The impact of chlorhexidine bathing on hospital-acquired bloodstream infections: a systematic review and meta-analysis

Risk, Predictive, and Preventive Factors for Noninfectious Ventriculitis and External Ventricular Drain Infection

BACKGROUND

External ventricular drain (EVD) is used for monitoring intracranial pressure or diverting cerebrospinal fluid. However, confirmation of an infection is not immediate and requires obtaining culture results, often leading to the excessive use of antibiotics. This study aimed to compare noninfectious ventriculitis and EVD infection in terms of the risk factors, predictors, prognosis, and effectiveness of care bundle interventions.

METHODS

This retrospective study was conducted at a medical center with 1,006 beds in northern Taiwan between January 2018 and July 2022. Standard EVD insertion protocols and care bundles have been implemented since 2018, along with the initiation of chlorhexidine.

RESULTS

In total, 742 EVD cases were identified. Noninfectious ventriculitis typically presents with fever approximately 8 days following EVD placement, whereas EVD infection typically manifests as fever after 20 days. Aneurysmal subarachnoid hemorrhage was strongly associated with the development of noninfectious ventriculitis (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.4). Alcoholism (adjusted OR 3.5, 95% CI 1.1-12.3) and arteriovenous malformation (adjusted OR 13.1, 95% CI 2.9-58.2) significantly increased the risk of EVD infection. The EVD infection rate significantly decreased from 3.6% (14 of 446) to 1.0% (3 of 219) (p = 0.03) after the implementation of chlorhexidine gluconate bathing.

CONCLUSIONS

Aneurysmal subarachnoid hemorrhage or fever with neuroinflammation within 2 weeks of EVD placement is indicative of a higher likelihood of noninfectious ventriculitis. Conversely, patients with arteriovenous malformation, alcoholism, or fever with neuroinflammation occurring after more than 3 weeks of EVD placement are more likely to necessitate antibiotic treatment for EVD infection. Chlorhexidine gluconate bathing decreases EVD infection.

Impact of the COVID-19 pandemic on the incidence and the epidemiology of catheter-related bloodstream infection two years later

Introduction

The COVID-19 pandemic increased catheter-related bloodstream infections (C-RBSI), but its subsequent impact has not been adequately described. Our hospital has already depicted the effects of the COVID-19 pandemic in the first wave. However, we still do not know whether C-RBSI rates and aetiology are similar to those described before the COVID-19 pandemic. We aimed to evaluate the impact of the COVID-19 pandemic on the evolution of C-RBSI in a large tertiary teaching hospital two years later.

Material and methods

We prospectively collected all confirmed C-RBSI episodes in a clinical microbiology laboratory database by matching blood cultures and catheter tip cultures with the isolation of the same microorganism (s). We compared our C-RBSI incidence rates and aetiology from 2018 to 2023. C-RBSI was defined as bacteremia or fungemia in a patient with clinical manifestations of infection and no other apparent source except the catheter.

Results

During the study period, we collected 556 C-RBSI episodes. C-RBSI incidence rate per 1000 admissions each year was as follows: 2018: 2.2; 2019: 1.7; 2020: 3.29; 2021: 2.92; 2022: 2.69. and 2023: 2.01. Mainly, C-RBSI episodes occurring in critical care units each year were, respectively: 2018: 57 (54.8 %), 2019: 38 (45.2 %), 2020: 89 (63.6 %), 2021: 69 (60.5 %), 2022: 58 (50.9 %) and 2023 (61.4 %). The distribution of microorganisms showed an increase in Gram-negative episodes after the pandemic.

Conclusion

Our study shows an increase in the incidence rate of C-RBSI during the COVID-19 pandemic, with a discrete decrease after that. C-RBSI episodes were mainly caused by coagulase-negative Staphylococci but with a rise in Gram-negative bacilli.

Best products for skin antisepsis

BACKGROUND

Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections.

METHODS

A PubMed search was performed to update the evidence on skin antiseptic products and practices.

RESULTS

Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs.

CONCLUSIONS

Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.

Horizontal approaches to infection prevention: daily chlorhexidine gluconate bathing

Healthcare-associated infections (HAIs) pose a significant challenge in hospitals. Infection control strategies have been widely employed to mitigate their incidence. In hospitals, chlorhexidine gluconate (CHG) solutions are commonly used as antiseptic skin cleansers as part of comprehensive infection prevention bundles, with daily CHG bathing being highly effective in reducing HAIs and lowering skin micro-organism density. This evidence review addresses the challenges of risk stratification in implementing CHG bathing protocols in hospitals. It highlights the benefits of a horizontal approach, where CHG bathing is implemented across the entire facility rather than being limited to specific patient populations. Evidence from systematic reviews and studies suggests that CHG bathing consistently reduces HAI rates in both intensive care unit (ICU) and non-ICU settings, supporting the adoption of a hospital-wide approach. The findings emphasise the significance of incorporating CHG bathing as part of a comprehensive approach to infection prevention in hospitals and highlight the potential for cost savings.

Central-line associated bloodstream infections in intensive care units before and after implementation of daily antiseptic bathing with chlorhexidine or octenidine: a post-hoc analysis of a cluster-randomised controlled trial

BACKGROUNDS

Antiseptic bathing did not reduce central-line (CL) associated bloodstream infection (CLABSI) rates in intensive care units (ICU) according to a recent cluster randomised controlled trial (cRCT). However, this analysis did not consider baseline infection rates. Our post-hoc analysis of this cRCT aimed to use a before-after comparison to examine the effect of daily bathing with chlorhexidine, octenidine or water and soap (control) on ICU-attributable CLABSI rates.

METHODS

A post-hoc analysis of a multi-center cRCT was done. ICUs that did not yet perform routine antiseptic bathing were randomly assigned to one of three study groups applying daily bathing with 2% chlorhexidine-impregnated cloths, 0.08% octenidine wash mitts or water and soap (control) for 12 months. Baseline data was assessed 12 months before the intervention started when all ICUs routinely used water and soap. Poisson regression and generalised estimating equation models were applied to identify changes of CLABSI rates per 1000 CL days between intervention and baseline periods in each study group.

RESULTS

The cRCT was conducted in 72 ICUs (24 per study group) including 76,139 patients in the baseline and 76,815 patients in the intervention period. In the chlorhexidine group, incidence density of CLABSI was reduced from 1.48 to 0.90 CLABSI per 1000 CL days comparing baseline versus intervention period (P = 0.0085). No reduction was observed in the octenidine group (1.26 versus 1.47 CLABSI per 1000 CL days, P = 0.8735) and the control group (1.20 versus 1.17, P = 0.3298). Adjusted incidence rate ratios (intervention versus baseline) were 0.63 (95%CI 0.46-0.87, P = 0.0172) in the chlorhexidine, 1.17 (95% CI 0.79-1.72, P = 0.5111) in the octenidine and 0.98 (95% CI 0.60-1.58, P = 0.9190) in the control group. Chlorhexidine bathing reduced CLABSI with gram-positive bacteria, mainly coagulase-negative staphylococci (CoNS).

CONCLUSIONS

In this post-hoc analysis of a cRCT, the application of 2% chlorhexidine-impregnated cloths reduced ICU-attributable CLABSI. This preventive effect of chlorhexidine was restricted to CLABSI caused by gram-positive pathogens (CoNS). In contrast, 0.08% octenidine wash mitts did not reduce CLABSI rates in ICUs. Trial registration Registration number DRKS00010475, registration date August 18, 2016.

Chlorhexidine and octenidine susceptibility of bacterial isolates from clinical samples in a three-armed cluster randomised decolonisation trial

BACKGROUND

Routine use of chlorhexidine or octenidine for antiseptic bathing may have unintended consequences. Our analysis aimed to assess the phenotypic susceptibility of bacterial isolates from clinical samples to chlorhexidine and octenidine collected from intensive care units (ICU) that routinely used 2% chlorhexidine-impregnated wash cloths or 0.08% octenidine wash mitts (intervention) or water and soap (control) for daily patient care.

METHODS

This study was conducted within the context of a three armed cluster-randomised controlled decolonisation trial (Registration number DRKS00010475, registration date August 18, 2016). Bacterial isolates were collected prior to and at the end of a 12-month-intervention period from patients with ≥ 3 days length of stay at an ICU assigned to one of two intervention groups or the control group. Phenotypic susceptibility to chlorhexidine and octenidine was assessed by an accredited contract research laboratory determining minimal inhibitory concentrations (MIC) as percentage of extraction solutions used. MIC were reported as estimated concentrations in μg/ml derived from the chlorhexidine and octenidine extraction solutions. Statistical analyses including generalized estimating equation models were applied.

RESULTS

In total, 790 ICU-attributable bacterial isolates from clinical samples (e.g. blood, urine, tracheal aspirate) were eligible for all analyses. Pathogens included were Staphylococcus aureus (n = 155), coagulase-negative staphylococci (CoNS, n = 122), Escherichia coli (n = 227), Klebsiella spp. (n = 150) and Pseudomonas aeruginosa (n = 136). For all species, chlorhexidine and octenidine MIC did not increase from baseline to intervention period in the antiseptic bathing groups. For proportions of bacterial isolates with elevated chlorhexidine / octenidine MIC (≥ species-specific chlorhexidine / octenidine MIC50), adjusted incidence rate ratios (aIRR) showed no differences between the intervention groups and the control group (intervention period).

CONCLUSION

We found no evidence for reduced phenotypic susceptibilities of bacterial isolates from clinical samples to chlorhexidine or octenidine in ICUs 12 months after implementation of routine antiseptic bathing with the respective substances.

Program Evaluation of Implementation Science Outcomes From an Intervention to Improve Compliance With Chlorhexidine Gluconate Bathing: A Qualitative Study

BACKGROUND AND OBJECTIVES

Evaluation of implementation science research is warranted to better understand and determine the success of translating evidence-based infection prevention practices at the bedside. The purpose of this program evaluation was to evaluate implementation outcomes from the perspectives of nurses and nursing leaders regarding a previously conducted chlorhexidine gluconate (CHG) bathing implementation science study among 14 critical care units.

METHODS

Focus groups and interviews, using semistructured interview questions, were conducted to examine the perceptions of nurses who participated in a CHG bathing implementation science study. A deductive qualitative analysis using Proctor and colleagues' implementation outcomes framework was used. Transcripts were analyzed and categorized using the framework as a predetermined code list to structure the implementation outcomes of acceptability, appropriateness, adoption, feasibility, and sustainability.

FINDINGS

A total of 19 nurses and nurse leaders participated in a focus group or interview. Participants noted that both implementation strategies used in the initial study (educational outreach and audit and feedback) were acceptable and appropriate and expressed that the evidence-based CHG bathing practice was feasible to integrate into practice and was being adopted.

DISCUSSION

The program evaluation identified strengths and opportunities for improvement related to the implementation strategies and evidence-based CHG bathing protocol. Findings can inform future studies that seek to implement CHG bathing protocols in the critical care setting using audit and feedback and educational outreach strategies.

Effect of antiseptic bathing with chlorhexidine or octenidine on central-line associated bloodstream infections in intensive care patients: a cluster-randomised controlled trial

OBJECTIVES

Our study aimed to compare the effect of daily bathing with chlorhexidine, octenidine or water and soap (routine care = control) on central-line (CL) associated bloodstream infection (CLABSI) rates in intensive care units (ICUs).

METHODS

A multi-center cluster-randomised controlled trial was done with a 12-months intervention period from February 1, 2017, to January 31, 2018 (octenidine and routine care group) or from June 1, 2017 to May 31, 2018 (chlorhexidine group). Wards were randomly assigned to one of two decolonisation regimes or routine care (control). Intervention included daily bathing with 2% chlorhexidine-impregnated cloths or 0.08% octenidine wash mitts for 12 months, while the control group used water and soap (routine care). The primary outcome was incidence density of CLABSI per 1,000 CL days. Poisson regression and generalised estimating equation models (GEE) were applied.

RESULTS

A total of 72 ICUs with 76,815 patients (22,897 patients in the chlorhexidine group, 25,127 in the octenidine group and 28,791 in the routine care group) were included. Incidence densities were 0.9 CLABSI per 1,000 CL days (95%CI 0.67 - 1.19) in the chlorhexidine group, 1.47 (95%CI 1.17 - 1.81) in the octenidine group and 1.17 (95%CI 0.93 - 1.45) in the routine care group. Adjusted incidence rate ratios of CLABSI were 0.69 (95%CI 0.37-1.22, p=0.25) in the chlorhexidine and 1.22 (95%CI 0.54-2.75, p=0.63) in the octenidine group (compared with routine care).

CONCLUSION

Antiseptic bathing with 2% chlorhexidine-impregnated cloths and 0.08% octenidine wash mitts lack a significant preventive effect on CLABSI rates in ICUs. However, our trial has a high likelihood of being underpowered as CLABSI rates in the routine care group were approximately 40% lower than initially assumed. This trial is registered with the German register for clinical trials (18/08/2016, number DRKS00010475).

Nosocomial Fungal Infections: Epidemiology, Infection Control, and Prevention

Invasive fungal infections are an important cause of morbidity and mortality in hospitalized patients and in the immunocompromised population. This article reviews the current epidemiology of nosocomial fungal infections in adult patients, with an emphasis on invasive candidiasis (IC) and invasive aspergillosis (IA). Included are descriptions of nosocomial infections caused by Candida auris, an emerging pathogen, and IC- and IA-associated with coronavirus disease 2019. The characteristics and availability of newer nonculture-based tests for identification of nosocomial fungal pathogens are discussed. Recently published recommendations and guidelines for the control and prevention of these nosocomial fungal infections are summarized.

Effectiveness of chlorhexidine in preventing infections among patients undergoing cardiac surgeries: a meta-analysis and systematic review

Background

Although several meta-analyses reported the impact of chlorhexidine (CHX) use in patients undergoing various types of surgery, no meta-analysis summarized the overall effectiveness of CHX specifically for cardiac surgery. This meta-analysis aimed to examine the impact of CHX on infections after cardiac surgery compared with other cleansers or antiseptics.

Methods

PubMed, Embase, and the Cochrane Library were searched from inception up to October 2020 for potentially eligible studies: (1) population: patients who underwent cardiac surgery; (2) intervention or exposure: any type of CHX use in the treatment or exposed group; (3) outcome: number of patients with infections; (4) comparison: placebo or other antiseptic agents; (5) English. The primary outcome was surgical site infection (SSI).

Results

Fourteen studies were included, with 8235 and 6901 patients in the CHX and control groups. CHX was not protective against SSI (OR = 0.77, 95% CI: 0.57–1.04, P = 0.090). CHX was protective for superficial wound infection (OR = 0.42, 95% CI: 0.26–0.70, P = 0.001), but not with deep wound infection (P = 0.509). CHX was not protective against urinary tract of infection (P = 0.415) but was protective for bloodstream infection (OR = 0.36, 95% CI: 0.16–0.80, P = 0.012), nosocomial infections (OR = 0.55, 95% CI: 0.44–0.69, P < 0.001), and pneumonia (OR = 0.26, 95% CI: 0.11–0.61, P = 0.002).

Conclusions

In patients undergoing cardiac surgery, CHX does not protect against SSI, deep wound infection, and urinary tract infections but might protect against superficial SSI, bloodstream infection, nosocomial infections, and pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01009-3.

Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff's compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff's knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates.

METHODS

A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability.

RESULTS

Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff's knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates.

CONCLUSIONS

Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.

Prevalence of recessive infection of pathogens of hand, foot, and mouth disease in healthy people in China: A meta-analysis

BACKGROUND

To analyze the prevalence of latent infection of pathogens of hand, foot, and mouth disease (HFMD) in Chinese healthy population and its influencing factors, so as to provide reference for the prevention and control of HFMD.

METHODS

A systematic literature searching about the incidence of latent infection of HFMD was conducted in Chinese and English databases. The inclusion and exclusion criteria of the retrieved literature were established. The qualified literatures were screened and the data were extracted. The pooled rate and its 95% confidence interval was used to assess the latent infection rate of HFMD pathogens in healthy Chinese population, and subgroup analysis was conducted based on gender and age. All statistical analyses were performed using the STATA version 12.0 software.

RESULTS

A total of 31 literatures were included in this meta-analysis. The recessive infection rate of HFMD pathogens reported in the literature of Chinese healthy people ranged from 4.59% to 44.12%. The results of meta-analysis showed that the latent infection rate of human enteroviruses (HEVs) in healthy Chinese population was 17.5% (14.9-20.1%), among which, the latent infection rates of EV-A71, CV-A16, and other HEVs were 3.3% (2.2-4.4%), 1.7% (1.0-2.5%), and 15.1% (11.1-17.1%), respectively. The latent infection rates of HEVs in healthy men and women in China were 16.7% (12.9-20.4%) and 14.4% (10.8-18.0%), respectively. The latent infection rates of HEVs in the healthy population aged 0 to 5 years and over 5 years were 24.4% (20.4-28.5%) and 9.4% (6.5-12.2%), respectively. Meta regression showed that the factors affecting the latent infection rate of HEVs in Chinese healthy population included sampling period, sampling area, and study population.

CONCLUSION

The latent infection rate of HEVs is high in healthy people in China, but it is mainly caused by other enteroviruses. The latent infection rate of HEVs in male was higher than that of female and was greater in people aged 0 to 5 than that of aged over 5 years. Limited by the quantity and quality of the included studies, more high-quality studies are needed for further verification in the future.

Is it cost effective to use a 2% chlorhexidine wipes bath to reduce central-line associated blood stream infection? A quasi-experimental study

Background

Bathing with 2% chlorhexidine (CHG) wipes is an important measure regarding infection prevention in critically ill patients. The aim of this study was to evaluate the impact of CHG wipes bath to prevent central-line associated bloodstream infection (CLABSI) in critically ill patients and determine if such measure is cost-saving.

Methods

a quasi-experimental study, conducted from July 2017 to April 2019. Daily bath with 2% CHG was used in all patients at the unit in the intervention period. The following were evaluated: CLABSI incidence density in both periods, 30- day mortality, guided antimicrobials used to treat CLABSI and 2% CHG costs.

Results

CLABSI incidence density dropped from 8.69 to 1.83 per 1.000 central line-days (p = 0.001), mainly by Klebsiella pneumoniae Carbapenen Resistant (Kp-KPC) (p = 0.05). Costs with guided antimicrobials for the treatment in pre-intervention were US$ 46,114.36, and in the intervention period, US$ 4,177.50. The 2% CHG monthly cost was US$ 2,698.00, achieving 30% savings when comparing both periods.

Discussion

An expressive reduction of 79% in CLABSI incidence density was observed, mainly due to Kp-KPC infection and also a reduction in guided antimicrobial costs.

Conclusions

Bathing with 2% CHG led to evident CLABSI reduction.

What is new in catheter use and catheter infection prevention in the ICU

PURPOSE OF REVIEW

Short-term intravascular catheters are instrumental in the care of critically ill patients. Despite their benefits, they also are potential entries for systemic infections. There is a growing body of literature on catheter use and the prevention of intravascular catheter infections in intensive care. This review highlights major recent contributions to the topic and put them into perspective to recommendations on best practice procedures.

RECENT FINDINGS

Many studies published in the last years have evaluated prevention strategies applying technology and addressing behavior change. Skin disinfection with 2% alcoholic chlorhexidine-gluconate (CHG) and CHG-impregnated dressings are increasingly used in clinical practice. However, the role of universal CHG bathing remains controversial. A number of new and innovative technologies are in development. Recent qualitative research offers new perspectives about behavior change interventions to improve implementation.

SUMMARY

Many options for effective intravascular catheter infection prevention are currently available. A number of recent systematic reviews and meta-analyses not only confirmed measures targeting best practice and technology at catheter insertion and catheter care but also challenged interventions, such as CHG bathing. More focus should be put to implementation strategies.

Chlorhexidine bathing of the exposed circuits in extracorporeal membrane oxygenation: an uncontrolled before-and-after study

BACKGROUND

Although the prevention of extracorporeal membrane oxygenation (ECMO) catheter-related infection is crucial, scientific evidence regarding best practices are still lacking.

METHODS

We conducted an uncontrolled before-and-after study to test whether the introduction of disinfection with 2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol (IPA) of the exposed circuits and hub in patients treated with ECMO would affect the rate of blood stream infection (BSI) and microbial colonization of the ECMO catheter. We compared the microbiological and clinical data before and after the intervention.

RESULTS

A total of 1740 ECMO catheter days in 192 patients were studied. These were divided into 855 ECMO catheter days in 96 patients before and 885 ECMO catheter days in 96 patients during the intervention. The rates of BSI were significantly decreased during the intervention period at 11.7/1000 ECMO catheter days before vs. 2.3/1000 ECMO catheter days during (difference 9.4, 95% confidence interval (CI) 1.5-17.3, p = 0.019). Furthermore, the colonization of the ECMO catheter was similarly significantly reduced during the intervention period at 10.5/1000 ECMO catheter days before vs. 2.3/1000 ECMO catheter days during intervention (difference 8.3, 95% CI 0.7-15.8, p = 0.032). Hospital mortality (41.7% vs. 24%, p = 0.009) and sepsis-related death (17.7% vs. 6.3%, p = 0.014) were also significantly decreased during intervention.

CONCLUSION

Extensive disinfection of exposed ECMO circuits and hub with 2% CHG/IPA was associated with a reduction in both BSI and microbial colonization of ECMO catheters. A further randomized controlled study is required to verify these results.

TRIAL REGISTRATION

KCT 0004431.

Central-line-associated bloodstream infections in a surgical paediatric intensive care unit: Risk factors and prevention with chlorhexidine bathing

AIM

The aims of the study are to evaluate the impact of a 4% chlorhexidine (CHG4%) bathing on the occurrence of central-line-associated bloodstream infection (CLABSI) and to identify risk factors (RFs) for CLABSI in our population. This is a retrospective monocentric cohort study in the paediatric surgical intensive care unit at the Necker Enfants Malades Hospital, Paris, France.

METHODS

All hospitalised patients with central venous catheters (CVCs) in 2015 were included. CHG4% bathing was prescribed in CLABSI high-risk patients, defined by the presence of exposition factors (EFs): constitutive or acquired immunosuppression, presence of an invasive medical device (IMD) and the carriage of Staphylococcus aureus. The overall 2015 CLABSI incidence rate was compared with 2014 CLABSI incidence rate (before CHG4% bathing).

RESULTS

In all, 775 patients were analysed. Some 182 had at least one EF, and 49 received CHG4%. The incidence rates of CLABSI in 2014 and 2015 were, respectively, 6.1 and 2.3/1000 days CVC (P < 0.01). The presence of at least one EF was associated with the CLABSI's occurrence: odds ratio = 15.13 (95% confidence interval: 4.26-53.71; P < 0.0001), particularly acquired immunosuppression, IMD and S. aureus colonisation. Other RFs were age <1 year and carrying duration >16 days.

CONCLUSIONS

This study showed a significant reduction in incidence of CLABSI after introduction of a targeted CHG4% bathing protocol. Presence of IMD, S. aureus colonisation, immunosuppression, age <1 year and carrying duration >16 days were CLABSI RFs. Regarding the literature, the presence of IMD seems to be underestimated in CLABSI prevention.

The effect of copper-oxide-treated soft and hard surfaces on the incidence of healthcare-associated infections: a two-phase study

BACKGROUND

Copper-oxide-impregnated linens and hard surfaces within the hospital environment have emerged as a novel technology to reduce environmental contamination and thereby potentially reduce the risk of healthcare-associated infections (HCAIs).

METHODS

This was a two-phase study. Phase 1 was a prospective, cluster-randomized, cross-over clinical trial in which one pod (eight beds) of our general ICU (GICU) utilized copper-oxide-impregnated linens whereas the other pod (eight beds) used standard hospital linens. Phase 2 was a two-year before-after study, following the relocation of three ICUs into a new ICU tower in which all the hard surfaces were treated with copper oxide (in addition to copper-impregnated linens). HCAIs were recorded using the National Healthcare Safety Network definitions.

FINDINGS

A total of 1282 patients were enrolled in phase 1. There was no difference in the rate of HCAI between the patients who received standard compared with copper oxide linen. In phase 2 there was a significant reduction in the number of infections due to Clostridioides difficile (2.4 per 1000 vs 0.7 per 1000 patient-days; incidence rate ratio: 3.3; 95% confidence interval: 1.4-8.7; P = 0.002) but no difference in the rate of central-line-associated bloodstream infections nor of catheter-associated urinary tract infections.

CONCLUSION

Copper-oxide-impregnated linens alone had no effect on the rate of HCAI. Our data suggest that copper-oxide-treated hard surfaces reduced the rate of infections due to C. difficile; however, important confounders cannot be excluded.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020

Background and Purpose

Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.

Methods

This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.

Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.

Results

This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.

Conclusion

In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.

Abbreviations list

ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO₂: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization

How to cite this article

Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.

Disinfectant Activity of A Portable Ultraviolet C Equipment

Healthcare-associated infections (HAIs) can be caused by microorganisms present in common practice instruments generating major health problems in the hospital environment. The aim of this work was to evaluate the disinfection capacity of a portable ultraviolet C equipment (UV Sanitizer Corvent^® -UVSC-) developed to disinfect different objects. For this purpose, six pathogens causing HAIs: Acinetobacter baumannii, Bacillus subtilis, Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Candida albicans, were inoculated on slides and discs of different biomaterials (borosilicate, polycarbonate, polyurethane, silicone, Teflon and titanium) and exposed to ultraviolet C radiation. UVSC disinfection was compared with ethanol and chlorhexidine antimicrobial activities following the standards EN14561 and EN14562. Disinfection, established as a reduction of five logarithms from the initial inoculum, was achieved with the UVSC at 120 s of exposure time, with and without the presence of organic matter. The disinfectant effect was observed against S. aureus, P. aeruginosa, E. coli, B. subtilis and C. albicans (reduction >99.999%). Disinfection was also achieved with 70% ethanol and 2% chlorhexidine. As conclusion, UVSC was effective disinfecting the most contaminated surfaces assayed, being a promising alternative for disinfecting hospital materials and inanimate objects that cannot be immersed in liquid biocides, reducing the risk of pathogen transmission.

Susceptibility of livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) to chlorhexidine digluconate, octenidine dihydrochloride, polyhexanide, PVP-iodine and triclosan in comparison to hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA): a standardized comparison

Background

Recent publications have raised concerns of reduced susceptibilities of clinical bacterial isolates towards biocides. This study presents a comparative investigation of the susceptibility of livestock-associated Methicillin-resistant Staphylococcus aureus (LA-MRSA), hospital-acquired MRSA (HA-MRSA) and community-aquired MRSA (CA-MRSA) to the commonly used antiseptics chlorhexidine (CHX), octenidine (OCT), polyhexanide (PHMB), PVP-iodine (PVP-I) and triclosan (TCX) based on internationally accepted standards.

Methods

In total, 28 (18 LA-, 5 HA- and 5 CA) genetically characterized MRSA strains representing a broad spectrum of hosts, clonal complexes and spa-types, as well as the reference methicillin-sensitive Staphylococcus aureus (MSSA) strain ATCC 6538, were selected. Minimal inhibitory concentration (MIC) and minimal microbicidal concentration (MBC) were determined in accordance with DIN 58940-7, 58940-8 and DIN EN ISO 20776-1. The microbicidal efficacy was determined in accordance with DIN EN 1040.

Results

Results from the MIC/MBC and quantitative suspension tests revealed differences between antiseptic substances but not between epidemiological groups of MRSA strains. OCT and PHMB were the most active substances with a minimal MIC of 1 mg/L, followed by CHX (2 mg/L), TCX (32 mg/L) and finally PVP-I (1024 mg/L). The MSSA reference strain showed a tendency to a higher susceptibility compared to the MRSA strains.

Conclusions

This investigation of the susceptibility of a range of LA-, HA- and CA-MRSA strains using standardized conditions gave no indication that LA-MRSA strains are less susceptible to commonly used antiseptics compared to HA- and CA-MRSA strains.