in-dwelling devices. Techniques of insertion and removal are reviewed and management of the problems which are most likely to occur following insertion including infection, misplacement and thrombosis are discussed. Care of patients with coagulopathies is addressed and there is a section addressing catheter-related problems.

Prevention of catheter-related blood stream infection

PURPOSE OF REVIEW

Catheter-related blood stream infections are a morbid complication of central venous catheters. This review will highlight a comprehensive approach demonstrated to prevent catheter-related blood stream infections.

RECENT FINDINGS

Elements of prevention important to inserting a central venous catheter include proper hand hygiene, use of full barrier precautions, appropriate skin preparation with 2% chlorhexidine, and using the subclavian vein as the preferred anatomic site. Rigorous attention needs to be given to dressing care, and there should be daily assessment of the need for central venous catheters, with prompt removal as soon as is practicable. Healthcare workers should be educated routinely on methods to prevent catheter-related blood stream infections. If rates remain higher than benchmark levels despite proper bedside practice, antiseptic or antibiotic-impregnated catheters can also prevent infections effectively. A recent program utilizing these practices in 103 ICUs in Michigan resulted in a 66% decrease in infection rates.

SUMMARY

There is increasing recognition that a comprehensive strategy to prevent catheter-related blood stream infections can prevent most infections, if not all. This suggests that thousands of infections can potentially be averted if the simple practices outlined herein are followed.

Evidence-based review of the use of the pulmonary artery catheter: impact data and complications

The pulmonary artery catheter (PAC) was introduced in 1971 for the assessment of heart function at the bedside. Since then it has generated much enthusiasm and controversy regarding the benefits and potential harms caused by this invasive form of hemodynamic monitoring. This review discusses all clinical studies conducted during the past 30 years, in intensive care unit settings or post mortem, on the impact of the PAC on outcomes and complications resulting from the procedure. Although most of the historical observational studies and randomized clinical trials also looked at PAC-related complications among their end-points, we opted to review the data under two main topics: the impact of PAC on clinical outcomes and cost-effectiveness, and the major complications related to the use of the PAC.

Utility of impedance cardiography for dyspneic patients in the ED

BACKGROUND

Dyspnea is one of the most common emergency department (ED) symptoms, but early diagnosis and treatment are challenging because of multiple potential causes. Hemodynamic parameters may aid in the evaluation of dyspnea, but are difficult to assess. Impedance cardiography is a noninvasive hemodynamic measurement method that may assist in early ED decision making.

METHODS

This study is intended to determine the accuracy in differentiating cardiac from noncardiac causes of dyspnea using impedance cardiography-derived hemodynamic parameters compared to ED physician opinion in light of initial history, and physical and laboratory tests. The final diagnosis, made after patient hospital record review, was compared with ED physician and impedance cardiography diagnoses.

RESULTS

A total of 52 patients were included: 14 women and 38 men, aged 68.5 +/- 14.2 years. There were significant differences in values of stroke index (25.7 vs 32.9, P < .05), cardiac index (2.3 vs 3.1, P < .0001), velocity index (35.1 vs 53.2, P < .01), and systolic time ratio (0.55 vs 0.44, P < .05) between the cardiac and noncardiac groups, respectively. Impedance cardiography measurements demonstrated better sensitivity (75% vs 60%), specificity (88% vs 66%), and positive and negative predictive values (79% vs 52% and 85% vs 72%, respectively) compared with those of the ED physician in distinguishing cardiac from noncardiac causes of dyspnea.

CONCLUSION

Impedance cardiography data result in improvement in ED physician differentiation of cardiac from noncardiac causes of dyspnea.

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Efficacy and safety of a two-step method of skin preparation for peripheral intravenous catheter insertion: a prospective multi-centre randomised trial

We have developed a two-step procedure for preparing the skin before peripheral venous catheter (PVC) insertions. This procedure involves two successive swabbings with wipes soaked in alcoholic antiseptic. We investigated whether this two-step procedure was as effective and safe as the standard four-step procedure--washing with detergent, rinsing, drying, applying antiseptic--by carrying out a multicentre randomised equivalence study comparing the frequency of precursor signs of infection at the site of insertion for the two skin preparation procedures. The study was carried out over an eight-month period, and 248 PVC insertion sites were evaluated. The two-step procedure was used for 130 subjects and the standard procedure for 118. Taking into account all the confounding factors predisposing patients to the complications studied, the characteristics of the two groups of patients were found to be similar, with no significant differences noted. The incidence of precursor signs of infection was 11% 24 hours after PVC insertion (27/248), 25% at 48 hours (50/203) and at 29% at 72 hours (34/119). Eleven patients had complications necessitating the withdrawal of the PVC: sensitivity of the insertion site, with redness and/or slight swelling and/or a palpable venous cord. No major complications were observed in this study. The frequency of local complications associated with PVCs reported in this study, whether simple or severe, was not affected by the skin preparation procedure used for PVC insertion (two-step or four-step procedure).

Characterization of an in vitro model for evaluating the interface between skin and percutaneous biomaterials

Percutaneous devices play an essential role in medicine; however, they are often associated with a significant risk of infection. One approach to circumvent infection would be to heal the wound around the devices by promoting skin cell attachment. We used two in vitro assay models to evaluate cutaneous response to poly(2-hydoxyethyl methacrylate) (poly(HEMA)). One approach was to use a cell adhesion assay to test the effects of surface modification of poly(HEMA), and the second used an organ culture system of newborn foreskin biopsies implanted with porous poly(HEMA) rods (20 microm pores) to evaluate the skin/poly(HEMA) interface. Surface modification of poly(HEMA) using 1,1'-carbonyldiimidazole (CDI) enhanced keratinocyte, fibroblast, and endothelial cell adhesion. Keratinocytes in the organ culture model not only remained functionally and structurally viable as observed by immunohistochemistry and electron microscopy, but migrated into the pores of CDI-modified poly(HEMA) rods. No biointegration was seen in the non-CDI-modified poly(HEMA). Laminin 5 immunostaining was seen along the poly(HEMA)/skin interface in a pattern resembling the junctional epithelium of the tooth, the unique natural interface between the skin and tooth that serves as a barrier to bacteria. In vitro systematic evaluation of biomaterials for use in animal implant studies is both cost effective and time efficient.

Guidelines for the validation and application of typing methods for use in bacterial epidemiology

For bacterial typing to be useful, the development, validation and appropriate application of typing methods must follow unified criteria. Over a decade ago, ESGEM, the ESCMID (Europen Society for Clinical Microbiology and Infectious Diseases) Study Group on Epidemiological Markers, produced guidelines for optimal use and quality assessment of the then most frequently used typing procedures. We present here an update of these guidelines, taking into account the spectacular increase in the number and quality of typing methods made available over the past decade. Newer and older, phenotypic and genotypic methods for typing of all clinically relevant bacterial species are described according to their principles, advantages and disadvantages. Criteria for their evaluation and application and the interpretation of their results are proposed. Finally, the issues of reporting, standardisation, quality assessment and international networks are discussed. It must be emphasised that typing results can never stand alone and need to be interpreted in the context of all available epidemiological, clinical and demographical data relating to the infectious disease under investigation. A strategic effort on the part of all workers in the field is thus mandatory to combat emerging infectious diseases, as is financial support from national and international granting bodies and health authorities.

Prospective cohort study of central venous catheters among internal medicine ward patients

BACKGROUND

Central venous catheter (CVC) use is less well described for patients outside the intensive care unit. We evaluated CVCs and the associated bloodstream infection rate among patients admitted to the general medical service.

METHODS

We performed a prospective cohort study of patients who had a CVC on admission or inserted during their stay on the general medical service in a public teaching hospital, November 15, 2004, to March 31, 2005.

RESULTS

We identified 106 CVCs, 52 were present on admission and 54 were inserted; there were 682 catheter-days. The primary bloodstream infection rate was 4.4 per 1000 catheter-days (95% CI: 0.9-13): highest for catheters inserted in the emergency department compared with those inserted on other units (24 vs 1.7 per 1000 catheter-days), P = .045. By multivariable analysis, inadequate dressings were more likely among patients with a body mass index > or =30 kg/m(2), adjusted odds ratio, 3.4 (95% CI: 1.4-8.0).

CONCLUSIONS

Many CVCs had previously been inserted in the emergency department or intensive care unit; therefore, strategies to reduce bloodstream infections that focus on ward insertion practices may not dramatically reduce bloodstream infection rates. Intervention strategies should target improved dressing care and consideration of early removal or replacement of catheters inserted in the emergency department.

Translating evidence into practice to prevent central venous catheter-associated bloodstream infections: a systems-based intervention

BACKGROUND

The central venous catheter (CVC) is a necessary, yet inherently risky, modern medical device. We aimed to carry out a systems-based intervention designed to facilitate the use of maximal sterile barrier precautions and the use of chlorhexidine for skin antisepsis during insertion of CVC.

METHODS

All patients in whom a CVC was inserted at a medical-surgical intensive care unit at a university-affiliated public hospital were included in a before-after trial. The standard CVC kit in routine use before the intervention included a small sterile drape (24" by 36") and 10% povidone-iodine for skin antisepsis. We special ordered a customized kit that, instead, included a large sterile drape (41" by 55") and 2% chlorhexidine gluconate in 70% isopropyl alcohol. Both the standard kit in use before the intervention and the customized kit included identical CVCs. Baseline data included the quarterly CVC-associated bloodstream infection (BSI) rates during the 15 months before the intervention. Comparison data included the quarterly CVC-associated BSI rates during the 15 months after we instituted exclusive use of the customized kit.

RESULTS

The mean quarterly CVC-associated BSI rate decreased from a baseline of 11.3 per 1000 CVC-days before the intervention to 3.7 per 1000 CVC-days after the intervention (P < .01). Assuming direct costs of at least 10,000 dollars per CVC-associated BSI, we calculated resultant annualized savings to the hospital of approximately 350,000 dollars.

CONCLUSION

Infection control interventions that rely on voluntary changes in human behavior, despite the best intentions of us all, are often unsuccessful. We have demonstrated that a systems-based intervention led to a sustained decrease in the CVC-associated BSI rate, thereby resulting in improved patient safety and decreased cost of care.

The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies

OBJECTIVE

To better understand the absolute and relative risks of bloodstream Infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults In which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI.

METHODS

English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremla [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream Infection AND the specific type of intravascular device (e.g., central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days.

RESULTS

Point incidence rates of IVD-related BSI were lowest with peripheral Intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the Intensive care unit. Surgically implanted long-term central venous devices--cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)--appear to have high rates of Infection when risk Is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

CONCLUSIONS

Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies In which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs In use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related Infection have focused on short-term noncuffed CVCs used in Intensive care units, Infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

Pulmonary artery catheters for adult patients in intensive care

BACKGROUND

Pulmonary artery catheterization was adopted about 30 years ago and widely disseminated without rigorous evaluation as to whether it benefited critically ill patients. The technique is used to measure cardiac output and pressures in the pulmonary circulation to guide diagnosis and treatment. Clinicians believe these data can improve patients' outcomes, even in the absence of consensus about the specific interpretation of the data.

OBJECTIVES

To assess the effect of pulmonary artery catheterization on mortality and cost of care in adult intensive care patients.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2006); MEDLINE (all records to April 2006); EMBASE (all records to April 2006); CINAHL (all records to April 2006) and reference lists of articles. We contacted manufacturers and researchers in the field.

SELECTION CRITERIA

We included all randomized controlled trials in adults, comparing management with and without a pulmonary artery catheter (PAC).

DATA COLLECTION AND ANALYSIS

We screened the titles and abstracts of the electronic search results and obtained the full text of studies of possible relevance for independent review. We determined the final results of the literature search by consensus between the authors. We did not contact study authors for additional information.

MAIN RESULTS

We identified 12 studies. Mortality was reported as hospital, 28-day, 30-day, or intensive care unit. We considered studies of high-risk surgery patients (eight studies) and general intensive care patients (four studies) separately for the meta-analysis. The pooled odds ratio for the studies of general intensive care patients was 1.05 (95% confidence interval (CI) 0.87 to 1.26) and for the studies of high-risk surgery patients 0.99 (95% CI 0.73 to 1.24). Of the eight studies of high-risk surgery patients, five evaluated the effectiveness of pre-operative optimization but there was no difference in mortality when these studies were examined separately. Pulmonary artery catheterization did not affect intensive care unit (reported by 10 studies) or hospital (reported by nine studies) length of stay. Four studies, conducted in the United States, measured costs based on hospital charges billed to patients, which on average were higher in the PAC groups.

AUTHORS' CONCLUSIONS

To date, there have been two multi-centre trials of the effectiveness of PACs for managing critically ill patients admitted to intensive care, although only one was adequately powered. Efficacy studies are needed to determine optimal management protocols and patient groups who could benefit from management with a PAC.

A multicenter intervention to prevent catheter-associated bloodstream infections

BACKGROUND

Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited.

OBJECTIVE

To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections.

DESIGN

An observational study with a planned intervention.

SETTING

Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers.

PATIENTS

Patients admitted during the study period.

INTERVENTION

Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care.

MEASUREMENTS

Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of nontunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection.

RESULTS

Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units.

CONCLUSIONS

An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

Patient education—a strategy for prevention of infections caused by permanent central venous catheters in patients with haematological malignancies: a randomized clinical trial

A functioning tunnelled central venous catheter (CVC) is a crucial device for patients with haematological malignancies receiving high-dose intravenous chemotherapy. Despite the advantages, CVC infections are a major cause of sepsis and prolonged hospital stay. This study investigated the impact of patient education regarding provision of their own catheter care on the frequency of CVC-related infections (CRIs) and was conducted at a specialized haematological unit at the University Hospital of Copenhagen Rigshospitalet. From May to September 2002, 82 patients fitted with tunnelled double-lumen Hickman catheters were randomized consecutively. The intervention group (42 participants) received individualized training and supervision by a clinical nurse specialist, with the aim of becoming independently responsible for their own catheter care. The control group (40 participants) followed the standard CVC procedures carried out by nurses inside and outside the central hospital. A significant reduction in CRIs was found in the intervention group, with a >50% reduction in the incidence rate of CRIs. We conclude that systematic individualized, supervised patient education is able to reduce catheter-related infections.

Hygienemaßnahmen auf Intensivstationen

BACKGROUND

Aim of this study was to determine to what extent evidence-based infection control recommendations are applied in German intensive care units (ICUs).

METHODS

A questionnaire concerning handling of tubes, central vascular catheters (CVC), urinary tract catheters and methicillin-resistant Staphylococcus aureus (MRSA) positive patients was sent to 230 participants of the German Nosocomial Infection Surveillance System (KISS).

RESULTS

Nasal intubation is routinely performed in 9% of ICUs, all recommended measures for CVC insertion were obeyed by 43% of ICUs and one-third of ICUs conduct regular screening of urine in catheterized patients. Urinary tract catheters are replaced at defined time intervals in 37% of ICUs. MRSA positive patients are not isolated in 5% of ICUs. MRSA screening on admission is not performed for high risk patients in 16% of ICUs.

CONCLUSIONS

There are still many German ICUs in which evidence-based recommendations are not implemented. Training of staff is necessary to improve quality of patient care.

Central venous catheter-related infection in a prospective and observational study of 2,595 catheters

Introduction

Central venous catheterization is commonly used in critically ill patients and may cause different complications, including infection. Although there are many studies about CVC-related infection, very few have analyzed it in detail. The objective of this study was to analyze the incidence of catheter-related local infection (CRLI) and catheter-related bloodstream infection (CRBSI) with central venous catheters (CVCs) according to different access sites.

Methods

This is a prospective and observational study, conducted in a 24-bed medical surgical intensive care unit of a 650-bed university hospital. All consecutive patients admitted to the ICU during 3 years (1 May 2000 and 30 April 2003) were included.

Results

The study included 2,018 patients. The number of CVCs and days of catheterization duration were: global, 2,595 and 18,999; subclavian, 917 and 8,239; jugular, 1,390 and 8,361; femoral, 288 and 2,399. CRLI incidence density was statistically higher for femoral than for jugular (15.83 versus 7.65, p < 0.001) and subclavian (15.83 versus 1.57, p < 0.001) accesses, and higher for jugular than for subclavian access (7.65 versus 1.57, p < 0.001). CRBSI incidence density was statistically higher for femoral than for jugular (8.34 versus 2.99, p = 0.002) and subclavian (8.34 versus 0.97, p < 0.001) accesses, and higher for jugular than for subclavian access (2.99 versus 0.97, p = 0.005).

Conclusion

Our results suggest that the order for punction, to minimize the CVC-related infection risk, should be subclavian (first order), jugular (second order) and femoral vein (third order).

A vancomycin-heparin lock solution for prevention of nosocomial bloodstream infection in critically ill neonates with peripherally inserted central venous catheters: a prospective, randomized trial

OBJECTIVE

Critically ill neonates are at high risk for vascular catheter-related bloodstream infection (CRBSI), most often caused by coagulase-negative staphylococci. Most CRBSIs with long-term devices derive from intraluminal contaminants. The objective of this study was to ascertain the safety and the efficacy of a vancomycin-heparin lock solution for prevention of CRBSI.

METHODS

A prospective, randomized double-blind trial was conducted during 2000-2001 at a community hospital level III NICU. Very low birth weight and other critically ill neonates with a newly placed peripherally inserted central venous catheter were randomized to have the catheter locked 2 or 3 times daily for 20 or 60 minutes with heparinized normal saline (n = 43) or heparinized saline that contained vancomycin 25 microg/mL (n = 42). The origin of each nosocomial bloodstream infection (BSI) was studied by culturing skin, catheter hubs, and implanted catheter segments and blood cultures, demonstrating concordance by restriction-fragment DNA subtyping. Surveillance axillary and rectal cultures were performed to detect colonization by vancomycin-resistant organisms. The main outcome measures were (1) CRBSIs and (2) colonization or infection by vancomycin-resistant Gram-positive bacteria.

RESULTS

Two (5%) of 42 infants in the vancomycin-lock group developed a CRBSI as compared with 13 (30%) of 43 in the control group (2.3 vs 17.8 per 1000 catheter days; relative risk: 0.13; 95% confidence interval: 0.01-0.57). No vancomycin-resistant enterococci or staphylococci were recovered from any cultures. Vancomycin could not be detected in the blood of infants who did not receive systemic vancomycin therapy. Twenty-six neonates (8 vancomycin-lock group, 18 control group) had at the end of a catheter-lock period asymptomatic hypoglycemia that resolved promptly when glucose-containing intravenous fluids were restarted.

CONCLUSIONS

Prophylactic use of a vancomycin-heparin lock solution markedly reduced the incidence of CRBSI in high-risk neonates with long-term central catheters and did not promote vancomycin resistance but was associated with asymptomatic hypoglycemia. The use of an anti-infective lock solution for prevention of CRBSI with long-term intravascular devices has achieved proof of principle and warrants selective application in clinical practice.

Perforation of the right ventricle by a pulmonary artery catheter that continues to measure cardiac output and mixed venous saturation

During urgent cardiopulmonary bypass for acute myocardial infarction, a pulmonary artery (PA) catheter was inserted in an 81-year-old male patient for monitoring of cardiopulmonary function. The presence of the PA catheter in the right pericardium was noted by the cardiothoracic surgeon during surgery. In retrospect, the malposition of the catheter in the pericardium could be clearly seen in the routine intraoperative transesophageal echocardiogram. The presence of a PA pressure waveform and the ability to measure cardiac output and mixed venous oxygen saturation from the PA catheter does not exclude the possibility that it could still be perforating the right ventricle.