Increased Rate of Catheter-Related Bloodstream Infection Associated With Use of a Needleless Mechanical Valve Device at a Long-Term Acute Care Hospital

The impact of central line bundles on the timing of catheter-associated bloodstream infections and their microbiological distribution in critically ill children

Catheter-associated bloodstream infection, also known as CLABSI, is the most serious consequence of central venous access devices. These infections increase the risk of mortality and morbidity. The use of central line bundles in clinical settings is increasing worldwide with the purpose of lowering the risk of catheter-associated bloodstream infections. In this study, we investigated the effect of implementing a central line bundle for the prevention of CLABSIs, the distribution of pathogens, and the duration of time it took for CLABSIs to develop in patients who had subclavian-inserted central venous catheters. This research project was a cross-sectional study investigation carried out in a pediatric tertiary teaching hospital. Participants consisted of children who had been admitted to the pediatric critical care unit with subclavian catheters during a period of 13 years. We compared the prebundle period with the bundle period for CLABSI specifically focusing on the time to infection, the number of polymicrobial infections, the proportion of Candida parapsilosis, and the percentage of Coagulase-negative staphylococci (CoNS). The "prebundle period" included the period from May 2007 to May 2013, and the "bundle period" included the period from June 2013 to June 2020. Throughout the course of the study, a total of 286 cases of CLABSI were documented. Among these patients, 141 (49.3%) had CLABSIs associated with subclavian catheters. During the prebundle period, 55 CLABSIs were diagnosed in 5235 central line days, with an overall rate of 10.5 CLABSIs per 1000 central line days; after the implementation of central line bundle, 86 CLABSIs were diagnosed in 12,450 CL days, with an overall rate of 3.6 CLABSIs per 1000 CL days. This showed a statistically significantly lower rate in the bundle period (p = 0.0126). In the prebundle period, the mean time to develop CLABSI was 15 days, whereas during the bundle period, the mean time to develop CLABSI was 27.9 days, a significantly longer time to onset (p = 0.001). While the percentage of other microorganisms was not statistically different between the prebundle and bundle periods (p > 0.05), the percentage of C. parapsilosis was significantly higher in the prebundle period (p = 0.001).   Conclusion: The results of this study imply that the use of central line bundles not only reduces the incidence of CLABSI but also delays the time to which CLABSI patients acquire an infection. In addition, as a direct consequence of the CLB, the number of CLABSIs caused by gram-positive cocci did not increase, while the proportion of CLABSIs caused by C. parapsilosis decreased. What is Known: • The most significant negative consequence of central venous access devices is catheter-associated bloodstream infections. • "Care bundles" for CLABSI prevention have been reported to reduce the CLABSI rate. What is New: • Consider what would happen if the "Care bundle" failed to prevent CLABSI. • The findings of this study imply that using central line bundles not only reduces the risk of CLABSI but also extends the time it takes for patients to develop CLABSI. While the number of CLABSIs caused by gram-positive cocci did not increase as a direct result of CLB, the rate of CLABSIs caused by C. parapsilosis, which has recently become a major problem, has decreased.

Needleless connector nursing care - Current practices, knowledge, and attitudes: An Australian perspective

BACKGROUND

Inappropriate needleless connector (NC) care is associated with device failure from catheter occlusion and patient blood stream infections (BSIs). This can be attributed to a lack of knowledge of connector designs and flushing, clamping, and syringe disconnection techniques. This study aimed to assess nurses' practice, knowledge, attitudes, and key influencers on appropriate care of NCs in an Australian facility and compare these with studies undertaken in the United States in 2011.

METHODS

A cross-sectional online survey was sent via email with a SurveyMonkey® link to all nurses working in clinical areas (total population sampling approach; approximately 1500 nurses), at an Australian hospital, in 2018. The survey was anonymous and open for 6 weeks. Analysis was with R software.

RESULTS

Response rate was approximately 19% (n = 283). Most (89%) of nurses stated that they clean NCs before each access. Only 25% correctly recognised the negative pressure NC, and 79% correctly identified the correct clamping and disconnection sequence. Positive pressure displacement devices were correctly identified by 44% of respondents, with 34% identifying the correct clamping and disconnecting technique. Nurses reported their behaviour was most influenced by local senior nurses.

CONCLUSIONS

There remains a significant gap in nurses' knowledge of NC device types, as well as the correct clamping and syringe disconnection for both negative and positive displacement NCs. This survey reaffirms that senior nurses are the key influencers of nurses' adherence to best practice guidelines.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

Even the Simplest Devices May Malfunction: Split Septum Design Revisited

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.

Even the Simplest Devices May Malfunction: Split Septum Design Revisited

Split septum medical devices are used in tubing for intravenous (IV) fluid administration-an extremely common clinical task. These tubing caps contain a needleless, valveless system that allows fluid to flow directly through the lumen of the catheter but prevents backflow of fluid or blood when the tubing extension is not connected. We experienced complete failure of a needle-free connector extension set with a Luer-access split septum device in multiple patients due to the split septum remaining fused and essentially unsplit despite being connected on both ends. This led to an adverse event in a patient due to repeated unnecessary IV insertion attempts. This case shows how even the simplest of devices can malfunction and highlights the need for vigilance in clinical practice.

Effect of the use of an antiseptic barrier cap on the rates of central line-associated bloodstream infections in neonatal and pediatric intensive care

BACKGROUND

The use of antiseptic barrier caps reduced the occurrence of central line-associated bloodstream infections (CLABSI) in adult intensive care settings. We assessed the effect of the use of antiseptic barrier caps on the incidence of CLABSI in infants and children and evaluated the implementation process.

METHODS

We performed a mixed-method, prospective, observational before-after study. The CLABSI rate was documented during the "scrub the hub method" and the antiseptic barrier cap phase. Main outcomes were the number of CLABSIs per 1,000 catheter days (assessed with a Poisson regression analysis) and nurses' adherence to antiseptic barrier cap protocol.

RESULTS

In total, 2,248 patients were included. The rate of CLABSIs per 1,000 catheter days declined from 3.15 to 2.35, resulting in an overall incidence reduction of 22% (95% confidence interval, -34%, 55%; P = .368). Nurses' adherence to the antiseptic barrier cap protocol was 95.2% and 89.0% for the neonatal intensive care unit and pediatric intensive care unit, respectively.

DISCUSSION

The CLABSI reducing effect of the antiseptic barrier caps seems to be more prominent in the neonatal intensive care unit population compared with the pediatric intensive care unit population.

CONCLUSIONS

The antiseptic barrier cap did not significantly reduce the CLABSI rates in this study.

Peripheral intravenous catheter needleless connector decontamination study-Randomized controlled trial

BACKGROUND

Needleless connectors (NCs) were introduced to reduce health care work needlestick injuries (NSIs). If not decontaminated prior to use, NCs can be a portal for patient blood stream infections. The optimal disinfectant, and its application duration, for NC decontamination has not been empirically established.

METHODS

Factorial design randomized controlled trial comparing 70% isopropyl alcohol (IPA) and 2% chlorhexidine gluconate (CHG) in 70% IPA for 5, 10, or 15 seconds, in adult medical patients with peripheral intravenous catheters.

RESULTS

At baseline, 153 of 300 NCs (51%) grew microorganisms commonly found on the skin. Decontamination was successful in 150/153 (98%). There was no significant difference in decontamination between 70% IPA or 2% CHG in 70% IPA (P = .62), or decontamination for 5, 10, or 15 seconds (P = .21).

CONCLUSIONS

There was no difference in the effectiveness of 70% IPA and 2% CHG in 70% IPA for NC decontamination for peripheral intravenous catheters in the clinical environment. Successful decontamination was not different for applications of 5, 10, and 15 seconds; 15 seconds did not always remove all microorganisms. Factors such as cost, feasibility of compliance, and low risk of allergy support 5 seconds decontamination with 70% IPA as an acceptable approach.

Connectors as a risk factor for blood-associated infections (3-way stopcock and needleless connector): A randomized-experimental study

BACKGROUND

Microorganisms causing catheter-related bloodstream infections colonize to intravenous catheters (IVC)-particularly to connectors mounted to catheters. The aim of this study was to examine the colonization in 3-way stopcock (TWS) connectors and needleless connectors (NCs) that integrated into central, port, and peripheral venous catheters.

METHODS

This random, experimental study consisted of 180 connectors that were inserted into the IVCs of patients in general surgery, reanimation intensive care, and daily chemotherapy units. Cultures of the connectors were obtained at least 48 hours after connecting to IVCs.

RESULTS

This study showed that gram-negative, gram-positive, and other pathogens reproduced, although their colonization level was not high enough to develop an infection. When the results of colonization for patients using TWS and NC were compared, the peripheral venous catheters (using a TWS) resulted in a significantly higher increase in reproduction than in patients using NC (P ≤ .01) and no significant difference in the level of colonization in other types of connectors or catheters (P ˃ .05).

CONCLUSIONS

The study's results indicated no significant difference between NC and TWSs in terms of reproduction. It should also be noted that connectors integrated into IVC pose a risk in the development of catheter-related bloodstream infections.

Clinical impact of needle-free connector design: A systematic review of literature

The objective of this systematic review is to analyze types of needle-free connectors and open systems and their effects on central line–associated bloodstream infection rates and other adverse outcomes through a research protocol consistent with the Preferred Reporting Items for Systematic Reviews’ recommendations. MEDLINE and Cochrane databases of systematic reviews were searched for relevant comparative studies published from January 2000 to September 2017. Eighteen studies compared central line–associated bloodstream infection (according to the Centers for Disease Control and Prevention/National Healthcare Safety Network definition), internal microbial contamination, occlusions, phlebitis, and other outcomes associated with needle-free connectors with a positive displacement device, negative displacement device, neutral displacement device, or three-way stopcock. Ten studies reported central line–associated bloodstream infection rates, which were lower with positive displacement devices versus negative displacement devices/neutral displacement devices (one study) and with negative displacement devices versus three-way stopcocks (three studies), but varied with different positive displacement device and negative displacement device/neutral displacement device designs (four studies). Seven studies reported internal microbial contamination rates, which were higher with three-way stopcocks versus negative displacement devices (two studies) and positive displacement devices (two studies), lower when positive displacement devices were used versus neutral displacement devices (one study), and varied with different types of negative displacement device (one study). Central line–associated bloodstream infection rates and most other outcomes analyzed were statistically significantly higher with three-way stopcocks (open devices) versus positive displacement device, negative displacement devices, and neutral displacement devices, but varied among closed device designs.

Management of peripheral venous catheters and implementation of guidelines in Germany: a national survey

BACKGROUND

Due to their frequent use, peripheral venous catheters (PVCs) are of importance in terms of catheter-related infections and their prevention. In 2017, revised national guidelines for the prevention of PVC-related infections were published in Germany.

AIM

To describe PVC handling practices and assess the implementation of national guidelines for the prevention of PVC-related infections in German acute care hospitals, 10 months after their release.

METHODS

An online survey on the management of PVCs in hospital wards was conducted. For this, 1191 acute care hospitals participating in the national surveillance system for healthcare-associated infections in Germany were invited to participate. Each hospital was asked to complete the survey for an intensive care unit (ICU), as well as a medical ward and a surgical ward. Participation in the survey was voluntary.

FINDINGS

In total, 701 hospitals (response rate 59%) participated and provided data on 1449 wards (599 ICUs, 446 medical wards, 404 surgical wards). Approximately 43% of wards reported that they had implemented the new national guidelines where necessary. Structured surveillance for PVC-associated infections was established in only 21% of wards. While 94% of wards reported the inclusion of aspects of PVC handling in their general infection prevention education, questions on the training methods yielded diverse results. Approximately 59% of wards reported that they did not routinely use a combination of alcohol and a remanant disinfectant for skin disinfection before PVC insertion.

CONCLUSION

Generally, PVC management in Germany is well organized. However, potential for improvement was identified, particularly considering surveillance and implementation of selected national guidelines.

Microbial colonization of intravascular catheter connectors in hospitalized patients

BACKGROUND

Central line-associated bloodstream infections may be due to catheter connector colonization and intraluminal migration of pathogens. We assessed the colonization of the split septum catheter connector system, and subsequently the luer lock catheter connector system.

METHODS

This was a prospective, 2 phase, quality improvement study at a tertiary referral center. Each phase of the study was performed over 3 consecutive days in hospitalized patients receiving an active infusion; first with a split septum lever lock connector and second with a luer lock connector and alcohol port protector. The connectors were inoculated onto blood agar plates and incubated. Plates were assessed for microbial growth after 48-72 hours.

RESULTS

In phase I, 98 (41.9%) of 234 split septum connectors yielded microbial growth. In phase II, 56 (23.1%) of 243 luer lock connectors yielded microbial growth. In phase II only, there was a significant increased rate of contamination in peripheral catheters compared with all other catheters, and the rate of contamination on the acute care wards was significantly higher when compared with the intensive care units.

CONCLUSIONS

Bacterial colonization of the lever lock system was unacceptably high among all catheter types and hospital locations. Transition to luer lock catheter connectors and alcohol port protectors decreased the colonization; however, colonization still remained substantial. Causation of colonization cannot be determined with these results.

Quantitative assessment of reflux in commercially available needle-free IV connectors

INTRODUCTION

Blood reflux is caused by changes in pressure within intravascular catheters upon connection or disconnection of a syringe or intravenous tubing from a needle-free connector (NFC). Changes in pressure, differing with each brand of NFC, may result in fluid movement and blood reflux that can contribute to intraluminal catheter occlusions and increase the potential for central-line associated bloodstream infections (CLABSI).

METHODS

In this study, 14 NFC brands representing each of the four market-categories of NFCs were selected for evaluation of fluid movement occurring during connection and disconnection of a syringe. Study objectives were to 1) theoretically estimate amount of blood reflux volume in microliters (μL) permitted by each NFC based on exact component measurements, and 2) experimentally measure NFC volume of fluid movement for disconnection reflux of negative, neutral and anti-reflux NFC and fluid movement for connection reflux of positive displacement NFC.

RESULTS

The results demonstrated fluid movement/reflux volumes of 9.73 μL to 50.34 μL for negative displacement, 3.60 μL to 10.80 μL for neutral displacement, and 0.02 μL to 1.73 μL for pressure-activated anti-reflux NFC. Separate experiment was performed measuring connection reflux of 18.23 μL to 38.83 μL for positive displacement NFC connectors.

CONCLUSIONS

This study revealed significant differences in reflux volumes for fluid displacement based on NFC design. While more research is needed on effects of blood reflux in catheters and NFCs, results highlight the need to consider NFCs based on performance of individual connector designs, rather than manufacturer designation of positive, negative and neutral marketing categories for NFCs without anti-reflux mechanisms.

Impact of MaxZero™ needle-free connector on the incidence of central venous catheter-related infections in surgical intensive care unit

BACKGROUND

Central venous catheter-related infections (CRIs) are a complication of central venous catheters in intensive care unit (ICU). Some needle-free connectors have been designed to decrease CRI, but there is a lack of data concerning their impact on infection.

OBJECTIVES

The objective was to explore the impact of MaxZero™ connectors (BD; Franklin Lakes, US) on CRI in ICU.

METHODS

Observational, pre-post design study (2011-2013 and 2014-2016) conducted in the surgical ICU of a tertiary care hospital (18 beds). Patients with a central venous catheter and a length of stay ≥48 h were included. The connectors replaced all disposable caps used on infusion stopcocks and ramps. The primary parameter was to compare the incidence of CRI between the "before" period and the "after" period.

RESULTS

A total of 1633 patients were included (789 "before" and 844 "after"). There was no difference between groups concerning the global duration of catheterisation (12.5 ± 11.5 days vs. 12.1 ± 10.9 days). There were 61 CRIs before and 28 CRIs after the introduction of connectors; the incidence of CRI in the "before" group was 20.33 CRI/year (6.18 CRI per 1000 catheter-days) vs. 9.33 CRI/year (2.73 CRI per 1000 catheter-days) in the "after" group (incidence rate ratio = 0.44; 95% confidence interval = 0.28-0.68, p < 0.001). However, after a global analysis of the 6-year period, when adjusting for seasonal effect and pre-existing linear trend, the effect was no longer significant (adjusted incidence rate ratio = 0.57; 95% confidence interval = 0.24-1.35, p = 0.20).

CONCLUSIONS

Our results do not allow us to conclude to a potential beneficial effect of MaxZero™ on CRI but are compatible with its prolonged and safe use in ICU. Only future prospective works will be able to confirm the value of these connectors for CRI prevention.

Outbreak column 19: needleless connectors (NCs) tales from nine outbreaks

A critical review of historical outbreak reports that are still influencing practice today is presented.  These outbreak reports were used as evidence in support of guideline recommendations and of the US Food and Drug Administration's (FDA) advisory notice requiring post-product surveillance for needleless connectors (NC) which have a positive displacement. Guideline recommendations were subsequently changed but not before other authorities had issued recommendations based on the original.  All the above led some purchasers to look for different NC designs.  The conclusions are that the evidence, as reported, does not support there being an increased risk from positive displacement NCs. Identified in this review were unsubstantiated claims, incompleteness in reporting of specifics, opinions considered as evidence and unexplored outbreak-provoking explanations.

Surface micropattern reduces colonization and medical device-associated infections

PURPOSE

Surface microtopography offers a promising approach for infection control. The goal of this study was to provide evidence that micropatterned surfaces significantly reduce the potential risk of medical device-associated infections.

METHODOLOGY

Micropatterned and smooth surfaces were challenged in vitro against the colonization and transference of two representative bacterial pathogens - Staphylococcus aureus and Pseudomonas aeruginosa. A percutaneous rat model was used to assess the effectiveness of the micropattern against device-associated S. aureus infections. After the percutaneous insertion of silicone rods into (healthy or immunocompromised) rats, their backs were inoculated with S. aureus. The bacterial burdens were determined in tissues under the rods and in the spleens.

RESULTS

The micropatterns reduced adherence by S. aureus (92.3 and 90.5 % reduction for flat and cylindrical surfaces, respectively), while P. aeruginosa colonization was limited by 99.9 % (flat) and 95.5 % (cylindrical). The micropatterned surfaces restricted transference by 95.1 % for S. aureus and 94.9 % for P. aeruginosa, compared to smooth surfaces. Rats with micropatterned devices had substantially fewer S. aureus in subcutaneous tissues (91 %) and spleens (88 %) compared to those with smooth ones. In a follow-up study, immunocompromised rats with micropatterned devices had significantly lower bacterial burdens on devices (99.5 and 99.9 % reduction on external and internal segments, respectively), as well as in subcutaneous tissues (97.8 %) and spleens (90.7 %) compared to those with smooth devices.

CONCLUSION

Micropatterned surfaces exhibited significantly reduced colonization and transference in vitro, as well as lower bacterial burdens in animal models. These results indicate that introducing this micropattern onto surfaces has high potential to reduce medical device-associated infections.

INFLUENCE OF LONG-TERM CYTOTOXIC CHEMOTHERAPY ON THE CONDITION OF PERIPHERAL VENOUS CHANNEL

The necessity of long-term venous access in cancer patients appears at frequent and long-term courses of cytotoxic therapy. Peripheral veins of forearms are most often used for these aims. The conditions of peripheral venous channel in 32 cancer patients, who underwent the long-term treatment with antitumor preparations were analyzed in the article on own investigatory material. The methods of dopplerography, morphological and immunohystochemical studies were used. The qualitative and quantitative dopplerographic changes in forearm veins in different terms after chemotherapy start were revealed in most patients. The conclusion was made about unsuitability of forearm peripheral veins for the long term administration of cytostatics and the necessity to create the alternative vascular access that would correspond to the criteria of safety, reliability and long-term exploitation.

Incidence of central venous catheter hub contamination

PURPOSE

To investigate microorganisms causing central venous catheter contamination and how this contamination differs across different catheter metrics.

MATERIALS AND METHODS

After obtaining IRB approval and informed consent, 830 cultures were prospectively obtained from 45 ICU patients with central venous catheter or peripherally inserted central catheter. Bacterial colonies were identified by mass spectrometry.

RESULTS

Bacterial contamination of central catheter hubs occurred 44% of the time in this study in the ICU setting. Coagulase-positive staphylococci cultures had higher median (±interquartile range) CFUs (12±232) versus coagulase-negative (3±10) and other bacteria (1±3; P<0.001). Bacterial contamination was associated with various metrics. Higher incidence (P<0.05) of coagulase-positive staphylococci cultures was associated with hub-only connections (a "hub" being a female connection; 10.9% vs. 7.9% male connections), connections without a manifold (1lumen device that mixes multiple infusions together; 9.7% vs. 0% with manifold); and central venous pressure monitoring connections (25.8% vs. 7.1% without). Internal jugular sites (10.0% vs. 2.7% femoral, 6.2% PICC, P=0.031) and medial lumens of triple lumen catheters (11.9% vs. 5.6% distal, 7.0% proximal, P=0.049) had increased incidence of higher bacteria loads (>15 CFUs).

CONCLUSIONS

This study found a high incidence of central access catheter hub bacterial contamination, which correlated with positive blood cultures in 2 of 3 total bacteremia cases identified in the 45 patients.

Prospective observational study on central line-associated bloodstream infections and central venous catheter occlusions using a negative displacement connector with an alcohol disinfecting cap

BACKGROUND

Major complications of central venous catheter (CVC) use include bloodstream infection and occlusion. We performed a prospective, observational study to determine the rate of central line-associated bloodstream infection (CLABSI) and CVC occlusion using a negative displacement connector with an alcohol disinfecting cap.

METHODS

Patients were followed from the time of CVC insertion through 2 days after removal, at the time of hospital discharge if there was no documentation of removal, or 90 days after the insertion of the CVC if it was not removed. CLABSI was defined using National Healthcare Safety Network criteria. Data for evidence of lumen occlusions were extracted from the electronic health record. Direct observations were performed to assess adherence to hospital policy regarding CVC insertion practice.

RESULTS

A total of 2,512 catheters from 2,264 patients were enrolled for this study. There were 21 CLABSIs (0.84%; 95% confidence interval [CI], 0.48%-1.19%; 0.62 per 1,000 line days) and 378 occlusions (15.05%; 95% CI, 13.65%-16.45%; 11.23 per 1,000 line days). Eighty-five direct observations demonstrated insertion protocol adherence in 881 of 925 (95.24%; 95% CI, 93.87%-96.61%) measured criteria.

CONCLUSIONS

Lines placed following a standardized protocol using a negative displacement connector with an alcohol cap have low rates of infection compared with historically published findings. We also established that the occlusion rate is >15-fold the CLABSI rate.

Clinical impact and cost-effectiveness of a central line bundle including split-septum and single-use prefilled flushing devices on central line-associated bloodstream infection rates in a pediatric intensive care unit

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are among the most frequent health care-associated infections. Central line bundle (CLB) programs are useful for reducing CLABSIs.

METHODS

A retrospective study was designed to compare 2 periods: the prebundle and bundle periods. We evaluated the impact of a CLB including implementation of split-septum (SS) devices and single-use prefilled flushing (SUF) devices in critically ill children.

RESULTS

During the prebundle period, the overall rate was 24.5 CLABSIs per 1,000 central line (CL) days, whereas after the initiation of the CLB, the CLABSIs per 1,000 CL days dropped to 14.29. In the prebundle period, the daily cost per patient with CL and CLABSI were $232.13 and $254.83 consecutively. In the bundle period, the daily cost per patient with CL and CLABSI were $226.62 and $194.28 consecutively. Compared with the period with no CLB, the CLB period, which included SUF and SS devices, resulted in more costs saving by lowering the daily total costs of patients and indirectly lowering total drug costs by decreasing antibacterial and more significantly antifungal drugs.

CONCLUSIONS

CLB programs including SS and SUF devices were found to be effective in decreasing the CLABSI rate and decreasing the daily hospital costs and antimicrobial drug expenditures in children.

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

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

In vitro study on the disinfectability of two split-septum needle-free connection devices using different disinfection procedures

This in vitro study investigated the external disinfection of two needle-free connection devices (NFC) using Octeniderm^® (spraying and wiping technique) vs. Descoderm^® pads (wiping technique). The split-septum membrane of the NFC was contaminated with >10⁵ CFU K. pneumoniae or S. epidermidis. The efficacy of the disinfection at 30 sec. exposure time was controlled by taking a swab sample and by flushing the NFC with sterile 0.9% sodium chloride solution. Disinfection with octenidine dihydrochloride 0.1 g, 1-Propanol 30.0 g, and 2-Propanol 45.0 g in 100 g solution was highly effective (CFU reduction ≥4 log) against both microorganisms, whereas the use of 63.1 g 2-Propanol in 100 ml solution led to residual contamination with S. epidermidis. Our investigation underlines that (i) in clinical practice disinfection of NFCs before use is mandatory, and that (ii) details of disinfection technique are of utmost importance regarding their efficacy. Our investigation revealed no significant differences between both split-septum NFC types. Clinical studies are needed to confirm a possible superiority of disinfectants with long-lasting residual antimicrobial activity.

Comparison of a silver-coated needleless connector and a standard needleless connector for the prevention of central line-associated bloodstream infections

OBJECTIVE

To assess the impact of a novel, silver-coated needleless connectors (NCs) on central-line-associated bloodstream infection (CLABSI) rates compared with a mechanically identical NCs without a silver coating.

DESIGN

Prospective longitudinal observation study SETTING Two 500-bed university hospitals

PATIENTS

All hospitalized adults from November 2009 to June 2011 with non-hemodialysis central lines

INTERVENTIONS

Hospital A started with silver-coated NCs and switched to standard NCs in September 2010; hospital B started with standard NCs and switched to silver-coated NCs. The primary outcome was the difference revealed by Poisson multivariate regression in CLABSI rate using standard Centers for Disease Control and Prevention surveillance definitions. The secondary outcome was a comparison of organism-specific CLABSI rates by NC type.

RESULTS

Among 15,845 hospital admissions, 140,186 central-line days and 221 CLABSIs were recorded during the study period. In a multivariate model, the CLABSI rate per 1,000 central-line days was lower with silver-coated NCs than with standard NCs (1.21 vs 1.79; incidence rate ratio=0.68 [95% CI: 0.52-0.89], P=.005). A lower CLABSI rate per 1,000 central-line days for the silver-coated NCs versus the standard NCs was observed with S. aureus (0.11 vs 0.30, P=.02), enterococci (0.10 vs 0.27, P=.03), and Gram-negative organisms (0.28 vs 0.63, P=.003) but not with coagulase-negative staphylococci (0.31 vs 0.36) or Candida spp. (0.42 vs 0.40).

CONCLUSIONS

The use of silver-coated NCs decreased the CLABSI rate by 32%. CLABSI reduction efforts should include efforts to minimize contamination of NCs.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock on central line-associated bloodstream infection rates in India: a randomized clinical trial conducted by the International Nosocomial Infection Control Consortium (INICC)

BACKGROUND

Three-way stopcocks (3WSCs) are open systems used on intravenous tubing. Split septums (SSs) are closed systems with prepierced septums. Single-use prefilled flushing devices (SUFs) carry a lower risk of contamination than standard intravenous flushing. 3WSC and standard flushing are widely used in developing countries. This is the first randomized clinical trial (RCT) to compare rates of central line-associated bloodstream infection (CLABSI) between patients using an SS + SUF and those using a 3WSC.

METHODS

An RCT with 1096 patients in 5 adult intensive care units was conducted between April 2012 and August 2014 to evaluate their impact on CLABSI rates. Centers for Disease Control and Prevention/National Healthcare Safety Network definitions were applied and International Nosocomial Infection Control Consortium methodology were followed.

RESULTS

The study cohort included 547 patients and 3619 central line (CL)-days for the SS + SUF group, and 549 patients and 4061 CL-days for the 3WSC group. CLABSI rates were 2.21 per 1000 CL-days for SS + SUF and 6.40 per 1000 CL-days for 3WSC (relative risk, 0.35; 95% confidence interval [CI], 0.16-0.76; P = .006). The SS + SUF group had significantly better cumulative infection-free catheter survival compared with the 3WSC group (hazard ration, 0.33; 95% CI, 0.15-0.73; P = .006). Using an SS + SUF represents savings of $402.88 and an increase in quality-adjusted life years of 0.0008 per patient. For each extra dollar invested in an SS + SUF, $124 was saved.

CONCLUSION

The use of SS + SUF is cost-effective and associated with a significantly lower CLABSI rate compared with the use of 3WSC.

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

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

Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review

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

Closed catheter access system implementation in reducing the bloodstream infection rate in low birth weight preterm infants

BACKGROUND

Bloodstream infection (BSI) is one of the significant causes of morbidity and mortality encountered in a neonatal intensive care unit, especially in developing countries. Despite the implementation of infection control practices, such as strict hand hygiene, the BSI rate in our hospital is still high. The use of a closed catheter access system to reduce BSI related to intravascular catheter has hitherto never been evaluated in our hospital.

OBJECTIVE

To determine the effects of closed catheter access system implementation in reducing the BSI rate in preterm neonates with low birth weight.

METHODS

Randomized clinical trial was conducted on 60 low birth weight preterm infants hospitalized in the neonatal unit at Cipto Mangunkusumo Hospital, Jakarta, Indonesia from June to September 2013. Randomized subjects either received a closed or non-closed catheter access system. Subjects were monitored for 2 weeks for the development of BSI based on clinical signs, abnormal infection parameters, and blood culture.

RESULTS

Closed catheter access system implementation gave a protective effect toward the occurrence of culture-proven BSI (relative risk 0.095, 95% CI 0.011-0.85, p = 0.026). Risk of culture-proven BSI in the control group was 10.545 (95% CI 1.227-90.662, p = 0.026). BSI occurred in 75% of neonates without risk factors of infection in the control group compared to none in the study group.

CONCLUSION

The use of a closed catheter access system reduced the BSI in low birth weight preterm infants. Choosing the right device design, proper disinfection of device, and appropriate frequency of connector change should be done simultaneously.

Meta-analysis on central line-associated bloodstream infections associated with a needleless intravenous connector with a new engineering design

BACKGROUND

Intravenous needleless connectors (NCs) with a desired patient safety design may facilitate effective intravenous line care and reduce the risk for central line-associated bloodstream infection (CLA-BSI). We conducted a meta-analysis to determine the risk for CLA-BSI associated with the use of a new NC with an improved engineering design.

METHODS

We reviewed MEDLINE, Cochrane Database of Systematic Reviews, Embase, ClinicalTrials.gov, and studies presented in 2010-2012 at infection control and infectious diseases meetings. Studies reporting the CLA-BSIs in patients using the positive-displacement NC (study NC) compared with negative- or neutral-displacement NCs were analyzed. We estimated the relative risk of CLA-BSIs with the study NC for the pooled effect using the random effects method.

RESULTS

Seven studies met the inclusion criteria: 4 were conducted in intensive care units, 1 in a home health setting, and 2 in long-term acute care settings. In the comparator period, total central venous line (CL) days were 111,255; the CLA-BSI rate was 1.5 events per 1,000 CL days. In the study NC period, total CL days were 95,383; the CLA-BSI rate was 0.5 events per 1,000 CL days. The pooled CLA-BSI relative risk associated with the study NC was 0.37 (95% confidence interval, 0.16-0.90).

CONCLUSION

The NC with an improved engineering design is associated with lower CLA-BSI risk.

Needleless closed system does not reduce central venous catheter-related bloodstream infection: a retrospective study

The needleless closed system (NCS) has been disseminated in several clinical fields to prevent central venous catheter-related bloodstream infection (CVC-RBSI), in place of the conventional Luer cap system (LCS). The purpose of this study is to examine whether NCS is really superior to conventional LCS for prevention of CVC-RBSI. Between May 2002 and December 2008, 1767 patients received CVC in our department. The time interval from insertion to development of CVC-RBSI was compared retrospectively between selected patients who were treated using the conventional LCS (group 1, n = 89, before June 2006) and the NCS (group 2, n = 406, June 2006 and after). Kaplan-Meier analysis revealed no significant difference in the time interval from insertion to development of CVC-RBSI between the two groups. NCS does not reduce CVC-RBSI in adult colorectal cancer patients who undergo CVC insertion.

Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine

Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.

Comparison of central line-associated bloodstream infection rates when changing to a zero fluid displacement intravenous needleless connector in acute care settings

This was a multicenter, quasiexperimental, 140-month, acute care study comparing central line-associated bloodstream infection rates associated with positive or negative intravenous connectors to a zero fluid displacement connector. A decrease in central line-associated bloodstream infections was found after changing from either negative or positive intravenous connectors to the zero fluid displacement connector (P = .004) with total cost savings of over $3 million.

Risk of infection due to medical interventions via central venous catheters or implantable venous access port systems at the middle port of a three-way cock: luer lock cap vs. luer access split septum system (Q-Syte)

Background

Many cancer patients receive a central venous catheter or port system prior to therapy to assure correct drug administration. Even appropriate hygienic intervention maintenance carries the risk of contaminating the middle port (C-port) of a three-way cock (TWC), a risk that increases with the number of medical interventions. Because of the complexity of the cleaning procedure with disconnection and reconnection of the standard luer lock cap (referred as “intervention”), we compared luer lock caps with a “closed access system” consisting of a luer access split septum system with regard to process optimization (work simplification, process time), efficiency (costs) and hygiene (patient safety).

Methods

For determination of process optimization the workflow of an intervention according to the usual practice and risks was depicted in a process diagram. For determining the actual process costs, we analyzed use of material and time parameters per intervention and used the process parameters for programming the process into a simulation run (n = 1000) to determine the process costs as well as their differences (ACTUAL vs. NOMINAL) within the framework of a discrete event simulation.

Additionally cultures were carried out at the TWC C-ports to evaluate possible contamination.

Results

With the closed access system, the mean working time of 5.5 minutes could be reduced to 2.97 minutes. The results for average process costs (labour and material costs per use) were 3.92 € for luer lock caps and 2.55 € for the closed access system. The hypothesis test (2-sample t-test, CI 0.95, p-value<0.05) confirmed the significance of the result.

In 50 reviewed samples (TWC’s), the contamination rate for the luer lock cap was 8% (4 out of 50 samples were positive), the contamination rate of the 50 samples with the closed access system was 0%.

Possible hygienic risks (related to material, surroundings, staff handling) could be reduced by 65.38%.

Conclusions

In the present research, the closed access system with a divided split septum was superior to conventional luer lock caps. The advantage of the closed access system lies in the simplified handling for staff, which results in a reduced risk of patient infection due to improved clinical hygiene.

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.

Microbial biofilms on needleless connectors for central venous catheters: comparison of standard and silver-coated devices collected from patients in an acute care hospital

Microorganisms may colonize needleless connectors (NCs) on intravascular catheters, forming biofilms and predisposing patients to catheter-associated infection (CAI). Standard and silver-coated NCs were collected from catheterized intensive care unit patients to characterize biofilm formation using culture-dependent and culture-independent methods and to investigate the associations between NC usage and biofilm characteristics. Viable microorganisms were detected by plate counts from 46% of standard NCs and 59% of silver-coated NCs (P=0.11). There were no significant associations (P>0.05, chi-square test) between catheter type, side of catheter placement, number of catheter lumens, site of catheter placement, or NC placement duration and positive NC findings. There was an association (P=0.04, chi-square test) between infusion type and positive findings for standard NCs. Viable microorganisms exhibiting intracellular esterase activity were detected on >90% of both NC types (P=0.751), suggesting that a large percentage of organisms were not culturable using the conditions provided in this study. Amplification of the 16S rRNA gene from selected NCs provided a substantially larger number of operational taxonomic units per NC than did plate counts (26 to 43 versus 1 to 4 operational taxonomic units/NC, respectively), suggesting that culture-dependent methods may substantially underestimate microbial diversity on NCs. NC bacterial communities were clustered by patient and venous access type and may reflect the composition of the patient's local microbiome but also may contain organisms from the health care environment. NCs provide a portal of entry for a wide diversity of opportunistic pathogens to colonize the catheter lumen, forming a biofilm and increasing the potential for CAI, highlighting the importance of catheter maintenance practices to reduce microbial contamination.

Impact of different catheter lock strategies on bacterial colonization of permanent central venous hemodialysis catheters

Thirty-nine hemodialysis patients with permanent central venous catheters were analyzed for bacterial catheter colonization comparing different catheter-lock strategies. The closed needleless Tego connector with sodium chloride lock solution was significantly more frequently colonized with bacteria than the standard catheter caps with antimicrobially active citrate lock solution (odds ratio, 0.22 [95% confidence interval, 0.07-0.71]; P = .011).

Low rate of bacteremia with a subcutaneously implanted central venous access device

PURPOSE

Patients at long-term acute care hospitals (LTACs) are medically complex with multiple comorbidities and high rates of antibiotic and device use. The objective of the study was to analyze the incidence and rate of central line-associated bloodstream infections (CLABSI) and the critical factors for patient care, management, placement and maintenance of the implanted central venous access device at this LTAC.

METHODS

A 13-year retrospective chart review was performed comprising 191 medically complex patients with multiple comorbidities who had an implanted central line port. Information analyzed included (1) number of catheters; (2) number of patients; (3) number of catheter line days; (4) patient demographics; (5) port location; (6) admission diagnoses; (7) type, incidence and rate of catheter-related complications.

RESULTS

The total number of catheter days was over 183,183 with a mean of 959 catheter days per patient. The mean rate of CLABSI was 0.087 per 1,000 days; incidence was less than 8% of patients with catheters.

CONCLUSIONS

The study found a markedly lower rate of CLABSI than reported for other LTACs as well as intensive care units, over 14- to 100-fold lower than other LTACs. The authors propose that standardized catheter placement with implementation of rigorous, prospective catheter care plans and a team approach to management were responsible for extremely low complication rates. These results can be extrapolated to different settings across the healthcare continuum.

In vitro study assessing the antibacterial activity of three silver-impregnated/coated mechanical valve needleless connectors after blood exposure

This in vitro study's purpose was to assess antibacterial activity of 3 different connectors: V-Link (Baxter, Deerfield, IL), Ultrasite Ag (B. Braun, Bethlehem, PA), and MaxGuard (CareFusion, Ontario, CA), impregnated with silver nanoparticles after blood exposure. All 3 silver-coated/impregnated connectors grew Staphylococcus aureus and Staphylococcus epidermidis. Log reduction of bacteria was not significant (range, +0.19 to -1.82). There was substantial bacterial recovery from all 3 connectors (mean ranges, 2.09 × 10 to 4.00 × 10) indicating that, once blood comes in contact with silver-coated/impregnated needleless connectors, their antibacterial activity is significantly reduced.

Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection

BACKGROUND

Catheter hub decontamination requires a thorough scrub and compliance varies. This study evaluates the effectiveness of a disinfection cap with 70% alcohol in preventing contamination/infection.

METHODS

A 3-phased, multifacility, quasi-experimental study of adult patients with central lines divided into P1 (baseline), when the standard scrub was used; P2, when the cap was used on all central lines; and P3, when standard disinfection was reinstituted. House-wide central-line associated bloodstream infection (CLABSI) rates are reported with catheter-associated urinary tract infections (CAUTI) as a control measure. Adults with peripherally inserted central catheters inserted during hospitalization having 5+ consecutive line-days gave consent and were enrolled, and 1.5 mL of blood was withdrawn from each lumen not in use and quantitatively cultured.

RESULTS

Contamination was 12.7% (32/252) during P1; 5.5% (20/364) in P2 (P = .002), and 12.0% (22/183; P = 0.88 vs P1 and P = .01 vs P2) in P3 (P = .001 vs P2). The median colony-forming units per milliliter was 4 for P1, 1 for P2 (P = .009), and 2 for P3 (P = .05 vs P2). CLABSI rates declined from 1.43 per 1,000 line-days (16/11,154) to 0.69 (13/18,972) in P2 (P = .04) and increased to 1.31 (7/5,354) in P3. CAUTI rates remained stable between P1 and P2 (1.42 and 1.41, respectively, P = .90) but declined in P3 (1.04, P = .03 vs P1 and P2).

CONCLUSION

Disinfecting caps reduce line contamination, organism density, and CLABSIs.

Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling

BACKGROUND

Device-related bloodstream infections are associated with a significant increase in patient morbidity and mortality in multiple health care settings. Recently, intraoperative bacterial contamination of conventional open-lumen 3-way stopcock sets has been shown to be associated with increased patient mortality. Intraoperative use of disinfectable, needleless closed catheter devices (DNCCs) may reduce the risk of bacterial injection as compared to conventional open-lumen devices due to an intrinsic barrier to bacterial entry associated with valve design and/or the capacity for surface disinfection. However, the relative benefit of DNCC valve design (intrinsic barrier capacity) as compared to surface disinfection in attenuation of bacterial injection in the clinical environment is untested and entirely unknown. The primary aim of the current study was to investigate the relative efficacy of a novel disinfectable stopcock, the Ultraport zero, with and without disinfection in attenuating intraoperative injection of potential bacterial pathogens as compared to a conventional open-lumen stopcock intravascular device. The secondary aims were to identify risk factors for bacterial injection and to estimate the quantity of bacterial organisms injected during catheter handling.

METHODS

Four hundred sixty-eight operating room environments were randomized by a computer generated list to 1 of 3 device-injection schemes: (1) injection of the Ultraport zero stopcock with hub disinfection before injection, (2) injection of the Ultraport zero stopcock without prior hub disinfection, and (3) injection of the conventional open-lumen stopcock closed with sterile caps according to usual practice. After induction of general anesthesia, the primary anesthesia provider caring for patients in each operating room environment was asked to perform a series of 5 injections of sterile saline through the assigned device into an ex vivo catheter system. The primary outcome was the incidence of bacterial contamination of the injected fluid column (effluent). Risk factors for effluent contamination were identified in univariate analysis, and a controlled laboratory experiment was used to generate an estimate of the bacterial load injected for contaminated effluent samples.

RESULTS

The incidence of effluent bacterial contamination was 0% (0/152) for the Ultraport zero stopcock with hub disinfection before injection, 4% (7/162) for the Ultraport zero stopcock without hub disinfection before injection, and 3.2% (5/154) for the conventional open-lumen stopcock. The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of bacterial injection as compared to the conventional open-lumen stopcock (RR = 8.15 × 10(-8), 95% CI, 3.39 × 10(-8) to 1.96 × 10(-7), P = <0.001), with an absolute risk reduction of 3.2% (95% CI, 0.5% to 7.4%). Provider glove use was a risk factor for effluent contamination (RR = 10.48, 95% CI, 3.16 to 34.80, P < 0.001). The estimated quantity of bacteria injected reached a clinically significant threshold of 50,000 colony-forming units per each injection series.

CONCLUSIONS

The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of inadvertent bacterial injection as compared to the conventional open-lumen stopcock. Future studies should examine strategies designed to facilitate health care provider DNCC hub disinfection and proper device handling.

Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010

OBJECTIVE

To evaluate national data on healthcare-associated infections (HAIs), device utilization, and antimicrobial resistance in long-term acute care hospitals (LTACHs).

DESIGN AND SETTING

Comparison of data from LTACHs and from medical and medical-surgical intensive care units (ICUs) in short-stay acute care hospitals reporting to the National Healthcare Safety Network (NHSN) during 2010.

METHODS

Rates of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and ventilator-associated pneumonia (VAP) as well as device utilization ratios were calculated. For each HAI, pathogen profiles and antimicrobial resistance prevalence were evaluated. Comparisons were made using Poisson regression and the mood median and χ2 tests.

RESULTS

In 2010, 104 LTACHs reported CLABSIs and 57 reported CAUTIs and VAP to the NHSN. Median CLABSI rates in LTACHs (1.25 events per 1,000 device-days reported; range, 0.0-5.96) were comparable to rates in major teaching ICUs and were higher than those in other ICUs. CAUTI rates in LTACHs (median, 2.61; range, 0.0-9.92) were higher and VAP rates (median, 0.0; range, 0.0-3.29) were generally lower than those in ICUs. Central line utilization in LTACHs was higher than that in ICUs, whereas urinary catheter and ventilator utilization was lower. Methicillin resistance among Staphylococcus aureus CLABSIs (83%) and vancomycin resistance among Enterococcus faecalis CAUTIs (44%) were higher in LTACHs than in ICUs. Multidrug resistance among Pseudomonas aeruginosa CAUTIs (25%) was higher in LTACHs than in most ICUs.

CONCLUSIONS

CLABSIs and CAUTIs associated with multidrug-resistant organisms present a challenge in LTACHs. Continued HAI surveillance with pathogen-level data can guide prevention efforts in LTACHs.

[Impact of the use of luer access devices on the quality of chronic hemodialysis]

Luer access valves are medical devices used to reduce infectious risks by securing repetitive handling in chronic hemodialysis using central catheter. Their impact on the effectiveness of a hemodialysis session still remains poorly studied. This in vivo study aims to evaluate its effectiveness. Tego(®) and Q-Syte(®) valves were used in alternation for each patient for four weeks (428 hemodialysis sessions). The two-luer access valves have led to a significant increase in the dysfunction of the hemodialysis sessions (51.8% compared to the usual care (39.3%) (P=0.012). The analysis by sub-category suggests a heterogeneous behavior of the two devices. The Q-Syte(®) valve showed significantly more dysfunction than the Tego(®) valve or the absence of valve. However, both valve systems tested can maintain the performance of the hemodialysis session as they don't change the dose of dialysis. This study highlights that an evaluation of each device must be performed prior to their use to assess the risk-benefit balance.

Incidence of catheter-related bloodstream infection in a general hospital using two different detection methods

INTRODUCTION

The aim of this study was to determine the incidence of central venous catheter-related bloodstream infection (CRBSI) in a general hospital, using two different assessment methods.

METHODS

Method A: One observer prospectively followed up all patients with central venous catheters (CVCs) placed in our hospital over a period of 1 year, recording all CRBSI episodes. Incidence was calculated in two ways, in relation to the total number of catheter days, and in relation to the total number of hospital days of all patients hospitalized during this period. Method B: Another observer recorded all CRBSI episodes diagnosed during the same time period using microbiology data in which blood culture and catheter culture were positive for the same microorganism. Incidence was calculated in relation to the total number of hospital days of all hospitalized patients. The patient's demographic characteristics and the catheter-related variables were recorded and analysed. Based on clinical and microbiological criteria, catheters were classified as uninfected, colonized, or CRBSI.

RESULTS

Over the study period, 878 central venous catheters were placed in 704 patients. The total number of catheter days was 7357, and the mean duration of catheter use was 8.15 days (1-86). The total number of hospital stays in this period was 92,167. Method A: 15 episodes of CRBSI were detected, yielding an overall incidence of 2.03 episodes/1000 catheter days or 0.16 episodes/1000 hospital days. Method B: 11 episodes of CRBSI, with an incidence of 0.12 episodes/1000 hospital days.

CONCLUSION

The two methods studied yielded different CRBSI rates, with a higher incidence reported by prospective follow-up (Method A). In addition, this method enabled a better assessment to be made of CRBSI risk as the calculation could be performed in relation to the days patients were catheterized.