The Role of Intravascular Devices in Sepsis

Therapeutic Potential of Antimicrobial Peptides in Polymicrobial Biofilm-Associated Infections

It is widely recognized that many chronic infections of the human body have a polymicrobial etiology. These include diabetic foot ulcer infections, lung infections in cystic fibrosis patients, periodontitis, otitis, urinary tract infections and even a proportion of systemic infections. The treatment of mixed infections poses serious challenges in the clinic. First, polymicrobial communities of microorganisms often organize themselves as biofilms that are notoriously recalcitrant to antimicrobial therapy and clearance by the host immune system. Secondly, a plethora of interactions among community members may affect the expression of virulence factors and the susceptibility to antimicrobials of individual species in the community. Therefore, new strategies able to target multiple pathogens in mixed populations need to be urgently developed and evaluated. In this regard, antimicrobial or host defense peptides (AMPs) deserve particular attention as they are endowed with many favorable features that may serve to this end. The aim of the present review is to offer a comprehensive and updated overview of studies addressing the therapeutic potential of AMPs in mixed infections, highlighting the opportunities offered by this class of antimicrobials in the fight against polymicrobial infections, but also the limits that may arise in their use for this type of application.

Preventing catheter-related infections in cancer patients: a review of current strategies

Introduction: Central line-associated bloodstream infections (CLABSI) are a frequent cause of healthcare-associated infections, increasing healthcare costs and decreasing the quality of life for critically and chronically ill patients such as those with cancer. These infections are largely preventable and have been significantly reduced throughout the United States. However, further reduction of CLABSI requires continued innovation in preventive strategies.Areas covered: We provide an overview of the recent medical literature on catheter-related infections among cancer patients, discussing epidemiology, risk factors, and pathogenesis of CLABSI with a focus on the newest and current preventive measures. The data discussed here were retrieved mainly from clinical trials, meta-analyses, and systematic reviews published in the English language using a MEDLINE database search from 1 January 1990 until the end of December 2019.Expert opinion: The growing impact of CLABSI on the healthcare setting and mortality and morbidity rates in cancer patients calls for novel technologies for preventing central line-related infections. Advances in antimicrobial lock therapy are not limited to salvage therapy but have also provided a novel and promising prophylactic approach to CLABSI. Also, the use of antimicrobial-coated catheters with chlorhexidine-impregnated dressings, along with the application of insertion and maintenance bundles, is an effective and cost-effective approach for preventing central line-related infections.

Epidemiologic Shift in Candidemia Driven by Candida auris, South Africa, 2016-20171

Candida auris is an invasive healthcare-associated fungal pathogen. Cases of candidemia, defined as illness in patients with Candida cultured from blood, were detected through national laboratory-based surveillance in South Africa during 2016–2017. We identified viable isolates by using mass spectrometry and sequencing. Among 6,669 cases (5,876 with species identification) from 269 hospitals, 794 (14%) were caused by C. auris. The incidence risk for all candidemia at 133 hospitals was 83.8 (95% CI 81.2–86.4) cases/100,000 admissions. Prior systemic antifungal drug therapy was associated with a 40% increased adjusted odds of C. auris fungemia compared with bloodstream infection caused by other Candida species (adjusted odds ratio 1.4 [95% CI 0.8–2.3]). The crude in-hospital case-fatality ratio did not differ between Candida species and was 45% for C. auris candidemia, compared with 43% for non–C. auris candidemia. C. auris has caused a major epidemiologic shift in candidemia in South Africa.

'Adiós Bacteriemias': a multi-country quality improvement collaborative project to reduce the incidence of CLABSI in Latin American ICUs

QUALITY PROBLEM

The incidence of central line-associated bloodstream infections (CLABSI) in Latin America has been estimated at 4.9 episodes per 1000 central line (CL) days, compared to a pooled incidence of 0.9 in the United States. CLABSI usually result from not adhering to standardized health procedures and can be prevented using evidence-based practices.

INITIAL ASSESSMENT

The first phase of the 'Adiós Bacteriemias' Collaborative was implemented in 39 intensive care units (ICUs) from Latin America from September 2012 to September 2013 with a 56% overall reduction in the incidence of CLABSI.

CHOICE OF SOLUTION

Bundles of care for the processes of insertion and maintenance of CLs have proven to be effective in the reduction of CLABSI across different settings.

IMPLEMENTATION

Building on the results of the first phase, we implemented a second phase of the 'Adiós Bacteriemias' Collaborative between June 2014-July 2015. We adapted the Breakthrough Series (BTS) Collaborative model to guide the adoption of bundles of care for CLABSI prevention through virtual learning sessions and continuous feedback.

EVALUATION

Eighty-three ICUs from five Latin American countries actively reported process and outcome measures. The overall reduction in the CLABSI incidence rate was 22% (incidence rate 0.78; 95% CI 0.65, 0.95), from 2.58 episodes per 1000 CL days at baseline to 2.02 episodes per 1000 CL days (P < 0.01) during the intervention period.

LESSONS LEARNED

Adiós Bacteriemias was effective in reducing the incidence of CLABSI and improving the adherence to good practices for CL insertion and maintenance processes in participating ICUs in Latin America.

Monitoring quality of care for peripheral intravenous catheters; feasibility and reliability of the peripheral intravenous catheters mini questionnaire (PIVC-miniQ)

BACKGROUND

Peripheral intravenous catheters (PIVCs) account for a mean of 38% of catheter associated bloodstream infections (CABSI) with Staphylococcus aureus, which are preventable if deficiencies in best practice are addressed. There exists no feasible and reliable quality surveillance tool assessing all important areas related to PIVC quality. Thus, we aimed to develop and test feasibility and reliability for an efficient quality assessment tool of overall PIVC quality.

METHODS

The Peripheral Intravenous Catheter- mini Questionnaire, PIVC-miniQ, consists of 16 items calculated as a sum score of problems regarding the insertion site, condition of dressing and equipment, documentation, and indication for use. In addition, it contains background variables like PIVC site, size and insertion environment. Two hospitals tested the PIVC-miniQ for feasibility and inter-rater agreement. Each PIVC was assessed twice, 2-5 min apart by two independent raters. We calculated the intraclass correlation coefficient (ICC) for each hospital and overall. For each of the 16 items, we calculated negative agreement, positive agreement, absolute agreement, and Scott's pi.

RESULTS

Sixty-three raters evaluated 205 PIVCs in 177 patients, each PIVC was assessed twice by independent raters, in total 410 PIVC observations. ICC between raters was 0.678 for hospital A, 0.577 for hospital B, and 0.604 for the pooled data. Mean time for the bedside assessment of each PIVC was 1.40 (SD 0.0007) minutes. The most frequent insertion site symptom was "pain and tenderness" (14.4%), whereas the most prevalent overall problem was lack of documentation of the PIVC (26.8%). Up to 50% of PIVCs were placed near joints (wrist or antecubital fossae) or were inserted under suboptimal conditions, i.e. emergency department or ambulance.

CONCLUSIONS

Our study highlights the need for PIVC quality surveillance on ward and hospital level and reports the PIVC-miniQ to be a reliable and time efficient tool suitable for frequent point-prevalence audits.

Managing and preventing vascular catheter infections: A position paper of the international society for infectious diseases

A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview recommendations on managing and preventing vascular catheter infections, specifically for the prevention and management of central line-associated bloodstream infections. These recommendations are intended to provide insight for healthcare professionals regarding the prevention of infection in the placement and maintenance of the catheter and diagnosis as well as treatment of catheter infection. Aspects of this area in pediatrics and in limited-resource situations and a discussion regarding the selection of empiric or targeted antimicrobial therapy are particular strengths of this position paper.

Urokinase Lock or Flush Solution for Prevention of Bloodstream Infections Associated with Central Venous Catheters for Chemotherapy: A Meta-Analysis of Prospective Randomized Trials

Background

Intravascular devices (IVDs) carry significant risk of device-associated bloodstream infection (BSI). Catheter thrombosis increases the likelihood of microbial colonization of the catheter and BSI. Urokinase has been studied for the prevention of BSI associated with IVDs. We undertook a systematic review to determine the efficacy of urokinase-heparin lock or flush solution compared with heparin alone in preventing IVD-associated BSI.

Methods

Computerized databases were searched for relevant publications in English from January 1966 to 1 January 2007. We identified randomized controlled trials comparing a urokinase-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term IVDs. Summary effect sizes were calculated with assessment of heterogeneity.

Results

Five randomized, controlled trials involving a total of 991 patients being treated with IVDs met the inclusion criteria; all five studies were conducted among patients with cancer; three of these studies were undertaken in children and two in adults. The summary risk ratio with a urokinase-heparin lock solution for IVD-associated BSI was 0.77 (95% confidence interval [CI], 0.60–0.98; p=0.01). Results of the test for heterogeneity were not statistically significant (p=0.53).

Conclusions

Use of a urokinase lock solution in high-risk patient populations being treated with long-term central IVDs may reduce the risk of BSI. However, there are few randomized trials and methodologic limitations of these preclude more robust recommendations regarding the use of urokinase to prevent BSI. Further adequately powered studies should seek to evaluate the efficacy of urokinase and optimize dosage and instillation regimen.

Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India

Objective

To evaluate the incidence, risk factors and associated mortality of central line-associated bloodstream infection (CLABSI) in an adult intensive care unit (ICU) in India.

Design

This prospective observational study was conducted over a period of 16 months at a tertiary care referral medical center.

Setting

We conducted this study over a period of 16 months at a tertiary care referral medical center.

Participants

All patients with a central venous catheter (CVC) for >48 h admitted to the ICU were enrolled.

Intervention and main outcome measures

Patient characteristics included were underlying disease, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) scores and outcome. Statistical analysis of risk factors for their association with mortality was also done.

Results

There were 3235 inpatient-days and 2698 catheter-days. About 46 cases of CLABSI were diagnosed during the study period. The overall rate of CLABSI was 17.04 per 1000 catheter-days and 14.21 per 1000 inpatient-days. The median duration of hospitalization was 23.5 days while the median number of days that a CVC was in place was 17.5. The median APACHE II and SOFA scores were 17 and 10, respectively. Klebsiella pneumoniae was the most common organism (n = 22/55, 40%). Immunosuppressed state and duration of central line more than 10 days were significant factors for developing CLABSI. SOFA and APACHE II scores showed a tendency towards significance for mortality.

Conclusions

Our results underscore the need for strict institutional infection control measures. Regular training module for doctors and nurses for catheter insertion and maintenance with a checklist on nurses' chart for site inspection and alerts in all shifts are some measures planned at our center.

Central line-associated blood stream infections: characteristics and risk factors for mortality over a 5.5-year period

BACKGROUND/AIM

Central line-associated bloodstream infections (CLABSIs) are associated with substantial morbidity and mortality and the infection rates vary in a wide range1397645907(high: 62.5%; low: 20%) in developing countries. We aimed to investigate the characteristics and the risk factors for mortality in patients with CLABSIs in intensive care units (ICUs) and provide the relevant data.

MATERIALS AND METHODS

The electronic medical records database and file records obtained through active surveillance by an infection control committee of a hospital were screened to identify patients with CLABSIs hospitalized from January 2008 through July 2013.

RESULTS

A total of 166 CLABSI episodes in 158 patients out of 17,553 on 38,562 catheter and 94,512 hospitalization days were evaluated. The infection developed in catheterized patients at a median of 14 days (range 2-88), and the highest infection rate with 13.4% (n = 20) was the femoral region among the places where the catheter was inserted. Of the patients catheterized, 54.4% survived whereas 45.6% died. In patients having Candida infection, the mortality was significantly higher. High APACHE II scores and Candida infections were found to be significant risk factors associated with mortality.

CONCLUSION

APACHE II scores and bloodstream infection with Candida species were the most powerful predictors of mortality. In ICU practice, health-care givers must consider the emerging role of Candida for both invasiveness and mortality.

Risk Factors for Central line associated Bloodstream Infections

OBJECTIVE

To carry out surveillance of central line associated bloodstream infections in a Pediatric intensive care unit (PICU) and determine associated risk factors.

METHODS

This prospective study was conducted over 1.5 years in the PICU. CDC definitions for these infections were followed and associated risk factors were identified.

RESULTS

Of 265 enrolled children with central line, 13 developed blood stream infections (incidence density 5.03/1000 central line days). Significant risk factors included changing the central-line, especially triple lumen, and frequently accessing the central line.

CONCLUSION

Central line associated bloodstream infections are preventable primary bacteremias and intervention strategies for prevention should be based on evidence generated to devise future protocols.

Impact of Switching from an Open to a Closed Infusion System on Rates of Central Line–Associated Bloodstream Infection: A Meta-analysis of Time-Sequence Cohort Studies in 4 Countries

Background.

We report a meta-analysis of 4 identical time-series cohort studies of the impact of switching from use of open infusion containers (glass bottle, burette, or semirigid plastic bottle) to closed infusion containers (fully collapsible plastic containers) on central line-associated bloodstream infection (CLABSI) rates and all-cause intensive care unit (ICU) mortality in 15 adult ICUs in Argentina, Brazil, Italy, and Mexico.

Methods.

All ICUs used open infusion containers for 6–12 months, followed by switching to closed containers. Patient characteristics, adherence to infection control practices, CLABSI rates, and ICU mortality during the 2 periods were compared by χ2test for each country, and the results were combined using meta-analysis.

Results.

Similar numbers of patients participated in 2 periods (2,237 and 2,136). Patients in each period had comparable Average Severity of Illness Scores, risk factors for CLABSI, hand hygiene adherence, central line care, and mean duration of central line placement. CLABSI incidence dropped markedly in all 4 countries after switching from an open to a closed infusion container (pooled results, from 10.1 to 3.3 CLABSIs per 1,000 central line-days; relative risk [RR], 0.33 [95% confidence interval {CI}, 0.24-0.46];P<.001). All-cause ICU mortality also decreased significantiy, from 22.0 to 16.9 deaths per 100 patients (RR, 0.77 [95% CI, 0.68-0.87];P<.001).

Conclusions.

Switching from an open to a closed infusion container resulted in a striking reduction in the overall CLABSI incidence and all-cause ICU mortality. Data suggest that open infusion containers are associated with a greatiy increased risk of infusion-related bloodstream infection and increased ICU mortality that have been unrecognized. Furthermore, data suggest CLABSIs are associated with significant attributable mortality.

Excess Length of Stay Due to Central Line–Associated Bloodstream Infection in Intensive Care Units in Argentina, Brazil, and Mexico

Objective.

To estimate the excess length of stay in an intensive care unit (ICU) due to a central line-associated bloodstream infection (CLABSI), using a multistate model that accounts for the timing of infection.

Design.

A cohort of 3,560 patients followed up for 36,806 days in ICUs.

Setting.

Eleven ICUs in 3 Latin American countries: Argentina, Brazil, and Mexico.

Patients.

All patients admitted to the ICU during a defined time period with a central line in place for more than 24 hours.

Results.

The average excess length of stay due to a CLABSI increased in 10 of 11 ICUs and varied from -1.23 days to 4.69 days. A reduction in length of stay in Mexico was probably caused by an increased risk of death due to CLABSI, leading to shorter times to death. Adjusting for patient age and Average Severity of Illness Score tended to increase the estimated excess length of stays due to CLABSI.

Conclusions.

CLABSIs are associated with an excess length of ICU stay. The average excess length of stay varies between ICUs, most likely because of the case-mix of admissions and differences in the ways that hospitals deal with infections.

Excess Length of Stay Due to Central Line–Associated Bloodstream Infection in Intensive Care Units in Argentina, Brazil, and Mexico

Objective.

To estimate the excess length of stay in an intensive care unit (ICU) due to a central line-associated bloodstream infection (CLABSI), using a multistate model that accounts for the timing of infection.

Design.

A cohort of 3,560 patients followed up for 36,806 days in ICUs.

Setting.

Eleven ICUs in 3 Latin American countries: Argentina, Brazil, and Mexico.

Patients.

All patients admitted to the ICU during a defined time period with a central line in place for more than 24 hours.

Results.

The average excess length of stay due to a CLABSI increased in 10 of 11 ICUs and varied from -1.23 days to 4.69 days. A reduction in length of stay in Mexico was probably caused by an increased risk of death due to CLABSI, leading to shorter times to death. Adjusting for patient age and Average Severity of Illness Score tended to increase the estimated excess length of stays due to CLABSI.

Conclusions.

CLABSIs are associated with an excess length of ICU stay. The average excess length of stay varies between ICUs, most likely because of the case-mix of admissions and differences in the ways that hospitals deal with infections.

Simultaneous placement of multiple central lines increases central line-associated bloodstream infection rates

BACKGROUND

Surveillance for central line (CL)-associated bloodstream infections (CLABSIs) is generally advocated. However, the standard definition of this surveillance does not take into account the number of CLs in place and thus the possibility of increased infection risk with multiple CLs in place simultaneously. In this study, we tested the hypothesis that simultaneous placement of more than 1 CL is associated with an increased CLABSI rate.

METHODS

The number of CLs, CL-days, and CLABSIs and CLABSI rates with regard to the number of CLs in place simultaneously was documented in 2 intensive care units between 2001 and 2011. Standard CLABSI rates, as well as the rates for 1 CL and multiple CLs in place, were calculated.

RESULTS

The average CLABSI rate was significantly lower in patients with 1 CL in place compared with those with more than 1 CL in place (3.69 per 1,000 CL-days vs 13.09/1,000 CL-days; incidence rate ratio [IRR], 3.63; 95% confidence interval [CI], 2.61-5.05). Importantly, all differences from the standard rate (5.94/1,000 CL-days) were significant (1 CL vs standard: IRR, 0.61; 95% CI, 0.51-0.74; more than 1 CL vs standard: IRR, 2.23; 95% CI, 1.87-2.65; both P < .0001).

CONCLUSIONS

Our data show that the number of CLs in place had a strong influence on CLABSI rates. Thus, we advocate stratifying patients by the number of CLs in place to take this increased risk of infection into account during surveillance.

In vitro activity and durability of a combination of an antibiofilm and an antibiotic against vascular catheter colonization

Catheter-associated infections can cause severe complications and even death. Effective antimicrobial modification of catheters that can prevent device colonization has the potential of preventing clinical infection. We studied in vitro the antimicrobial activities of central venous catheters impregnated with N-acetylcysteine (NAC), an antibiofilm agent, and a broad-spectrum antibiotic against a range of important clinical pathogens. NAC-levofloxacin-impregnated (NACLEV) catheters were also evaluated for their antiadherence activity. NACLEV catheters produced the most active and durable antimicrobial effect against both Gram-positive and Gram-negative isolates and significantly reduced colonization (P < 0.0001) by all tested pathogens compared to control catheters. These in vitro results suggest that this antimicrobial combination can potentially be used to combat catheter colonization and catheter-associated infection.

Density of microbial colonization on external and internal surfaces of concurrently placed intravascular devices

BACKGROUND

Intravascular devices provide essential vascular access for management of critically ill patients but can be associated with bloodstream infections.

OBJECTIVES

To determine colonization rates in segments of concurrently placed peripheral arterial, nontunnelled short-term central venous catheters and peripherally inserted central catheters and the pattern of heaviest colonization when the catheters are removed.

METHODS

A prospective study was conducted on inpatients with intravascular devices in place for 9 days or more. At removal, each catheter was cut into 3 segments, and each segment was cultured separately. The density of colonization on external and internal surfaces of each segment was compared by estimating odds ratios by repeated-measures ordinal logistic regression.

RESULTS

A total of 48 peripheral arterial, 135 central venous, and 106 peripherally inserted central catheters were obtained from 289 patients. Colonization was greatest at the proximal external segment of all catheters. On the external surface, colonization was lower on the middle (odds ratio, 0.70; P < .001) and distal (odds ratio, 0.56; P < .001) segments than on the proximal segments. On the internal surface, colonization was lower on the proximal (odds ratio, 0.39; P < .001), middle (odds ratio, 0.30; P < .001), and distal (odds ratio, 0.31; P < .001) segments than on the external proximal segments. This trend was similar for all catheter types.

CONCLUSION

Colonization of intravascular devices was heaviest on proximal segments.

In vitro potency and in vivo efficacy of a novel bis-indole antimicrobial compound in reducing catheter colonization

Vascular catheters coated with a novel antimicrobial agent (MBX1631) were studied for their ability to protect against bacterial colonization in vitro and in a rabbit model. MBX1631-coated catheters were significantly less likely to become colonized than control catheters both in vitro and in vivo (P < 0.001). Furthermore, device-associated infection was significantly lower in MBX1631-coated catheters than in uncoated ones (P < 0.005).

Influence of parenteral nutrition delivery system on the development of bloodstream infections in critically ill patients: an international, multicenter, prospective, open-label, controlled study--EPICOS study

BACKGROUND

Parenteral nutrition (PN) is associated with an increased risk of developing bloodstream infections (BSIs) but the impact of the PN delivery system upon BSI rates remains unclear. This was an international, multicenter, prospective, randomized, open-label, controlled trial that investigated the differences of BSIs associated with 2 different PN systems.

METHODS

Patients were randomly allocated in a 2:1:1 ratio to receive either PN delivered by a multichamber bag (MCB group), or by compounded PN made with olive oil (COM1 group) or with MCT/LCT (COM2 group). Blood cultures were performed to evaluate the incidence of BSIs, and catheter use data was collected to calculate CLAB and central venous catheter device use ratio (CVC-DUR). Secondary outcomes included the development of severe sepsis/septic shock, number of intensive care unit (ICU) and hospital days, and all-cause mortality at Day 28.

RESULTS

406 patients were included: 202 in the MCB group, 103 in the COM1 group, and 101 in the COM2 group. Baseline characteristics were well balanced between the 3 groups, BSIs were significantly higher in patients receiving compounded PN (46 BSIs for COM1+COM2 vs 34 BSIs for MCB; p = 0.03).CLAB was higher in patients receiving compounded PN (13.2 for COM1+COM2 vs 10.3 for MCB; p < 0.0001). No differences were observed for the secondary outcomes.

CONCLUSION

Compounded PN was associated with a higher incidence of BSIs and CLABs, suggesting that the use of MCB PN may play a role in reducing the incidence of BSIs in patients who receive PN.

TRIAL REGISTRATION NUMBER

NCT00798681.

Central Line-Associated Blood Stream Infection in the Critically Ill Trauma Patient

Blood stream infections in the critically ill are a common cause of morbidity. Strict adherence to sterile technique can reduce central line-associated blood stream infections (CLBSIs) and has become a quality improvement measure. We did a retrospective review of 6,014 trauma admissions representing 10,370 catheter days. CLBSI was defined as a positive blood culture with central venous access without evidence of other infectious sources. Thirty-five CLBSIs were identified in the study period (3.26/1,000 line days). The average Injury Severity Score was 32, the average intensive care unit stay was 24 days, and the average overall length of stay was 34 days, which is higher than that of nonCLBSI patients. In 25/35 cases, there was a break in sterile technique during central venous catheter placement (71%). Of the 25 cases, 16 of them were performed in the intensive care unit (64%), five in the operating room (20%), and four in the emergency department (16%). Twenty of the 35 patients with CLBSI (57%) had a total of 24 infections, a 2-fold increase in infectious complications for a given Injury Severity Score. Seventeen (17) of the 25 “dirty” central lines (68%) were changed within 24 hours in an effort to reduce the risk of CLBSI without success. A large percentage of CLBSI can be traced to the initial placement of a central venous line under less than ideal sterile technique. Changing a line within 24 hours may not be sufficient to reduce the risk of CLBSI. Every effort should be made to adhere to proper sterile technique while placing central venous catheter.

Efficacy of trypsin in enhancing assessment of bacterial colonisation of vascular catheters

Since the number of organisms isolated from a medical device is crucial in assessing the likelihood of device-associated infection, we examined whether incubation of catheters in trypsin before sonication can increase the yield of superficially colonised vascular catheters in vitro and those removed from patients. Polyurethane and silicone catheters were individually colonised in vitro with individual clinical isolates including Staphylococcus aureus and Escherichia coli. Equal numbers of 1 cm segments of colonised catheters were then individually incubated either in a trypsin-containing solution or a control solution without trypsin. Each solution containing the segment was then sonicated and cultured quantitatively. In the clinical arm, indwelling catheters removed from patients were also cut into 1 cm segments that were equally suspended in the trypsin-containing or control solution and then sonicated and cultured quantitatively. Trypsin-based sonication enhanced the detection of S. aureus on colonised polyurethane and silicone catheters in vitro by 14- and 30-fold, respectively (P = 0.03 and P = 0.04), and the detection of E. coli on colonised polyurethane and silicone catheters by 3- and 6-fold, respectively (P = 0.04 and P = 0.05). Compared with sonication alone, trypsin followed by sonication resulted in 10% increase in the detectability of significant colonisation of indwelling catheters removed from patients and 11% increase in the mean colony counts of colonising organisms (P = 0.04). Exposure of catheters to trypsin before sonication improves the sensitivity of sonication and enhances the accuracy of assessing significant catheter colonisation.

Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries

BACKGROUND

The International Nosocomial Infection Control Consortium (INICC) was established in 15 developing countries to reduce infection rates in resource-limited hospitals by focusing on education and feedback of outcome surveillance (infection rates) and process surveillance (adherence to infection control measures). We report a time-sequence analysis of the effectiveness of this approach in reducing rates of central line-associated bloodstream infection (CLABSI) and associated deaths in 86 intensive care units with a minimum of 6-month INICC membership.

METHODS

Pooled CLABSI rates during the first 3 months (baseline) were compared with rates at 6-month intervals during the first 24 months in 53,719 patients (190,905 central line-days). Process surveillance results at baseline were compared with intervention period data.

RESULTS

During the first 6 months, CLABSI incidence decreased by 33% (from 14.5 to 9.7 CLABSIs per 1,000 central line-days). Over the first 24 months there was a cumulative reduction from baseline of 54% (from 16.0 to 7.4 CLABSIs per 1,000 central line-days; relative risk, 0.46 [95% confidence interval, 0.33-0.63]; P < .001). The number of deaths in patients with CLABSI decreased by 58%. During the intervention period, hand hygiene adherence improved from 50% to 60% (P < .001); the percentage of intensive care units that used maximal sterile barriers at insertion increased from 45% to 85% (P < .001), that adopted chlorhexidine for antisepsis increased from 7% to 27% (P < .001), and that sought to remove unneeded catheters increased from 37% to 83% (P < .001); and the duration of central line placement decreased from 4.1 to 3.5 days (P < .001).

CONCLUSIONS

Education, performance feedback, and outcome and process surveillance of CLABSI rates significantly improved infection control adherence, reducing the CLABSI incidence by 54% and the number of CLABSI-associated deaths by 58% in INICC hospitals during the first 2 years.

Should we use closed or open infusion containers for prevention of bloodstream infections?

Background

Hospitalized patients in critical care settings are at risk for bloodstream infections (BSI). Most BSIs originate from a central line (CL), and they increase length of stay, cost, and mortality. Open infusion containers may increase the risk of contamination and administration-related (CLAB) because they allow the entry of air into the system, thereby also providing an opportunity for microbial entry. Closed infusion containers were designed to overcome this flaw. However, open infusion containers are still widely used throughout the world.

The objective of the study was to determine the effect of switching from open (glass, burettes, and semi-rigid) infusion containers to closed, fully collapsible, plastic infusion containers (Viaflex^®) on the rate and time to onset of central line-associated bloodstream infections CLABs.

Methods

An open label, prospective cohort, active healthcare-associated infection surveillance, sequential study was conducted in four ICUs in Mexico. Centers for Disease Control National Nosocomial Infections Surveillance Systems definitions were used to define device-associated infections.

Results

A total of 1,096 adult patients who had a central line in place for >24 hours were enrolled. The CLAB rate was significantly higher during the open versus the closed container period (16.1 versus 3.2 CLAB/1000 central line days; RR = 0.20, 95% CI = 0.11-0.36, P < 0.0001). The probability of developing CLAB remained relatively constant in the closed container period (1.4% Days 2-4 to 0.5% Days 8-10), but increased in the open container period (4.9% Days 2-4 to 5.4% Days 8-10). The chance of acquiring a CLAB was significantly decreased (81%) in the closed container period (Cox proportional hazard ratio 0.19, P < 0.0001). Mortality was statistically significantly lower during the closed versus the open container period (23.4% versus 16.1%; RR = 0.69, 95% CI = 0.54-0.88, P < 0.01).

Conclusions

Closed infusion containers significantly reduced CLAB rate, the probability of acquiring CLAB, and mortality.

Antimicrobial catheters in the ICU: is the juice worth the squeeze?

Catheter-related bloodstream infection is one of the most serious complications of central venous access devices. Antimicrobial-coated catheters represent one novel strategy to prevent catheter-related bloodstream infection. A comprehensive economic evaluation is essential to guide informed decision-making regarding the adoption of this technology and its expected benefits in healthcare institutions.

Impact on rates and time to first central vascular-associated bloodstream infection when switching from open to closed intravenous infusion containers in a hospital setting

An open-label, prospective cohort, active healthcare-associated infection surveillance sequential study was conducted in four Italian intensive-care units. The aim was to determine the effect of switching from open (glass) to closed fully collapsible plastic intravenous (i.v.) infusion containers (Viaflo®) on rate and time to onset of central venous catheter-associated bloodstream infections (CVC-BSI). A total of 1173 adult patients were enrolled. The CVC-BSI rate during the open container period was significantly higher than during the closed container period (8·2vs. 3·5 BSI/1000 CVC days, relative risk 0·43, 95% confidence interval 0·22–0·84,P=0·01). The probability of developing a CVC-BSI was assessed over time comparing open and closed i.v. infusion containers. In the closed container period, it remained fairly constant (0·8% at days 1–3 to 1·4% at days 7–9) whereas during the open container period it increased (2% at days 1–3 to 5·8% at days 7–9). Overall, the chance of acquiring a CVC-BSI significantly decreased by 61% in the closed container period (Cox proportional hazard ratio 0·39,P=0·004).

[Intensive care nurses' knowledge about the evidence-based guidelines of preventing central venous catheter related infection]

OBJECTIVES

To determine intensive care unit (ICU) nurses' knowledge of evidence-based guidelines for preventing central venous catheter (CVC) related infection.

METHOD

We used a validated multiple-choice questionnaire which was distributed to intensive care units between October and December 2006. We collected demographic data, like gender, years of ICU experience, number of ICU beds and whether respondents hold a special degree in intensive care.

RESULTS

We collected 178 questionnaires from 11 intensive care units; the mean score was 3.66 on 10 questions (37%). Eighteen per cent knew that CVCs should be replaced on indication only, and 61% knew that this recommendation concerns also replacement over a guidewire. Recommendations for replacing pressure transducers and tubing every 4 days, and for using coated devices in patients requiring a CVC < 5 days in settings with high infection rates were recognized only by 48% and 66%, respectively. Regarding CVC dressings, 15% knew that these should be changed only when indicated and at least once weekly, and 35% recognized that both poly-urethane and gauze dressings can be recommended. Only 20% checked 2% aqueous chlorhexidine as recommended disinfection solution; 14% knew antibiotic ointments are not recommended because they trigger resistance. The recommendation to replace administration sets within 24 hours after administering lipid emulsions was recognized by 85%, but it was known by 5% only that these sets should be replaced every 96 hours when administering neither lipid emulsions nor blood products. Professional seniority and the number of intensive care beds in the ICU where nurses work showed not to be associated with better scores on the test.

DISCUSSION

Knowledge regarding CVC-related infection is poor among Hungarian nurses. Prevention guidelines should be included in the nurse education curriculum as well as in continuing refresher nursing education programs.

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.

Use of Vancomycin-Containing Lock or Flush Solutions for Prevention of Bloodstream Infection Associated with Central Venous Access Devices: A Meta-Analysis of Prospective, Randomized Trials

BACKGROUND

Prolonged exposure to central venous access devices carries significant risk of device-associated bloodstream infection (BSI), which is associated with morbidity, added health care costs, and attributable mortality. We aimed to determine the efficacy of vancomycin-heparin lock or flush solution in preventing BSI in patients being treated with long-term central venous intravascular devices (IVDs).

METHODS

We collected data from January 1966 to January 2006 from multiple computerized databases and compiled reference lists of identified articles. We identified prospective, randomized controlled trials comparing a vancomycin-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term central venous IVDs. Using a standardized form, we abstracted data regarding study quality, patient characteristics, and incidence of BSI.

RESULTS

Seven randomized, controlled trials involving a total of 463 patients being treated with IVDs met the inclusion criteria; 5 studies were conducted among patients with cancer, 1 among a critically ill neonatal population, and 1 among patients with cancer or who required parenteral nutrition. We could not detect publication bias. The summary risk ratio with a vancomycin heparin-lock solution for IVD-associated BSI was 0.49 (95% confidence interval [CI], 0.26-0.95; P = .03). Results of the test for heterogeneity were statistically significant; however, when a single study was removed from the analysis, heterogeneity was no longer present. Use of vancomycin as a true lock solution--instilling it for a defined period, rather than simply flushing it directly through the device--conferred a much greater benefit, with a risk ratio of 0.34 (95% CI, 0.12-0.98; P = .04). The 2 studies that performed prospective surveillance cultures to identify colonization or infection by vancomycin-resistant organisms did not find an increased risk.

CONCLUSIONS

Use of a vancomycin lock solution in high-risk patient populations being treated with long-term central IVDs reduces the risk of BSI. The use of an anti-infective lock solution warrants consideration for patients who require central access but who are at high risk of BSI, such as patients with malignancy or low-birthweight neonates.

Infectious Complications of Cancer Therapy

Advances in the management of cancer, particularly the development of new chemotherapeutic agents, have greatly improved the survival and outcome of patients with hematologic malignancies and solid tumors; overall 5-year survival rates in cancer patients have improved from 39% in the 1960s to 60% in the 1990s.1 However, infection, caused by both the underlying malignancy and cancer chemotherapy, particularly myelosuppressive chemotherapy, remains a persistent challenge.

Diagnosis of catheter-related bloodstream infection

Catheter-related bloodstream infection is a potentially serious condition with a mortality rate of 12% to 25%. Catheter-related bacteremia is difficult to diagnose, and clinical manifestations of the condition have proved to be unspecific and often inconclusive. Microbiologic techniques to diagnose catheter-related bloodstream infection have been developed, some of which require catheter removal whereas others do not. Differential time to positivity has demonstrated marked accuracy and practicality as it allows the catheter to remain in place. Many other methods, such as skin or hub cultures, show less remarkable results, and some, such as intraluminal brushing, may produce adverse effects. Once a catheter-related bloodstream infection is diagnosed, it is classified as either complicated or uncomplicated and treated accordingly.

The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico

PURPOSE

To ascertain the effect of an infection control program including process control on intensive care unit (ICU) rates of intravascular device (IVD)-associated bloodstream infection (BSI).

SETTING

Two level III adult ICUs in one public university hospital in Mexico: one medical surgical ICU and one neurosurgical ICU. POPULATION STUDY: All adult patients admitted to study units who had a central venous catheter (CVC) in place for at least 24 hrs.

METHODS

A prospective before/after trial in which rates of IVD-associated BSI are determined during a period of active surveillance without process control (phase 1) were compared with rates of IVD-associated BSI after implementing an infection control program applying process control (phase 2).

RESULTS

Six hundred five IVD-days were accumulated in phase 1, and 2824 IVD-days were accumulated during phase 2. Compliance with CVC site care and hand hygiene improved significantly from baseline during the study period: placing a gauze dressing over the catheter insertion site (99.24% vs. 86.69%, respectively; relative risk [RR] = 1.14; 95% confidence interval [CI] = 1.07-1.22; p = .0000), proper use of gauze for vascular catheter insertion site (97.87% vs. 84.21%, respectively; RR = 1.16; 95% CI = 1.09-1.24; p = .0000), documentation of the duration of the administration set of the vascular catheter (93.85% vs. 40.69%, respectively; RR = 2.34; 95% CI = 2.14-2.56; p = .0000), and hand hygiene before contact with the patient (84.9% vs. 62%, respectively; RR = 1.37; 95% CI = 1.21-1.51; p = .0000). Overall rates of IVD-associated BSI were lowered significantly from baseline rates after implementation of process control (19.5 vs. 46.3 BSIs per 1000 IVD-days, respectively; RR = 0.42; 95% CI = 0.27-0.66; p = .0001). Overall rates of crude unadjusted mortality were lowered significantly from baseline rates (48.5% vs. 32.8% per 100 discharges, respectively; RR = 0.68; 95% CI = 0.50-0.31; p = .01).

CONCLUSION

Implementation of an infection control program utilizing education, process control, and performance feedback was associated with significant reductions in rates of IVD-associated BSI and mortality.

Central venous catheters in home infusion care: outcomes analysis in 50,470 patients

PURPOSE

Outpatient home infusion therapy is increasing; however, little data exist on the outcomes of patients receiving care. The purpose of this study was to document the natural history of central venous catheters (CVCs) used in home infusion care to determine the rate and type of catheter complications.

MATERIALS AND METHODS

Data from the Strategic HealthCare Programs National Database from April 1999 to September 2000 were analyzed. Primary study objectives were to identify (i) types of CVCs and principal diagnoses, (ii) type and rate of catheter complications, and (iii) outcomes in managing thrombotic catheter complications. Event rates were calculated per 1,000 catheter days; 50,470 patients representing 2.83 million catheter days met study criteria.

RESULTS

The rates of complications (per 1,000 catheter days) for the most common events were: catheter dysfunction (0.83 total; 0.6 nonthrombotic, 0.23 thrombotic), catheter site infections (0.26), and bloodstream infections (BSIs; 0.19). A total of 4,138 complication events were identified (event rate per 1,000 days: 1.5). The total rates of complications with each catheter type were: midline catheters (4.5), PICCs (2.0), nontunneled central catheters (1.1), tunneled catheters (1.0), and chest ports (0.52). Catheter dysfunction with loss of patency was the most common group of complications. Thrombotic occlusion was the principal cause of catheter dysfunction, occurring in 28% of patients in this group, typically within 7 days of catheter insertion. BSI was reported in 541 patients, generally more than 30 days after catheter insertion. Catheter thrombosis outcomes resulted in therapy interruption (43%), catheter replacement (29%), premature CVC removal (14%), unscheduled emergency room visits (9%), and/or hospitalizations (6%).

CONCLUSION

Catheter dysfunction is the most frequent complication of all CVCs in this population, almost twice that of infections. Outpatient home infusion catheter dysfunction results in delays to therapy, unscheduled hospitalizations, and need for device replacement.