Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine

Los isópodos terrestres de Andalucía, España (Crustacea: Isopoda, Oniscidea)

Los isópodos terrestres de Andalucía han sido objeto de numerosos estudios, por lo que el inventario de especies citadas ascendía a 90. En este trabajo se han estudiado 2.046 ejemplares pertenecientes a 41 especies y se ha realizado una revisión bibliográfica de todas las citas anteriores. Como consecuencia, 13 especies se eliminan del inventario original por tratarse de errores en la determinación, porque su estatus como especie es dudoso, o por la carencia en su descripción de rasgos que permitan distinguirlas de otras especies de manera inequívoca. Por tanto, la fauna conocida de isópodos terrestres de Andalucía está formada por 77 especies, pertenecientes a 30 géneros y 11 familias. Para todas ellas se facilita su distribución en Andalucía y una distribución general en el área iberobalear. Se proporcionan datos inéditos para 41 de ellas. Se citan 4 nuevas especies por primera vez para Andalucía, y otras 20 especies para alguna de las provincias andaluzas. La familia Porcellionidae Brandt & Ratzeburg, 1831, con 38 especies, y el género Porcellio Latreille, 1804, con 24 especies, son los que presentan mayor riqueza en la región. A nivel provincial, Málaga con 39 especies conocidas es la más rica, seguida de Cádiz (36) y Almería (34). En Andalucía solamente se conocen 11 especies endémicas de isópodos, el 14% de su fauna, frente al 52% del área iberobalear. De todas las especies citadas, solamente cuatro (5%) son cavernícolas.

Reduction of bacterial colonization at the exit site of peripherally inserted central catheters: A comparison between chlorhexidine-releasing sponge dressings and cyano-acrylate

INTRODUCTION

A serious complication associated with Central Venous Access Device (CVAD) is infection because of bacterial contamination, either by the extra-luminal or by the intra-luminal route.We evaluated the efficacy, the safety, and the cost-effectiveness of two strategies for non-inferiority in controlling bacterial colonization of the exit-site of Peripherally-Inserted Central Catheters (PICC).

METHODS

After PICC placement, a skin swab of the exit site was taken and cultured. In group A the exit site was sealed with N-butyl-cyanoacrylate glue, while in group B a chlorhexidine-releasing sponge dressing was applied. A second skin culture was taken at day 7.

RESULTS

A total of 51 patients were enrolled in each group. In 42 patients the second skin culture was not performed because of 20 patients were lost at follow-up or deceased and in 22 patients the dressing needed to be changed early, because of local bleeding (13 cases, in group B) or because of dressing detachment (four in group A and five in group B). The microbiological study was completed in 36 patients in group A and 24 in group B. No microorganisms were isolated in any patient.

CONCLUSIONS

Both strategies were effective in controlling bacterial colonization. Glue was effective in reducing local bleeding, and it was more cost-effective than sponge dressing. During the first week, when local bleeding and bacterial colonization must be prevented, glue might be more appropriate than chlorhexidine-releasing dressing; after the first week chlorhexidine-releasing dressing might be preferable, considering that the safety of glue application on the skin for prolonged periods is still questionable.

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.

Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis

BACKGROUND

Antimicrobial peripherally inserted central catheters (PICCs) may reduce the risk of central line-associated bloodstream infection (CLABSI). However, data regarding efficacy are limited. We aimed to evaluate whether antimicrobial PICCs are associated with CLABSI reduction.

METHODS

MEDLINE, EMBASE, CINHAL, and Web of Science were searched from inception to July 2016; conference proceedings were searched to identify additional studies. Study selection and data extraction were performed independently by 2 authors.

RESULTS

Of 597 citations identified, 8 studies involving 12,879 patients met eligibility criteria. Studies included adult and pediatric patients from intensive care, long-term care, and general ward settings. The incidence of CLABSI in patients with antimicrobial PICCs was 0.2% (95% confidence interval [CI], 0.0%-0.5%), and the incidence among nonantimicrobial catheters was 5.3% (95% CI, 2.6%-8.8%). Compared with noncoated PICCs, antimicrobial PICCs were associated with a significant reduction in CLABSI (relative risk [RR], 0.29; 95% CI, 0.10-0.78). Statistical heterogeneity (I², 71.6%; T2 = 1.07) was resolved by publication type, with peer-reviewed articles showing greater reduction in CLABSI (RR, 0.21; 95% CI, 0.06-0.74). Twenty-six patients (95% CI, 21-75) need to be treated with antimicrobial PICCs to prevent 1 CLABSI. Studies of adults at greater baseline risk of CLABSI experienced greater reduction in CLABSI (RR, 0.20; P = .003).

CONCLUSIONS

Available evidence suggests that antimicrobial PICCs may reduce CLABSI, especially in high-risk subgroups. Randomized trials are needed to assess efficacy across patient populations.

Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review

IMPORTANCE

Although quality improvement (QI) interventions can reduce central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI), their economic value is uncertain.

OBJECTIVE

To systematically review economic evaluations of QI interventions designed to prevent CLABSI and/or CRBSI in acute care hospitals.

EVIDENCE REVIEW

A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, Worldcat, prior systematic reviews (January 2004 to July 2016), and IDWeek conference abstracts (2013-2016), was conducted from 2013 to 2016. We included English-language studies of any design that evaluated organizational or structural changes to prevent CLABSI or CRBSI, and reported program and infection-related costs. Dual reviewers assessed study design, effectiveness, costs, and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net savings. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter-days per study per year.

FINDINGS

Of 505 articles, 15 unique studies were eligible, together representing data from 113 hospitals. Thirteen studies compared Agency for Healthcare Research and Quality-recommended practices with usual care, including 7 testing insertion checklists. Eleven studies were based on uncontrolled before-after designs, 1 on a randomized controlled trial, 1 on a time-series analysis, and 2 on modeled estimates. Overall, the weighted mean IRR was 0.43 (95% CI, 0.35-0.51) and incremental net savings were $1.85 million (95% CI, $1.30 million to $2.40 million) per hospital over 3 years (2015 US dollars). Each $100 000-increase in program cost was associated with $315 000 greater savings (95% CI, $166 000-$464 000; P < .001). Infections and net costs declined when hospitals already used checklists or had baseline infection rates of 1.7 to 3.7 per 1000 catheter-days. Study quality was not associated with effectiveness or costs.

CONCLUSIONS AND RELEVANCE

Interventions related to central venous catheters were, on average, associated with 57% fewer bloodstream infections and substantial savings to hospitals. Larger initial investments may be associated with greater savings. Although checklists are now widely used and infections have started to decline, additional improvements and savings can occur at hospitals that have not yet attained very low infection rates.

Chlorhexidine 2% and choice of transparent dressing increase skin reactions at central venous catheter insertion sites

Infection at central venous catheter (CVC) sites remains a common problem, particularly with long-term use. This report discusses the influence of choice of transparent dressing type and chlorhexidine concentration on skin reactions at CVC insertion sites. A concentration of 2% chlorhexidine is associated with a higher rate of skin reactions than either 0.5% or 1% chlorhexidine. Higher chlorhexidine concentrations may not decrease the number of central line-associated bloodstream infections.

The relationship between the tip position of an indwelling venous catheter and the subcutaneous edema

The present observational study aimed to clarify the relationship between the tip position of an indwelling venous catheter and the subcutaneous edema using ultrasonography images. Data were obtained before catheter removal in a medical ward of a university hospital in Tokyo, Japan. Two hundred peripheral intravenous catheters (PIVCs) from 154 patients were observed just before removal. We analyzed data for 194 PIVCs from 150 patients. Subcutaneous edema was observed in 43.8% of ultrasonography images. According to the univariate analysis, insertion site, PIVC tip contact with the vessel wall, and irritant drug's presence were selected as independent variables for logistic regression analysis. Both irritant drug and PIVC tip contact were associated with the presence of subcutaneous edema [adjusted odds ratio (OR) = 2.68, 95% confidence interval (CI) = 1.14-6.33; and OR = 2.01, 95% CI = 1.04-3.88, respectively]. To the best of our knowledge, this is the first study to use ultrasonography to simultaneously observe PIVC tip position and subcutaneous edema. Using ultrasonography to observe PIVC may be a useful method to understand these mechanisms. Medical staff should select an appropriate vein and indwelling catheter to avoid contact of PIVC tip with the vessel wall. Further studies exploring the causality of the relationship between subcutaneous edema, catheter placement, and thrombus formation is required. In addition, further development of nursing skills and medical devices to reduce mechanical stress is required.

Skin antisepsis for reducing central venous catheter-related infections

BACKGROUND

The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs.

OBJECTIVES

To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities.

SEARCH METHODS

In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs).

MAIN RESULTS

Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data.Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidone-iodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidone-iodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study.There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency).Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events.

AUTHORS' CONCLUSIONS

It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.

Eliminating Infections in the ICU: CLABSI

Central line-associated bloodstream infections (CLABSI) are one of the leading causes of death in the USA and around the world. As a preventable healthcare-associated infection, they are associated with significant morbidity and excess costs to the healthcare system. Effective and long-term CLABSI prevention requires a multifaceted approach, involving evidence-based best practices coupled with effective implementation strategies. Currently recommended practices are supported by evidence and are simple, such as appropriate hand hygiene, use of full barrier precautions, avoidance of femoral lines, skin antisepsis, and removal of unnecessary lines. The most successful and sustained improvements in CLABSI rates further utilize an adaptive component to align provider behaviors with consistent and reliable use of evidence-based practices. Great success has been achieved in reducing CLABSI rates in the USA and elsewhere over the past decade, but more is needed. This article aims to review the initiatives undertaken to reduce CLABSI and summarizes the sentinel and recent literature regarding CLABSI and its prevention.

Infection control in the intensive care unit

It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Economic evaluation of chlorhexidine cloths on healthcare costs due to surgical site infections following total knee arthroplasty

The purpose of this study was to evaluate the overall annual healthcare cost savings of adding a pre-operative chlorhexidine cloth preparation protocol. We used reports from the National Healthcare Safety Network and previously published reports to determine a range of surgical site infection rates following total knee arthroplasty and the cost per revision procedure. The savings listed are potential, but may be less. The cost benefit of using chlorhexidine at our institution per 1,000 total knee arthroplasty patients was a net savings of approximately $2.1 million. The annual healthcare savings ranged from $0.78 to $3.18 billion. This epidemiologic evaluation of using chlorhexidine prior to undergoing total knee arthroplasty has demonstrated the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections.

The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis

Background

Skin antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin antisepsis. However, study outcomes due to chlorhexidine-alcohol combinations are often attributed to chlorhexidine alone. Thus, we sought to review the efficacy of chlorhexidine for skin antisepsis and the extent of a possible misinterpretation of evidence.

Methods

We performed a systematic literature review of clinical trials and systematic reviews investigating chlorhexidine compounds for blood culture collection, vascular catheter insertion and surgical skin preparation. We searched PubMed, CINAHL, the Cochrane Library, the Agency for Healthcare Research and Quality website, several clinical trials registries and a manufacturer website. We extracted data on study design, antiseptic composition, and the following outcomes: blood culture contamination, catheter colonisation, catheter-related bloodstream infection and surgical site infection. We conducted meta-analyses of the clinical efficacy of chlorhexidine compounds and reviewed the appropriateness of the authors′ attribution.

Results

In all three application areas and for all outcomes, we found good evidence favouring chlorhexidine-alcohol over aqueous competitors, but not over competitors combined with alcohols. For blood cultures and surgery, we found no evidence supporting chlorhexidine alone. For catheters, we found evidence in support of chlorhexidine alone for preventing catheter colonisation, but not for preventing bloodstream infection. A range of 29 to 43% of articles attributed outcomes solely to chlorhexidine when the combination with alcohol was in fact used. Articles with ambiguous attribution were common (8–35%). Unsubstantiated recommendations for chlorhexidine alone instead of chlorhexidine-alcohol were identified in several practice recommendations and evidence-based guidelines.

Conclusions

Perceived efficacy of chlorhexidine is often in fact based on evidence for the efficacy of the chlorhexidine-alcohol combination. The role of alcohol has frequently been overlooked in evidence assessments. This has broader implications for knowledge translation as well as potential implications for patient safety.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

A research framework for reducing preventable patient harm

Programs to reduce central line-associated bloodstream infections (CLABSIs) have improved the safety of hospitalized patients. Efforts are underway to disseminate these successes broadly to reduce other types of hospital-acquired infectious and noninfectious preventable harms. Unfortunately, the ability to broadly measure and prevent other types of preventable harms, especially infectious harms, needs enhancement. Moreover, an overarching research framework for creating and integrating evidence will help expedite the development of national prevention programs. This article outlines a 5-phase translational (T) framework to develop robust research programs that reduce preventable harm, as follows: phase T0, discover opportunities and approaches to prevent adverse health care events; phase T1, use T0 discoveries to develop and test interventions on a small scale; phase T2, broaden and strengthen the evidence base for promising interventions to develop evidence-based guidelines; phase T3, translate guidelines into clinical practice; and phase T4, implement and evaluate T3 work on a national and international scale. Policy makers should use this framework to fill in the knowledge gaps, coordinate efforts among federal agencies, and prioritize research funding.

Central line-associated bloodstream infections: prevention and management

Approximately 80,000 central venous line-associated bloodstream infections (CLA-BSI) occur in the United States each year. CLA-BSI is most commonly caused by coagulase-negative staphylococci, Staphylococcus aureus, Candida spp, and aerobic gram-negative bacilli. These organisms commonly gain entrance in into the bloodstream via the catheter-skin interface (insertion site) or via the catheter hub. Use of strict aseptic technique for insertion is the key method for the prevention of CLA-BSI. Various methods can be used to reduce unacceptably high rates of CLA-BSI, including use of an antiseptic- or antibiotic-impregnated catheter, daily chlorhexidine baths/washes, and placement of a chlorhexidine-impregnated sponge over the insertion site.

Intervention to reduce catheter-related bloodstream infections in a pediatric intensive care unit

OBJECTIVE

Identification of catheter-related bloodstream infection (CR-BSI) risk factors and determination of whether intervention related to identified risk factors would reduce CR-BSI rates.

DESIGN

Prospective, observational, interventional and interrupted time-series study.

SETTING

Pediatric Intensive Care Unit (PICU) in a university hospital.

METHODS

During a 7-year period, 609 central venous catheters (CVC) were placed in 389 patients. CR-BSI risk factors were determined by multivariate analysis during two periods (January 2000-November 2002 and January 2003-April 2007). An intervention to reduce identified risk factors was performed after the first period. CR-BSI rates per 1,000 catheters-days were compared during the two periods.

RESULTS

The CR-BSI rate was 11.94 [(95% CI 7.94-15.94)/1,000 catheter-days during the first period]. Weight [OR 0.96 (0.91-0.99)], parenteral nutrition (PN) [OR 3.38 (1.40-8.19)] and indwelling time (IT) [OR 1.08 (1.02-1.14)] were CR-BSI risk factors. Practice changes aimed at reducing PN and IT were introduced. PN decreased from 49.8% [95% CI (49.7-49.9)] to 26.7% [(95% CI 26.6-26.8)] (p < 0.001), and IT dropped from 9.92 (95% CI 9.09-10.75) to 8.13 (95% CI 7.47-8.79) days (p < 0.001). The CR-BSI rate was reduced to 3.05 (95% CI 0.93-5.17)/1,000 catheter-days. During the last period, PN and IT were no longer CR-BSI risk factors. Type of catheterisation (guide wire exchange) [OR 6.66 (1.40-31.7)] was the only CR-BSI risk factor.

CONCLUSIONS

PN and IT were independent CR-BSI risk factors during the first period. An intervention focused on PN and IT reduction resulted in a sustained decrease of CR-BSI rates in our PICU.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

Analytic Reviews: Prevention of Central Venous Catheter Bloodstream Infections

The majority of nosocomial bloodstream infections in critically ill patients originate from an infected central venous catheter (CVC). Catheter-related bloodstream infections (CRBSIs) cause significant morbidity and mortality and increase the cost of care. The most frequent causative organisms for CRBSI are coagulase-negative staphylococci (CoNSs), Staphylococcus aureus, enterococci, and Candida species. The path to infection frequently includes migration of skin organisms at the insertion site into the cutaneous catheter tract, resulting in microbial colonization of the catheter tip and formation of biofilm. Evidence-based strategies for the prevention of CRBSI include behavioral and educational interventions, effective skin antisepsis coupled with maximum barrier precautions, the use of antiseptic dressings, and the use of antiseptic or antibiotic impregnated catheters. Achieving and maintaining very low rates of CRBSI requires a multidisciplinary approach involving the entire health care team, the use of novel technologies in patients with the highest risk of CRBSI, and frequent reeducation of staff.

Catheter-related bloodstream infection

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

Assessment of transparency of cost estimates in economic evaluations of patient safety programmes

OBJECTIVES

Transparency of costing is essential for decision-makers who require information on the efficiency of a health care programme, because effective decisions depend largely on applicability to their settings. The main objectives of this study were to assess published studies for transparency of cost estimates.

METHODS

We first developed criteria with two axes by reviewing publications dealing with economic evaluations and cost accounting studies: clarification of the scope of costing and accuracy of method evaluating costs. We then performed systematic searches of the literature for studies which estimated prevention costs and assessed the transparency and accuracy of costing based on our criteria.

RESULTS

Forty studies met the inclusion criteria. Half of the studies reported data for both the quantity and unit price of programmes in regard to prevention costs. Although 30 studies estimated costs of adverse events, 19 of these described the scope of costing only, and just five studies used a micro-costing method. Among 30 studies that estimated 'gross cost savings' and 'net cost savings', there was a huge discrepancy in labels.

CONCLUSIONS

Even if a cost study was conducted in accordance with existing techniques of economic evaluation which mostly paid attention to internal validity of cost estimates, without adequate explanation of the process of costing, reproducibility cannot be assured and the study may lose its value as scientific information. This study found that there is tremendous room for improvement.

Prevention of catheter-related bloodstream infections

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

Tiny patients, tiny dressings: a guide to the neonatal PICC dressing change

Advances in neonatology now support the survival of the tiniest of infants. The peripherally inserted central catheter (PICC) has now become an integral part of routine practice in neonatal intensive care units around the world. Keen attention to safe maintenance of these devices is essential. A properly applied and maintained PICC dressing is the first line of defense to minimize the risk of complications such as dislodgement, migration, and infection. This article describes a neonatal PICC dressing change and discusses the frequently encountered quandaries surrounding this important procedure, including dressing materials, frequency, site preparation, barrier precautions, and other relevant concerns.

Implementation of chlorhexidine gluconate for central venous catheter site care at Siriraj Hospital, Bangkok, Thailand

BACKGROUND

A meta-analysis and cost-effectiveness analysis of randomized controlled trials comparing chlorhexidine gluconate with povidone-iodine solutions for venous catheter site care found that the use of chlorhexidine gluconate significantly reduced the risk for catheter-related bloodstream infections and that it was cost-effective. The objective of the study was to implement locally formulated chlorhexidine gluconate for central venous catheter (CVC) site care in intensive care units (ICUs) at Siriraj Hospital.

METHODS

The study was conducted in 312 subjects who needed CVC insertions in 3 ICUs from January to July 2006. One hundred twenty subjects received 2% chlorhexidine gluconate in 70% alcohol, whereas 192 subjects received 10% povidone-iodine as the antiseptic solution for CVC site care. The patients were assessed for CVC-related infections and for any adverse effects of 2% chlorhexidine gluconate in 70% alcohol.

RESULTS

The incidence of CRBSIs in the indwelling CVC subjects who received 2% chlorhexidine gluconate in 70% alcohol was less than those who received 10% povidone-iodine during the same period, 3.2 versus 5.6 episodes per 1000 CVC days, respectively (P= .06; OR, 3.26; 95% CI: 0.97-10.92). No adverse effects related to using 2% chlorhexidine gluconate in 70% alcohol were observed.

CONCLUSION

The locally formulated 2% chlorhexidine gluconate in 70% alcohol was safe, effective, and efficient for CVC site care in ICUs at Siriraj Hospital.

[Infection control measures and surveillance of patients with ventricular assist devices]

Ventricular assist devices (VAD) are a new routine therapy option for end-stage heart failure. However, the incidence of VAD-related infections varies between 20 and 188% and makes a major contribution to VAD-related morbidity. Therefore, optimised infection control policies should be applied to prevent VAD-related infections. As to date only a few studies exist investigating particular prevention measures for VAD recipients, we have tried to adapt evidence-based guidelines. In detail the following preventive measures are discussed: antibiotic prophylaxis, endocarditis prophylaxis, dressing technique for the driveline-exit site and education of patients and medical staff. A new patient-based surveillance system is proposed which reflects the different times since implantation of VADs and therefore allows a fair method for interhospital comparison.

Comparison of the Safety and Efficacy of Two Topical Antiseptic Products: Chlorhexidine Gluconate + Isopropyl Alcohol and Povidone- Iodine + Isopropyl Alcohol

While antiseptic products containing a combination of chlorhexidine gluconate and isopropyl alcohol (CHG+IPA) have gained in popularity over the past several years in preparing and maintaining vascular access sites, the data used to support their use over products containing povidone-iodine (PVP-I) have been based solely on comparisons of aqueous CHG or CHG+IPA to aqueous PVP-I alone. No studies have compared aqueous CHG or CHG+IPA to PVP-I+IPA or aqueous PVP-I preceded by IPA. When compared using methods established by the U.S. Food and Drug Administration (FDA) and the American Society of Testing and Materials (ASTM), the safety and efficacy of PVP-I+IPA was found to be less irritating and faster acting than CHG+IPA; both PVP-I+IPA and CHG+IPA demonstrated persistence for 7 days.

Prevention of catheter-related blood stream infection

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Economic evaluation and catheter-related bloodstream infections

Catheter-related bloodstream infections are a serious problem. Many interventions reduce risk, and some have been evaluated in cost-effectiveness studies. We review the usefulness and quality of these economic studies. Evidence is incomplete, and data required to inform a coherent policy are missing. The cost-effectiveness studies are characterized by a lack of transparency, short time-horizons, and narrow economic perspectives. Data quality is low for some important model parameters. Authors of future economic evaluations should aim to model the complete policy and not just single interventions. They should be rigorous in developing the structure of the economic model, include all relevant economic outcomes, use a systematic approach for selecting data sources for model parameters, and propagate the effect of uncertainty in model parameters on conclusions. This will inform future data collection and improve our understanding of the economics of preventing these infections.

Use of central venous catheter-related bloodstream infection prevention practices by US hospitals

OBJECTIVE

To examine the extent to which US acute care hospitals have adopted recommended practices to prevent central venous catheter-related bloodstream infections (CR-BSIs).

PARTICIPANTS AND METHODS

Between March 16, 2005, and August 1, 2005, a survey of infection control coordinators was conducted at a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n=600) and at all Department of Veterans Affairs (VA) medical centers (n=119). Primary outcomes were regular use of 5 specific practices and a composite approach for preventing CR-BSIs.

RESULTS

The overall survey response rate was 72% (n=516). A higher percentage of VA compared to non-VA hospitals reported using maximal sterile barrier precautions (84% vs 71%; P=.01); chlorhexidine gluconate for insertion site antisepsis (91% vs 69%; P<.001); and a composite approach (62% vs 44%; P=.003) combining concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Those hospitals having a higher safety culture score, having a certified infection control professional, and participating in an infection prevention collaborative were more likely to use CR-BSI prevention practices.

CONCLUSION

Most US hospitals are using maximal sterile barrier precautions and chlorhexidine gluconate, 2 of the most strongly recommended practices to prevent CR-BSIs. However, fewer than half of non-VA US hospitals reported concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Wider use of CR-BSI prevention practices by hospitals could be encouraged by fostering a culture of safety, participating in infection prevention collaboratives, and promoting infection control professional certification.

Evidence-Based Practice in the Management of Vascular Access Devices for Home Parenteral Nutrition Therapy

Catheter-related bloodstream infection and catheter occlusion are potential significant complications of parenteral nutrition therapy. The increased incidence and associated morbidity, mortality, increased costs, and quality-of-life issues experienced with these adverse events necessitate specialized management of vascular access devices. The host coagulation response to biomaterials and the associated development of biofilm on vascular devices are complex phenomena. Multiple interventions are required to prevent access of bacteria to both intraluminal and extraluminal catheter surfaces, and the occurrence of catheter occlusion. The discovery of the biofilm form of microbial life and the associated recalcitrance of biofilm bacteria to antimicrobials has provided insight into the failure of current prevention, diagnostic, and treatment protocols. Critical interventions are presented correlating current evidence with new discoveries in pathogenesis.

Combination Povidone-Iodine and Alcohol Formulations More Effective, More Convenient Versus Formulations Containing Either Iodine or Alcohol Alone

Topical antiseptic formulations containing single active ingredients of alcohol and iodine are recognized by the Food and Drug Administration as "generally safe and effective" for "preparation of the skin prior to surgery" or "prior to an injection" including "catheter care, ostomy hygiene, and intravenous site preparation" (Federal Register, 1994). However, a synergistic effect results from the combination of ethyl or isopropyl alcohol and povidone-iodine. Because each active ingredient has different modes of action and performance characteristics, these combination formulations are faster acting with a broader spectrum of antimicrobial activity than formulations containing povidone-iodine alone, and more persistent than formulations containing ethyl or isopropyl alcohol alone.

Pediatric catheter-related bloodstream infections: latest strategies to decrease risk

Central venous catheters are often mandatory devices when caring for critically ill children. They are required to deliver medications, nutrition, and blood products, as well as for monitoring hemodynamic status and drawing laboratory samples. Any foreign object that is introduced to the body is at risk for infection. Central venous catheters carry a particularly high risk of infection and these infections can be life threatening. Advanced practice nurses possess the power to influence catheter-related line infections in their critical care units. Understanding current recommendations for catheter material selection, site selection, site preparation, and site care can affect rates of catheter-related bloodstream infections. This article discusses risk factors for developing catheter-related bloodstream infections in critically ill children, as well as measures to decrease incidence of catheter-related bloodstream infections, including a review of recommendations from the Centers for Disease Control and Prevention.

Infection control issues in central venous catheter care

Central venous catheters (CVCs) are now a routine part of patient management in the intensive care unit (ICU). Over time, a vast amount of literature associated with the use and care of CVCs has accumulated. The purpose of this article is to discuss the literature associated with the care of these devices in a narrative format. Although particular attention is paid to infection control issues, other fundamental areas such as catheter design, dressings, line changing and post insertion management are also discussed. The article goes on to look at the future of CVC design and concludes with an analysis of future developments related to CVCs.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentration at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications of these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.