Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study

[Sterile film as a barrier method in central venous catheter placement]

Sepsis related to central venous catheter (CVC) is an important reason of nosocomial infection in which most of the causal microorganisms are originated in the patient's skin. This study aims to evaluate the efficiency of a sterile film as a method of antimicrobial barrier in the placement of CVC. We have studied the infection incidence and the number of days of the catheter placement in two groups, one experimental group in which the CVC was inserted through a sterile adherent film and another group in which the CVC was inserted according to the current hospital protocol. This is a randomized experimental quantitative study in the setting of an Intensive Care Unit (ICU) of the Bellvitge University Hospital. Our study sample was made up of 100 critical patients. The effectiveness of this film was measured by controlling the infection incidence in the different groups, using a point of insertion smear, culture of the catheter tip and blood cultures after withdrawal. The results were interpreted according to the criteria of the ICACC (Interscience Conference on Antimicrobial Agents and Chemotherapy). A decrease of the percentage of positive smears (12.3%), positive tops of catheter (6.1%) and bacteriemia related to the catheter (8.9%) with the use of the barrier method has been demonstrated. We conclude that using the polyethylene hypoallergenic sterile adherent film is an effective antimicrobial barrier method in insertion of the CVC.

[Impact on morbidity and costs of methicillin-resistant Staphylococcus aureus nosocomial pneumonia in intensive care patients]

OBJECTIVES

Prevention of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections in the intensive care units (ICU) has been recommended for several years. However, the workload and the costs of these programs are to be weighed against the benefit obtained in terms of reduction of morbidity and costs induced by the infection. The purpose of this study was to evaluate the cost and the current morbidity of the infection with MRSA in the ICU.

METHODS

In a retrospective case-control study carried out in 2004, all patients of the 6 intensive care units of a teaching hospital having developed a MRSA nosocomial infection were included. They were paired with controls on the following criteria: department, Simplified Acute Physiology Score II (SAPSII), age (+/- 5 years), type of surgery (for the surgical intensive care units). The duration of hospitalization of the paired control had to be at least equal to the time from admission to infection of the infected patient. The costs were evaluated using the following parameters: scores omega 1, 2 and 3, duration of artificial ventilation, hemodialysis, length of ICU stay, radiological procedures, surgical procedures, total antibiotic cost and other expensive drugs.

RESULTS

Twenty-one patients with MRSA infection were included. All had nosocomial pneumonia. The 21 paired patients were similar with regard to both initial criteria and sex. Hospital mortality was not different between the 2 groups (cases=8; controls=6; p=0.41), as well as median duration of hospital stay (cases=41 days; controls=43 days; p=0.9). The duration of mechanical ventilation, number of hemodialysis or hemofiltration sessions, number of radiological procedures were similar in both groups. The total omega score was not significantly different between cases (median 435; IQR: 218-579) and controls (median 281, IQR: 231-419; p=0.55). The median duration of isolation was 12 days for cases and 0 day for controls (p=0.0007). The pharmaceutical expenditure was significantly higher in cases (median: 1414euro; IQR: 795-4349), by comparison with the controls (median: 877euro, IQR: 687-2496) (p=0.049).

CONCLUSION

In the ICU having set up a policy intended to reduce the risk of MRSA nosocomial infections, MRSA pneumonia does not seem to involve major additional morbidity, as compared to a control population matched for similar severity of illness. It increases modestly the use of the medical resources.

Empiric therapy for intravenous central line infections and nosocomially-acquired acute bacterial endocarditis

Intravascular catheters are essential devices in the intensive care unit, yet catheter-related bloodstream infections (CR-BSI) are associated with increased morbidity and mortality, prolonged hospitalization, and increased medical costs. Management of a CR-BSI requires antibiotics, with or without catheter removal, depending on patient and etiologic factors. Because of the high frequency of staphylococcal infections, it is wise to use a glycopeptide empirically. Extra coverage for Gram-negative bacilli should be administered in severely ill or immunocompromised patients. Once culture and sensitivity results are known, antibiotic therapy can be more selective.

Mortality associated with bloodstream infection after coronary artery bypass surgery

BACKGROUND

Mortality attributable to bloodstream infection (BSI) is still controversial. We studied the impact of BSI on mortality after coronary artery bypass surgery, including the specific impact of different etiologic organisms.

METHODS

Our cohort consisted of 4515 patients who underwent coronary artery bypass procedures at a university hospital from 1996 through 2004. We used Society of Thoracic Surgery data supplemented with laboratory and infection control data. Mortality dates were identified using Society of Thoracic Surgery data and the Social Security Death Index. BSI within 90 days after surgery was defined by a positive blood culture result. Cox proportional hazards and propensity score models were used to analyze the association between BSI and mortality.

RESULTS

Patients with BSI had a 4.2-fold increased risk of death (95% confidence interval [CI], 3.0-5.9) 2-90 days after coronary artery bypass surgery, compared with uninfected patients. The risk of death was higher among patients with BSI due to gram-negative bacteria (hazard ratio [HR], 6.8; 95% CI, 3.9-12.0) and BSI due to Staphylococcus aureus (HR, 7.2; 95% CI, 3.3-15.7) and lowest among patients with BSI caused by gram-positive bacteria other than S. aureus (HR, 2.2; 95% CI, 1.1-4.6). The risk of death was highest among patients who developed BSI but had the lowest likelihood of infection (HR, 10.0; 95% CI, 3.5-28.8) and was lowest among patients who developed BSI but had the highest likelihood of infection (HR, 2.3; 95% CI, 1.2-4.6).

CONCLUSIONS

BSIs due to gram-negative bacteria and BSIs due to S. aureus contributed significantly to mortality. Mortality attributable to BSI was highest among patients predicted to be least likely to develop infection and was lowest among severely ill patients who were most likely to develop infection. BSI appears to be an important contributor to death after coronary artery bypass surgery, particularly among the healthiest patients.

A systematic review comparing the relative effectiveness of antimicrobial-coated catheters in intensive care units

BACKGROUND

Bloodstream infection related to a central venous catheter is a substantial clinical and economic problem. To develop policy for managing the risks of these infections, all available evidence for prevention strategies should be synthesized and understood.

METHODS

We evaluate evidence (1985-2006) for short-term antimicrobial-coated central venous catheters in lowering rates of catheter-related bloodstream infection (CRBSI) in the adult intensive care unit. Evidence was appraised for inclusion against predefined criteria. Data extraction was by 2 independent reviewers. Thirty-four studies were included in the review. Antiseptic, antibiotic, and heparin-coated catheters were compared with uncoated catheters and one another. Metaanalysis was used to generate summary relative risks for CRBSI and catheter colonization by antimicrobial coating.

RESULTS

Externally impregnated chlorhexidine/silver sulfadiazine catheters reduce risk of CRBSI relative to uncoated catheters (RR, 0.66; 95% CI: 0.47-0.93). Minocycline and rifampicin-coated catheters are significantly more effective relative to CHG/SSD catheters (RR, 0.12; 95% CI: 0.02-0.67). The new generation chlorhexidine/silver sulfadiazine catheters and silver, platinum, and carbon-coated catheters showed nonsignificant reductions in risk of CRBSI compared with uncoated catheters.

CONCLUSION

Two decades of evidence describe the effectiveness of antimicrobial catheters in preventing CRBSI and provide useful information about which catheters are most effective. Questions surrounding their routine use will require supplementation of this trial evidence with information from more diverse sources.

Impact of multiresistance of gram-negative bacteria in bloodstream infection on mortality rates and length of stay

BACKGROUND

Bloodstream infections (BSI) with gram-negative bacteria (GNB) are one of the most serious infections in the hospital setting, a situation compounded by the increasing antibiotic resistance of gram-negative bacteria causing BSI. The aim of the study was to assess the impact of antibiotic multiresistance of GNB in BSI on mortality rates and length of stay (LOS).

MATERIALS AND METHODS

The setting was the University Hospital Aachen, a 1,500-bed tertiary-care hospital with over 100 ICU beds providing maximal medical care in all disciplines. We performed a 5-year hospital-wide matched cohort study (January 1996 to February 2001) in which 71 cases and 99 controls were enrolled. Matching criteria were sex, age and GNB isolated in blood cultures. Multiresistance was defined as resistance against at least two different classes of antibiotics such as penicillins (+beta-lactamase-inhibitor), third-generation cephalosporins, fluoroquinolones or carbapenems.

RESULTS

BSI were mainly nosocomially acquired, and cases of BSI with multiresistant bacteria were associated with a higher mortality (p=0.0418) and a prolonged LOS in the intensive care unit (ICU) (p=0.0049). Risk factors for BSI with multiresistant GNB were antibiotic treatment (p=0.0191) and mechanical ventilation (p=0.0283).

CONCLUSION

Multiresistance of GNB causing BSI was associated with higher mortality rates and longer LOS in ICU. The initial antibiotic therapy was significantly more often inadequate and might have had an impact on overall mortality. Thus, an effective strategy to administer an appropriate initial empirical antibiotic therapy, especially in patients with risk factors, must be sought. Moreover, the overall usage of antimicrobials must be limited and infection control guidelines should be followed to reduce the emergence and transmission of multiresistant GNB.

A Simulation-Based Evaluation of Methods to Estimate the Impact of an Adverse Event on Hospital Length of Stay

INTRODUCTION

We used agent-based simulation to examine the problem of time-varying confounding when estimating the effect of an adverse event on hospital length of stay. Conventional analytic methods were compared with inverse probability weighting (IPW).

METHODS

A cohort of hospitalized patients, at risk for experiencing an adverse event, was simulated. Synthetic individuals were assigned a severity of illness score on admission. The score varied during hospitalization according to an autoregressive equation. A linear relationship between severity of illness and the logarithm of the discharge rate was assumed. Depending on the model conditions, adverse event status was influenced by prior severity of illness and, in turn, influenced subsequent severity. Conditions were varied to represent different levels of confounding and categories of effect. The simulation output was analyzed by Cox proportional hazards regression and by a weighted regression analysis, using the method of IPW. The magnitude of bias was calculated for each method of analysis.

RESULTS

Estimates of the population causal hazard ratio based on IPW were consistently unbiased across a range of conditions. In contrast, hazard ratio estimates generated by Cox proportional hazards regression demonstrated substantial bias when severity of illness was both a time-varying confounder and intermediate variable. The direction and magnitude of bias depended on how severity of illness was incorporated into the Cox regression model.

CONCLUSIONS

In this simulation study, IPW exhibited less bias than conventional regression methods when used to analyze the impact of adverse event status on hospital length of stay.

Prevention of catheter-related venous thrombosis with nadroparin in patients receiving chemotherapy for hematologic malignancies: a randomized, placebo-controlled study

BACKGROUND

Hemato-oncology patients treated with intensive chemotherapy usually require the placement of a central venous catheter (CVC). CVCs are frequently complicated by catheter-related central venous thrombosis (CVT), which has been associated with an increased risk of pulmonary embolism and catheter-related infection.

OBJECTIVES

To determine the efficacy and safety of thromboprophylaxis with s.c. low-molecular-weight heparin (nadroparin) administered once daily in a randomized placebo-controlled, double-blind trial in patients with hematologic malignancies.

PATIENTS AND METHODS

Consecutive patients with hematologic malignancies requiring intensive chemotherapy including autologous stem cell transplantation were eligible. The patients were randomized to receive nadroparin 2850 antifactor Xa units once daily or placebo s.c. for 3 weeks. Venography was performed on day 21 after CVC insertion. Secondary outcomes were bleeding and catheter-related infection.

RESULTS

In total, 113 patients were randomized to nadroparin or placebo, and 87 patients (77%) underwent venography. In total, 11 venographically proven catheter-related CVTs were diagnosed. The frequency of catheter-related CVT was not significantly different between study groups, namely four catheter-related CVTs in the placebo group [9%; 95% CI: 0.002-0.16] vs. seven catheter-related CVTs in the nadroparin group (17%; 95% CI: 0.06-0.28). In addition, no difference in the incidence of catheter-related infection or bleeding was observed between the groups.

CONCLUSION

This study showed that the actual risk for catheter-related CVT in patients with hematologic malignancies is lower than suggested in earlier studies in cancer patients. Although prophylactic administration of nadroparin appeared to be safe in this group of patients with a high risk of bleeding, it cannot be recommended for the prevention of catheter-related CVT or catheter-related infection in patients with hematologic malignancies.

Bloodstream infection related to catheter connections: a prospective trial of two connection systems

Bloodstream infections (BSIs) related to central venous catheters (CVCs) and arterial catheters (ACs) are an increasing problem in the management of critically ill patients. Our objective was to assess the efficacy of a needle-free valve connection system (SmartSite), Alaris Medical Systems, San Diego, CA, USA) in the prevention of catheter-related bloodstream infection (CR-BSI). Patients admitted to an intensive care unit were prospectively assigned to have a CVC and AC connected with either a needle-free valve connection system (NFVCS) or a three-way stopcock connection (3WSC). The characteristics of the patients were similar in the two groups. Before manipulation, the NFVCS was disinfected with chlorhexidine digluconate 0.5% alcoholic solution. The 3WSC was not disinfected between use but it was covered with a protection cap. A total of 799 patients requiring the insertion of a multilumen CVC or AC for >48h from 1 April 2002 to 31 December 2003 were included. CR-BSI rates were 4.61 per 1000 days of catheter use in the disinfected NFVCS group and 4.11 per 1000 days of catheter use in the 3WSC group (P=0.59). When CVC-BSIs and AC-BSIs were analysed separately, the rate of CVC-BSI was 4.26 per 1000 days of catheter use in the NFVCS group, compared with 5.27 in the 3WSC group (P=0.4). The incidence rate of AC-BSI was 5.00 per 1000 days of catheter use in the NFVCS group, compared with 2.83 in the 3WSC group (P=0.08). The use of NFVCS does not reduce the incidence of catheter-related bacteraemia. The arterial catheter (AC) is a significant source of infection in critically ill patients.

Effect of Chlorhexidine/Silver Sulfadiazine-Impregnated Central Venous Catheters in an Intensive Care Unit with a Low Blood Stream Infection Rate after Implementation of an Educational Program: A Before–After Trial

BACKGROUND

Current guidelines recommend using antiseptic- or antibiotic-impregnated central venous catheters (CVCs) if, following a comprehensive strategy to prevent catheter-related blood stream infection (CR-BSI), infection rates remain above institutional goals based on benchmark values. The purpose of this study was to determine if chlorhexidine/silver sulfadiazine-impregnated CVCs could decrease the CR-BSI rate in an intensive care unit (ICU) with a low baseline infection rate.

METHODS

Pre-intervention and post-intervention observational study in a 24-bed surgical/trauma/burn ICU from October, 2002 to August, 2005. All patients requiring CVC placement after March, 2004 had a chlorhexidine/silver sulfadiazine-impregnated catheter inserted (post-intervention period).

RESULTS

Twenty-three CR-BSIs occurred in 6,960 catheter days (3.3 per 1,000 catheter days)during the 17-month control period. After introduction of chlorhexidine/silver sulfadiazine-impregnated catheters, 16 CR-BSIs occurred in 7,732 catheter days (2.1 per 1,000 catheter days; p = 0.16). The average length of time required for an infection to become established after catheterization was similar in the two groups (8.4 vs. 8.6 days; p = 0.85). Chlorhexidine/silver sulfadiazine-impregnated catheters did not result in a statistically significant change in the microbiological profile of CR-BSIs, nor did they increase the incidence of resistant organisms.

CONCLUSIONS

Although chlorhexidine/silver sulfadiazine-impregnated catheters are useful in specific patient populations, they did not result in a statistically significant decrease in the CR-BSI rate in this study, beyond what was achieved with education alone.

Application of the sequential organ failure assessment (SOFA) score to bacteremic ICU patients

BACKGROUND

Patients admitted to intensive care units (ICUs) are at a high risk of acquiring blood stream infections. We examined whether SOFA score on ICU admission and on the day of bacteremia can predict the occurrence of bacteremia and the outcome of bacteremic ICU patients.

PATIENTS AND METHODS

All patients admitted to a multidisciplinary ICU for more than 48 h from January 1, 2002 to December 31, 2004, were prospectively studied. Demographic, clinical and laboratory data were recorded on admission for all patients and additionally, on the day of the first bacteremic episode for those patients who developed bacteremia. Accordingly, APACHE II and SOFA scores were calculated on the same day.

RESULTS

A total of 185 patients developed one or more episodes of bacteremia, giving an incidence of 9.6 per 1,000 ICU days. The ICU mortality rate was 43.9% for bacteremic and 25.8% for the remaining patients (p < 0.001). Admission SOFA score was independently associated with the occurrence of bacteremia (OR = 1.20, 95% CI: 1.11-1.26, p < 0.001). Among bacteremic patients, SOFA score on the day of bacteremia was the only independent prognostic factor for outcome (OR = 1.44, 95% CI: 1.21-1.71, p < 0.001). When all patients were included in the multivariate analysis, admission SOFA (OR = 1.3, CI: 1.16-1.38, p < 0.001), APACHE II (OR = 1.1, CI: 1.02-1.11, p = 0.003) score and the presence of bacteremia (OR = 1.8, CI: 1.1-2.9, p = 0.023) were independently associated with the outcome.

CONCLUSION

Admission SOFA score is independently associated with the occurrence of ICU-acquired bacteremia, whereas it is not sufficient to predict the outcome of patients who subsequently will develop this complication. However, SOFA score on the first day of bacteremia is an independent prognostic factor for outcome in these patients.

Economics of central line--associated bloodstream infections

Hospital-acquired infections add considerable morbidity and mortality to patient care. However, a detailed economic analysis of these infections on an individual case basis has been lacking. The authors examined both the hospital revenues and expenses in 54 cases of patients with central line-associated bloodstream infections (CLABs) over 3 years in 2 intensive care units and compared these financial data with patients who were matched for age, severity of illness on admission, and principal diagnosis. The average payment for a case complicated by CLAB was $64 894, and the average expense was $91733 with gross margin of -$26 839 per case and a total loss from operations of $1 449 306 in the 54 cases. The costs of CLABs and the associated complications averaged 43% of the total cost of care. The elimination of these preventable infections constitutes not only an opportunity to improve patient outcomes but also a significant financial opportunity.

Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

BACKGROUND

The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997.

METHODS AND RESULTS

A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS

The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

A randomized and prospective study of 3 procedures for the diagnosis of catheter-related bloodstream infection without catheter withdrawal

BACKGROUND

Suspicion of catheter-related bloodstream infection (CR-BSI) leads frequently to unnecessary catheter withdrawals, and many catheter-tip cultures yield negative results. The objective of this study was to compare the yield of 3 microbiological procedures to assess CR-BSI without catheter withdrawal.

METHODS

The study was prospectively performed in a group of patients without neutropenia or blood disorders who were admitted to the intensive care unit during a 37-month period with sepsis suspected on clinical grounds and who had central venous catheters inserted for >48 h. The microbiological procedures compared were semiquantitative cultures from hub and skin (superficial), differential quantitative blood cultures, and differential time to positivity between cultures of blood obtained from catheter hubs and peripheral blood.

RESULTS

Of the 204 episodes of suspected CR-BSI included in the study, 28 were confirmed to be CR-BSI. We obtained the following results for sensitivity, specificity, positive and negative predictive values, and accuracy: superficial cultures, 78.6%, 92.0%, 61.1%, 96.4%, and 90.2%, respectively; differential quantitative blood cultures, 71.4%, 97.7%, 83.3%, 95.6%, and 94.1%, respectively; and differential time to positivity, 96.4%, 90.3%, 61.4%, 99.4%, and 91.2%, respectively.

CONCLUSIONS

CR-BSI can be assessed without catheter withdrawal in patients without neutropenia or blood disorders who have catheters inserted for a short time and are hospitalized in the intensive care unit. Convenience, use of resources, and expertise should determine the technique of choice in different medical contexts. Because of ease of performance, low cost, and wide availability, we recommend combining semiquantitative superficial cultures and peripheral vein blood cultures to screen for CR-BSI, leaving differential quantitative blood cultures as a confirmatory and more specific technique.

Comparative in vitro efficacies and antimicrobial durabilities of novel antimicrobial central venous catheters

We investigated the efficacies and durability of novel antimicrobial central venous catheters (CVCs) in preventing the adherence of microbial organisms to the surfaces of the CVCs. Novel antimicrobial CVCs investigated in this in vitro study were impregnated with antibiotics (minocycline and rifampin), with Oligon agent (silver, platinum, and carbon black), with approved antiseptics (chlorhexidine and silver sulfadiazine), or with a novel antiseptic agent, gendine, which contains gentian violet and chlorhexidine. When tested against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, gendine-coated CVC segments provided protection against bacterial adherence significantly more than all other types of tested CVCs (P < 0.05). Gendine-coated CVCs also provided better protection against Candida albicans and Candida parapsilosis than CVCs impregnated with antibiotics or with silver, platinum, and carbon (P < 0.02). After 28 days of being soaked in serum, the CVCs impregnated with chlorhexidine and silver sulfadiazine and the CVCs impregnated with silver, platinum, and carbon had lost antimicrobial activity against MRSA, P. aeruginosa, and C. parapsilosis, and the CVCs impregnated with minocycline and rifampin had lost activity against P. aeruginosa and C. parapsilosis. The CVCs impregnated with gendine maintained antimicrobial activities against MRSA, P. aeruginosa, and C. parapsilosis after 28 days of being soaked in serum. Central venous catheters impregnated with the novel investigational antiseptic gendine showed in vitro efficacy and provided protection against bacterial adherence more than other approved novel antimicrobial-coated CVCs.

Intensive care acquired infection is an independent risk factor for hospital mortality: a prospective cohort study

Introduction

The aim of this study was to elucidate the impact of intensive care unit (ICU)-acquired infection on hospital mortality.

Methods

Patients with a longer than 48 hour stay in a mixed 10 bed ICU in a tertiary-level teaching hospital were prospectively enrolled between May 2002 and June 2003. Risk factors for hospital mortality were analyzed with a logistic regression model.

Results

Of 335 patients, 80 developed ICU-acquired infection. Among the patients with ICU-acquired infections, hospital mortality was always higher, regardless of whether or not the patients had had infection on admission (infection on admission group (IAG), 35.6% versus 17%, p = 0.008; and no-IAG, 25.7% versus 6.1%, p = 0.023). In IAG (n = 251), hospital stay was also longer in the presence of ICU-acquired infection (median 31 versus 16 days, p < 0.001), whereas in no-IAG (n = 84), hospital stay was almost identical with and without the presence of ICU-acquired infection (18 versus 17 days). In univariate analysis, the significant risk factors for hospital mortality were: Acute Physiology and Chronic Health Evaluation (APACHE) II score >20, sequential organ failure assessment (SOFA) score >8, ICU-acquired infection, age ≥ 65, community-acquired pneumonia, malignancy or immunosuppressive medication, and ICU length of stay >5 days. In multivariate logistic regression analysis, ICU-acquired infection remained an independent risk factor for hospital mortality after adjustment for APACHE II score and age (odds ratio (OR) 4.0 (95% confidence interval (CI): 2.0–7.9)) and SOFA score and age (OR 2.7 (95% CI: 2.9–7.6)).

Conclusion

ICU-acquired infection was an independent risk factor for hospital mortality even after adjustment for the APACHE II or SOFA scores and age.

Central venous catheter infection in adults in acute hospital settings

As well as the human cost, central venous catheter (CVC)-related bloodstream infections significantly inflate hospital costs, mainly through increased length of stay in hospital, particularly in intensive care. This literature review appraises recent research on measures used to minimize CVC-related infection and compares it with current best practice. Randomized controlled trials and systematic reviews published on the subject between 2000 and 2005 were reviewed, concentrating on non-tunnelled, short-term CVCs in the acute hospital setting. The new evidence mainly backs up current best practice. However, skin disinfection could be improved by using alcoholic chlorhexidine followed by aqueous povidone-iodine before CVC insertion. Also, alcoholic chlorhexidine is the preferred solution for cleaning the hubs/connectors before accessing the CVC. Good hand hygiene and quality control and education programmes are vital to improve patient care. More research is needed to clarify the effectiveness of certain interventions and technologies, such as antimicrobial CVCs.

Colonization of the medial lumen is a risk factor for catheter-related bloodstream infection

OBJECTIVE

To analyze the colonization of each lumen and the risk factors for triple-lumen central venous catheter-related bloodstream infection (CRBI).

DESIGN AND SETTING

Prospective, observational study in the medical-surgical intensive care unit (ICU) of a teaching hospital.

PATIENTS

A total of 120 patients requiring the insertion of a triple-lumen catheter.

INTERVENTIONS

Cultures of the catheter.

MEASUREMENTS AND RESULTS

The catheters were removed when CRBI was suspected or at discharge from ICU. At the removal time, blood cultures, a swab of the insertion site and a culture of the catheter tip were performed. Furthermore, we made quantitative cultures of the proximal, medial and distal lumen. We diagnosed CRBI in six patients (3.35 CRBI/1,000 days at risk), and we observed that in these patients colonization of the medial lumen was more frequent (5/6) than in patients without CRBI (9/114; p = 0.0001). The logistic regression analysis showed that colonization of the medial lumen was an independent risk factor for CRBI (OR 28.1, 95% CI 2.2-364.9).

CONCLUSIONS

Colonization of the medial lumen is an independent risk factor for triple-lumen catheter-related bloodstream infection, possibly due to the absence of use of this lumen.

Evidence-Based Practice to Reduce Central Line Infections

BACKGROUND

In 2003, through the Greater Cincinnati Health Council nine health care systems agreed to participate and fund 50% of a two-year project to reduce hospital-acquired infections among patients in intensive care units (ICU) and following surgery (SIP).

METHODS

Hospitals were randomized to either the CR-BSI or SIP project in the first year, adding the alternative project in year 2. Project leaders, often the infection control professionals, implemented evidence-based practices to reduce catheter-related blood stream infections (CR-BSIs; maximal sterile barriers, chlorhexidine) at their hospitals using a collaborative approach. Team leaders entered process information in a secure deidentifled Web-based database.

RESULTS

Of the four initial sites randomized to CR-BSI reduction, all reduced central line infections by 50% (CR-BSI, 1.7 to 0.4/1000 line days, p < .05). At the project midpoint (3 quarters of 2004), adherence to evidence-based practices increased from 30% to nearly 95%.

DISCUSSION

The direct role of hospital leadership and development of a local community of practice, facilitated cooperation of physicians, problem solving, and success. Use of forcing functions (removal of betadine in kits, creation of an accessory pack and a checklist for line insertion) improved reliability. The appropriate floor for central line infections in ICUs is < 1 infection /1,000 line days.

Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs

The aim of this study was to compare the efficacy of surgical hand rubbing (SHR) with the efficacy of surgical hand scrubbing (SHS), and to determine the costs of both techniques for surgical hand disinfection. A review of studies reported in the literature that compared the efficacy of SHS and SHR was performed using MEDLINE. The costs of SHR and SHS were estimated based on standard hospital costs. The literature showed that SHR had immediate efficacy that was similar to that of SHS, but SHR had a more lasting effect. SHR reduced costs by 67%. In conclusion, SHR is a cost-effective alternative to SHS.

The Burden of Nosocomial Infection in the Intensive Care Unit: Effects on Organ Failure, Mortality and Costs. A Nested Case-Control Study

BACKGROUND

Nosocomial infections increase mortality and costs in the intensive care units; however, few studies have addressed organ failure that developed in infected patients and their overall costs. The goal of this study was to measure the frequency of organ failure in nosocomial infection and the mortality and costs of these in critical care areas.

METHODS

This was a nested 1:2 case-control study in a cohort of all consecutively hospitalized patients comparing those with and without nosocomial infections over a year in an institutional intensive care unit (ICU). Those patients who acquired an infection during hospitalization were considered cases. Controls were matched by hospital stay at least as long as the cases' time acquisition of nosocomial infection, age +/-5 years and APACHE II +/-5 points.

RESULTS

Forty-three patients developed at least one nosocomial infection event (cases). The matching success was about 94%. Higher frequency and duration of organ failures was observed in the cases, as well as the number of devices and procedures (p < 0.05). Attributable mortality was 16.3% (p < 0.001). Attributable total cost of a nosocomial infection acquired in the ICU was 12,155 dollars.

CONCLUSIONS

Nosocomial infection acquired in the ICU increases length of stay, frequency and duration of organ failures, mortality, and costs.

Excess risk of death from intensive care unit-acquired nosocomial bloodstream infections: a reappraisal

BACKGROUND

Overall rates of bloodstream infection (BSI) are often used as quality indicators in intensive care units (ICUs). We investigated whether ICU-acquired BSI increased mortality (by > or = 10%) after adjustment for severity of infection at ICU admission and during the pre-BSI stay.

METHODS

We conducted a matched, risk-adjusted (1:n), exposed-unexposed study of patients with stays longer than 72 h in 12 ICUs randomly selected from the Outcomerea database.

RESULTS

Patients with BSI after the third ICU day (exposed group) were matched on the basis of risk-exposure time and mortality predicted at admission using the Three-Day Recalibrated ICU Outcome (TRIO) score to patients without BSI (unexposed group). Severity was assessed daily using the Logistic Organ Dysfunction (LOD) score. Of 3247 patients with ICU stays of >3 days, 232 experienced BSI by day 30 (incidence, 6.8 cases per 100 admissions); among them, 226 patients were matched to 1023 unexposed patients. Crude hospital mortality was 61.5% among exposed and 36.7% among unexposed patients (P<.0001). Attributable mortality was 24.8%. The only variable associated with both BSI and hospital mortality was the LOD score determined 4 days before onset of BSI (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.03-1.16; P = .0025). The adjusted OR for hospital mortality among exposed patients (OR, 3.20; 95% CI, 2.30-4.43) decreased when the LOD score determined 4 days before onset of BSI was taken into account (OR, 3.02; 95% CI, 2.17-4.22; P<.0001). The estimated risk of death from BSI varied considerably according to the source and resistance of organisms, time to onset, and appropriateness of treatment.

CONCLUSIONS

When adjusted for risk-exposure time and severity at admission and during the ICU stay, BSI was associated with a 3-fold increase in mortality, but considerable variation occurred across BSI subgroups. Focusing on BSI subgroups may be valuable for assessing quality of care in ICUs.

Rate, risk factors and outcomes of catheter-related bloodstream infection in a paediatric intensive care unit in Saudi Arabia

The aim of this study was to determine the rate, risk factors and outcomes of catheter-related bloodstream infections (CRBSIs) in patients in a paediatric intensive care unit (PICU). A prospective cohort study was performed in King Abdulaziz Medical City, Riyadh, Saudi Arabia; a 650-bed academic/tertiary care centre with a combined 10-bed medical and surgical PICU. All patients admitted to the PICU from July 2000 to February 2003 who had a central line placed were monitored for the development of bloodstream infection (BSI) from insertion until 48 h after removal. Four hundred and forty-six patients with 2493 central-line-days were documented; 273 (55%) were male and the mean age was 2.6 years. Of the 446 patients, 278 (56%) had congenital heart disease, 108 (22%) had genetic disorders and/or congenital malformations, 55 (11%) had respiratory disease, and 42 (8%) had trauma. There were 50 episodes of CRBSI in 46 patients with a rate of 20.06 per 1,000 central-line-days and a device-utilization rate of 57%. Of these 50 episodes, 24 (48%) were polymicrobial, 16 (32%) were due to Gram-negative organisms, five (10%) were due to Gram-positive organisms, and five (10%) were fungal. The most common organisms isolated were Klebsiella pneumoniae (N=12, 16%), coagulase-negative staphylococci (N=10, 14%) and Pseudomonas aeruginosa (N=8, 11%). The mean duration of line insertion was 11.8 days for CRBSI patients and 4.22 days for non-BSI patients (P<0.0001). The mean PICU stay was 30.20 days for CRBSI patients and 6.35 days for non-BSI patients (P<0.0001). BSI occurred more often in catheters inserted in the PICU compared with the operating room, and in the femoral site compared with jugular or subclavian sites (P<0.001). In multiple logistic regression analysis of the risk factors, CRBSI patients were more likely to have multiple central lines [odds ratio (OR) 9.19; 95% confidence intervals (CI): 3.76-22.43), the line was more likely to be used for total parenteral nutrition (OR: 8.69; 95% CI: 3.5-21.4), and guidewire exchange was more likely to be performed on the line. CRBSI was not associated with a higher mortality rate. The CRBSI rate in our hospital is high compared with that reported by the National Nosocomial Infection Surveillance system. This study has established a benchmark for future comparisons. Additional studies from Saudi Arabia are necessary for national comparison and development of preventive measures.

Prognostic indexes of septic syndrome in the emergency department

OBJECTIVE

Sepsis is a frequent and often lethal condition. Rapid identification and aggressive therapy in the emergency department (ED) are essential for outcome. Several indexes were found to be significantly related to short-term clinical outcome, but only bedside, rapidly available tests are thought to be useful in the ED. To define the prevalence and mortality of patients with severe sepsis presenting to the ED of a tertiary care hospital in Italy, we furthermore investigated the ability of bedside, non-invasive prognostic indexes to identify patients with adverse short-term clinical outcome.

METHODS

All patients admitted to the ED with a diagnosis of severe sepsis or septic shock were included. Retrospective data were collected by a dedicated software program using predefined searching criteria including clinical data, vital sign parameters, sepsis-related organ failure assessment (SOFA) score, and blood tests. The relationship between prognostic indexes and 24-h or 28-day mortality was evaluated by multivariate logistic regression analysis.

RESULTS

Ninety patients were enrolled from June 2004 to June 2005 (0.2% of all incoming patients to ED and 0.7% of all critical patients). Mean age was 77 +/- 15 years, 54.4% were women. During follow-up (28 days) 46 patients died (51.1%), 21 patients (23.3%) within 24 h. At multivariate analyses, age >80 (odds ratio [OR] 4.10; 95% confidence intervals [CI] 1.39-11.90, p = 0.01), serum lactate >5 mmol/l (OR 3.40; 95% CI 1.21-9.60, p = 0.02) and acute renal failure (OR 18.90; 95% CI 1.80-200, p = 0.02) were independent predictors of 28-day mortality.

CONCLUSIONS

Among critical patients admitted to an Italian ED, those with severe sepsis/septic shock represent about 1%, with a very high mortality rate. Bedside non-invasive prognostic indexes are able to identify with high accuracy patients with adverse short-term clinical outcome.

Predictive perioperative factors for developing severe sepsis after major surgery

BACKGROUND

Early identification of high-risk patients undergoing major surgery can result in an aggressive management affecting the outcome.

METHODS

We designed a prospective cohort study of 93 adult patients undergoing major oncological surgery to identify the predictive risk factors for developing postoperative severe sepsis.

RESULTS

Nineteen of 93 patients developed a severe sepsis after surgery; seven of the septic patients died in intensive care unit. Multivariate analysis discriminated preoperative and postoperative (first and second day after surgery) predictive risk factors. The postoperative severe sepsis was independently associated with preoperative factors like male gender (OR 4.7, 95% CI between 1.5 and 15.5, P<0.01) and Charlson co-morbidity index (OR 1.3, 95% CI between 1.07 and 1.6, P<0.01). After the surgery, the presence of systemic inflammatory response syndrome (OR 4.0, 95% CI between 1.02 and 15.7, P<0.05) and a logistic organ dysfunction score on day 2 (OR 3.3, 95% CI between 1.9 and 5.7, P<0.001) were found as independent predictive factors.

CONCLUSION

We have shown that some of the markers that can be easily collected in the preoperative or postoperative visits can be used to screen the patients at high risk for developing severe sepsis after major surgery.

Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections

BACKGROUND

Central venous catheters are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk, potentially leading to increased mortality and costs. We evaluate clinical and economic outcomes associated with nosocomial central venous catheter-related bloodstream infection (CR-BSI) in intensive care unit (ICU) patients.

METHODS

A retrospective (1992-2002), pairwise-matched (ratio of case patients to control subjects, 1:2 or 1:1), risk-adjusted cohort study was performed at a 54-bed general ICU at a university hospital. ICU patients with microbiologically documented CR-BSI (n = 176) were matched with control subjects (n = 315) on the basis of disease severity, diagnostic category, and length of ICU stay (equivalent or longer) before the onset of CR-BSI in the index case patient. Clinical outcome was principally evaluated by in-hospital mortality. Economic outcome was evaluated on the basis of duration of mechanical ventilation, length of ICU and hospital stays, and total hospital costs, as derived from the patient's hospital invoices.

RESULTS

The attributable mortality rate for CR-BSI was estimated to be 1.8% (95% confidence interval, -6.4% to 10.0%); in-hospital mortality rates for patients with CR-BSI and matched control subjects were 27.8% and 26.0%, respectively. CR-BSI was associated with significant excesses in duration of mechanical ventilation, duration of ICU and hospital stays, and a significant increase in total hospital cost. Linear regression analysis with adjustment for duration of hospitalization and clinical covariates, revealed that CR-BSI is independently associated with higher costs.

CONCLUSIONS

In ICU patients, CR-BSI does not result in increased mortality. It is, however, associated with a significant economic burden, emphasizing the importance of continuous efforts in prevention.

The attributable mortality of acute renal failure in critically ill patients with liver cirrhosis

OBJECTIVE

To determine outcome and mortality risk related to acute renal failure (ARF) in critically ill patients with cirrhosis.

DESIGN AND SETTING

A retrospective cohort analysis and two independent case-control analyses in a medical ICU.

PATIENTS

41 and 32 patients who developed mild and severe ARF, respectively, matched (1:2 ratio) with cirrhotic patients without ARF during their ICU stay.

MEASUREMENTS AND RESULTS

Cirrhotic patients with ARF had higher MELD, APACHE II, and SOFA scores at baseline that those without ARF. They had more respiratory failure and cardiovascular failure during ICU stay, longer stay in ICU, and a greater crude hospital mortality rate (65% vs. 32%). Multivariate survival analysis identified ARF (hazard ratio, HR, 4.1), alcohol abuse or dependency, and severe sepsis or septic shock as independent predictors of death. In case-control studies both mild and severe ARF were independently associated with mortality (HR, 2.6, and 4.2, respectively). Cirrhotic patients with mild ARF patients had a higher risk of death than those without ARF (relative risk, RR, 2.0). Severe ARF was associated with an increase matched risk of death (RR 2.6), higher mortality of 51%, and higher risk-adjusted mortality rate (2.1 vs. 0.9).

CONCLUSIONS

ICU patients with liver cirrhosis still have a high crude mortality. In this specific population ARF is associated with an excess mortality, depending on the severity of renal dysfunction.

Optimal timing for intravenous administration set replacement

BACKGROUND

Administration of intravenous therapy is a common occurrence within the hospital setting. Routine replacement of administration sets has been advocated to reduce intravenous infusion contamination. If decreasing the frequency of changing intravenous administration sets does not increase infection rates, a change in practice could result in considerable cost savings.

OBJECTIVES

The objective of this review was to identify the optimal interval for the routine replacement of intravenous administration sets when infusate or parenteral nutrition (lipid and non-lipid) solutions are administered to people in hospital via central or peripheral venous catheters.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE: all from inception to February 2004; reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. We did not have a language restriction.

SELECTION CRITERIA

We included all randomized or quasi-randomized controlled trials addressing the frequency of replacing intravenous administration sets when parenteral nutrition (lipid and non-lipid containing solutions) or infusions (excluding blood) were administered to people in hospital via a central or peripheral catheter.

DATA COLLECTION AND ANALYSIS

Two authors assessed all potentially relevant studies. We resolved disagreements between the two authors by discussion with a third author. We collected data for the outcomes; infusate contamination; infusate-related bloodstream infection; catheter contamination; catheter-related bloodstream infection; all-cause bloodstream infection and all-cause mortality.

MAIN RESULTS

We identified 23 references for review. We excluded eight of these studies; five because they did not fit the inclusion criteria and three because of inadequate data. We extracted data from the remaining 15 references (13 studies) with 4783 participants. We conclude that there is no evidence that changing intravenous administration sets more often than every 96 hours reduces the incidence of bloodstream infection. We do not know whether changing administration sets less often than every 96 hours affects the incidence of infection. In addition, we found that there were no differences between participants with central versus peripheral catheters; nor between participants who did and did not receive parenteral nutrition, or between children and adults.

AUTHORS' CONCLUSIONS

It appears that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the incidence of infection. There was no evidence to suggest that administration sets which contain lipids should not be changed every 24 hours as currently recommended.

[How to improve central venous catheter use in intensive care unit?]

OBJECTIVE

Central venous catheter (CVC) insertion is routinely performed in critically ill patients but causes mechanical, thrombotic, or infectious adverse events in 15% of cases. It should be possible to improve the benefit/risk ratio of central venous catheterization in intensive care unit.

DATA SOURCE

We searched Pubmed using the terms: "catheterization, central venous, peripheral, adverse effects"; then "thrombosis, phlebitis, thrombophlebitis, jugular vein, femoral vein, subclavian vein, pneumothorax, haemothorax, extravasation of diagnostic and therapeutic materials". We then discuss this with a panel of intensivists in a workshop.

DATA SYNTHESIS

Few data are available on the risk/benefit ratio of central vs. peripheral venous catheterization. In some cases (cardiac arrest, rapid fluid loading, parenteral nutrition) the choice is based on clear recommendations. In others (irritating drugs, pressure monitoring, peripheral access failure), the choice depends on medical and nurses daily evaluation. When CVC insertion is mandatory, it is important to implement the recommendations of the consensus conferences to prevent infectious and thrombotic complications. Mechanical complications should be improved by selecting the most appropriate insertion site, and, if unsuccessful, switching to another operator before the complications occurs. Doppler-ultrasound guidance is recommended, but is limited by the cost and training of the technique.

CONCLUSION

Studies evaluating the risk/benefit ratio of CVCs versus peripheral catheters are needed to develop a venous-access strategy for ICU patients. When a CVC is mandatory, recent data are available to improve the risk/benefit ratio and can be used to build a decision algorithm.

Use of Corporate Six Sigma Performance-Improvement Strategies to Reduce Incidence of Catheter-Related Bloodstream Infections in a Surgical ICU

BACKGROUND

Corporate performance-improvement methodologies can outperform traditional ones in addressing ICU-based adverse events. My colleagues and I used Six Sigma methodology to address our catheter-related bloodstream infection (CR-BSI) rate, which considerably exceeded the nationally established median over a 9-year period. We hypothesized that use of Six Sigma methodology would result in a substantial and sustainable decrease in our CR-BSI rate.

STUDY DESIGN

All patients were directly cared for by a geographically localized surgical ICU team in an academic tertiary referral center. CR-BSIs were identified by infection control staff using CDC definitions. Personnel trained in Six Sigma techniques facilitated performance-improvement efforts. Interventions included barrier precaution kits, new policies for catheter changes over guide wires, adoption of a new site-preparation antiseptic, direct attending supervision of catheter insertions, video training for housestaff, and increased frequency of dressing changes. After additional data analysis, chlorhexidine-silver catheters were used selectively in high-risk patients. The impact of interventions was assessed by monitoring the number of catheters placed between CR-BSIs.

RESULTS

Before the intervention period, 27 catheters were placed, on average, between individual CR-BSIs, a CR-BSI rate of 11 per 1,000 catheter days. After all operations were implemented, 175 catheters were placed between line infections, and average CR-BSI rate of 1.7/1,000 catheter days, a 650% improvement (p < 0.0001). Compared with historic controls, adoption of chlorhexidine-silver catheters in high-risk patients had a considerable impact (50% reduction; p < 0.05).

CONCLUSIONS

This represents the first successful application of Six Sigma corporate performance-improvement method impacting purely clinical outcomes. CR-BSI reduction was highly substantial and sustained after other traditional strategies had failed.

Increased risk of bloodstream and urinary infections in intensive care unit (ICU) patients compared with patients fitting ICU admission criteria treated in regular wards

Critically ill patients, eligible for admission into intensive care units (ICUs), are often hospitalized in other wards due to a lack of ICU beds. Differences in morbidity between patients managed in ICUs and elsewhere are unknown, specifically the morbidity related to hospital-acquired infection. Patients fitting ICU admission criteria were identified by screening five entire hospitals on four separate days. Hospital infections within a 30-day follow-up period were compared in ICU patients and in patients on other wards using Kaplan-Meier curves. Residual differences in the patients' case mix between ICUs and other wards were adjusted for utilizing multivariate Cox models. Of 13415 patients screened, 668 were critically ill. The overall infection rates (per 100 patient-days) were 1.2 for bloodstream infection (BSI) and 1.9 for urinary tract infection (UTI). The adjusted hazard ratios in ICU patients compared with patients on regular wards were 3.1 (P<0.001) for BSI and 2.5 (P<0.001) for UTI. This increased risk persisted even after adjusting for the disparity in the number of cultures sent from ICUs compared with ordinary wards. No interdepartmental differences were found in the rates of pneumonia, surgical wound infections and other infections. Minimizing the differences between characteristics of patients hospitalized in ICUs and in other wards, and controlling for the higher frequency of cultures sent from ICUs did not eliminate the increased risk of BSI and UTI associated with admission into ICUs.

Risk of Mortality with a Bloodstream Infection Is Higher in the Less Severely Ill at Admission

RATIONALE

Health care-associated bloodstream infections are common in critically ill patients; however, investigators have had difficulty in quantifying the clinical impact of these infections given the high expected mortality among these patients.

OBJECTIVE

To estimate the impact of health care-associated bloodstream infections on in-hospital mortality after adjusting for severity of illness at critical care admission.

METHOD

A cohort of medical and surgical intensive care unit patients.

MEASUREMENTS

Severity of illness at admission, bloodstream infection, and in-hospital mortality.

MAIN RESULTS

Among the 2,783 adult patients, 269 developed unit-associated bloodstream infections. After adjusting for severity of illness, patients with a lower initial severity of illness who developed an infection had a greater than twofold higher risk for in-hospital mortality (hazard ratio [HR] = 2.42, 95% confidence interval [CI] 1.70, 3.44) when compared with patients without infection and with a similar initial severity of illness. In contrast, patients with a higher initial severity of illness who subsequently developed an infection did not have an increased risk for in-hospital mortality (HR = 0.96, 95%CI 0.76, 1.23) when compared with patients without infection but with a similar initial severity of illness.

CONCLUSIONS

These results suggest that these infections in less ill patients have a higher attributable impact on subsequent mortality than in more severely ill patients. Focusing interventions to prevent bloodstream infections in less severely ill patients would be expected to have a greater benefit in terms of mortality reduction.

Faut-il faire des changements de cathéters sur guide ?

Two types of catheter replacement with the help of wire introducer are reported: systematic scheduled replacement and replacement in case of suspicion of catheter related infection. Guidelines do not recommend systematic scheduled replacement of the catheters. In case of suspicion of catheter infection, French consensus guidelines allow the use of wire introducer in the absence of local risk and of signs of severity. The American guidelines do not recommend the catheter change over guidewire in this setting.

Are Antimicrobial-Impregnated Catheters Effective? Replace the Water and Grab Your Washcloth, Because We Have a Baby to Wash

Significant controversy surrounds the usefulness of central venous catheters (CVCs) impregnated with antimicrobial agents (A-CVCs) for the prevention of catheter-related bloodstream infections (CRBSIs). In a recent issue of Clinical Infectious Diseases, we reviewed 11 published trials of A-CVCs versus uncoated CVCs, and we concluded that there is a lack of solid evidence to support a benefit of A-CVCs in reducing the rate of CRBSIs. A response to our review was recently published in Clinical Infectious Diseases. In this response, our colleagues assert that there is a large body of evidence that demonstrates a powerful decrease in the risk of infection, and they conclude that we should not waste precious resources while we perform additional research to confirm what we have already found to be true. Although these authors agree with us on the significant shortcomings of the studies used to support the use of A-CVCs, they dismiss the need for additional trials to demonstrate that the use of A-CVCs does reduce infections. This dismissal, however, cannot be justified, because of the existence of an ongoing, federally supported, multicenter, prospective, placebo-controlled trial, led by our colleagues, that compares the rate of CRBSIs among patients randomized to receive either an A-CVC or a "placebo" uncoated CVC. That our colleagues are leading a trial that assesses the efficacy of A-CVCs versus placebo uncoated CVCs supports our viewpoint that the truth regarding the protective role of A-CVCs has yet to be determined. Because of the significant cost, potential toxicity, and risk of increased antimicrobial resistance associated with the use of A-CVCs, and until the results of the important trial conducted by our colleagues convincingly demonstrate that A-CVCs reduce the rate of clinically significant events (not just catheter colonization), we recommend that the use of A-CVCs be limited to investigational settings.

The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infection in a Medical ICU

OBJECTIVE

To determine whether an education initiative could decrease the rate of catheter-associated bloodstream infection.

DESIGN

Preintervention and postintervention observational study.

SETTING

The 19-bed medical ICU in a 1,400-bed university-affiliated urban teaching hospital.

PATIENTS

Between January 2000 and December 2003, all patients admitted to the medical ICU were surveyed prospectively for the development of catheter-associated bloodstream infection.

INTERVENTION

A mandatory education program directed toward ICU nurses and physicians was developed by a multidisciplinary task force to highlight correct practices for the prevention of catheter-associated bloodstream infection. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related bloodstream infections and in-services at scheduled staff meetings. Each participant was required to complete a pretest before reviewing the study module and an identical test after completion of the study module. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU.

MEASUREMENTS AND MAIN RESULTS

Seventy-four episodes of catheter-associated bloodstream infection occurred in 7,879 catheter-days (9.4 per 1,000 catheter-days) in the 24 months before the introduction of the education program. Following implementation of the intervention, the rate of catheter-associated bloodstream infection decreased to 41 episodes in 7,455 catheter days (5.5 per 1,000 catheter-days) [p = 0.019]. The estimated cost savings secondary to the decreased rate of catheter-associated bloodstream infection for the 24 months following introduction of the education program was between $103,600 and $1,573,000.

CONCLUSIONS

An intervention focused on the education of health-care providers on the prevention of catheter-associated bloodstream infections may lead to a dramatic decrease in the incidence of primary bloodstream infections. Education programs may lead to a substantial decrease in medical-care costs and patient morbidity attributed to central venous catheterization when implemented as part of mandatory training.

Strategies for the diagnosis and treatment of bacteraemia in children with central venous catheters: an analysis

The aim of this study was to analyse the diagnostic, empirical and therapeutic strategies adopted when a blood culture from a hospitalized child with a central venous catheter is 'positive', and to assess whether practices complied with the consensus adopted in our hospital, inspired by published recommendations. One hundred and ten cases of bacteraemia were studied prospectively. Investigations to determine whether the catheter was the cause of infection were carried out in 45% of cases, and the catheter was removed as recommended in 39% of cases. Of the patients that received empirical treatment, 56% received broad-spectrum antibiotics with no apparent clinical justification. Following susceptibility testing on the isolated strain, the antibiotic treatment was considered to be appropriate in 58% of cases. Overall, compliance with the consensus recommendations was poor. This was partly due to the high turnover rate of antibiotic prescribers.