Incidence Of Catheter-related Bloodstream Infection Research Articles

Catecholamine Inotrope Resuscitation of Antibiotic‐Damaged Staphylococci and Its Blockade by Specific Receptor Antagonists

The increasing use of antibiotic-coated catheters, such as those containing rifampin or minocycline, has led to a decrease in catheter colonization by staphylococci but not to a decrease in the incidence of catheter-related bloodstream infection (BSI). Because catheters are used for the administration of catecholamine inotropes to maintain cardiac function, we examined whether 2 commonly employed inotropes, dopamine and norepinephrine, could affect bacterial viability after exposure to rifampin and minocycline. Rifampin inhibition and minocycline inhibition of staphylococcal growth could be reversed by exposure to dopamine or norepinephrine as a result, in part, of catecholamine-mediated increased provision of host-sequestered iron. The simultaneous addition of inotropes with an antibiotic did not affect antibiotic susceptibility. Inotrope-induced growth in bacteria previously exposed to antibiotics was blocked by the inclusion in culture media of specific catecholamine-receptor antagonists. Considered collectively, these results provide a mechanistic basis for understanding how host-related factors, such as inotrope-based therapeutics, may influence the recovery of antibiotic-stressed bacteria in clinical settings.

Influence of insertion site on central venous catheter colonization and bloodstream infection rates

To compare colonization and catheter-related bloodstream infection (CR-BSI) rates among three insertion sites (subclavian, internal jugular, femoral) used for central venous catheter (CVC) placement. Twenty-four-month prospective study, with relative effects analyzed by Cox proportional hazards regression. Eight-bed intensive care unit. Four hundred and ten critically ill patients requiring CVC placement. All short-term multi-lumen CVCs, including antimicrobial-coated devices, were studied with management standardized. Six hundred and five CVCs (4,040 catheter days) were analyzed. Colonization and CR-BSI incidence were, respectively, 15.1 (95% CI 13.5-21.0) and 1.8 (95% CI 1.2-4.2) per 1,000 catheter-days. Colonization was higher at the internal jugular (HR 3.64; 95% CI 1.32-10.00; p=0.01) and femoral (HR 5.15; 95% CI 1.82-14.51; p=0.004) sites than at the subclavian site. The femoral site carried a greater risk of being colonized by non-S. epidermidis species than the subclavian and internal jugular sites combined (HR 4.15; 95% CI 1.79-9.61; p=0.001). CVCs inserted in the Department of Emergency Medicine were more colonized than those inserted in the ICU or operating room (HR 2.66; 95% CI 1.27-5.56; p=0.01), and CVCs were less colonized in females than in males (HR 0.49; 95% CI 0.26-0.89; p=0.02). No difference in CR-BSI rates was noted between the three sites. Colonization was lowest at the subclavian site. Regional differences exist with respect to type of pathogen isolated. Colonization was influenced by insertion location and gender. The incidence of CR-BSI was not different.

Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters*

Peripheral arterial catheters are perceived as having low infective potential compared with other catheters and may be overlooked as a cause of catheter-related bloodstream infection. We aimed to measure colonization and rates of catheter-related bloodstream infection in arterial catheters, to investigate risk factors for arterial catheter colonization, and to compare arterial catheter infection rates with those in concurrently sited and managed central venous catheters. Prospective 24-month cohort study. Eight-bed combined general intensive care and high-dependency unit of a 350-bed Australian teaching hospital. Three hundred twenty-one arterial catheters in 252 adult and pediatric patients were observed for 1,082 catheter days, and 618 central venous catheters in 410 patients were observed for 4,040 catheter days. All catheters were inserted in, or presented to, the intensive care unit. Both arterial catheters and central venous catheters were inserted by trained personnel under aseptic conditions, and management was standardized. None. The incidence per 1,000 (95% confidence interval) catheter days of colonization (> or = 15 colonies) and catheter-related bloodstream infection was 15.7 (9.5-25.9) and 0.92 (0.13-6.44) for arterial catheters and 16.8 (13.3-21.3) and 2.23 (1.12-4.44) for central venous catheters. Arterial catheter colonization was not significantly different than that in central venous catheters (hazard ratio, 1.17; 95% confidence interval, 0.41-3.36; p = .77). Arterial catheter colonization increased with dwell time and was similar to central venous catheters over time. Femoral arterial catheters were colonized more often than radial arterial catheters (hazard ratio, 5.08; 95% confidence interval, 0.85, 30.3; p = .075), and colonization was significantly higher when the catheter was inserted in the operating theater or emergency department (hazard ratio, 4.45; 95% confidence interval, 1.42-13.9; p = .01) compared with the intensive care unit. The incidence of catheter-related bloodstream infection from arterial catheters was low. However, both arterial catheter colonization and rates of catheter-related bloodstream infection were similar to those in concurrently sited and identically managed central venous catheters. By inference, the arterial catheter should be accorded the same degree of importance as the central venous catheter as a potential source of sepsis.

461: Standardizing Central Venous Line Care in Inpatient Pediatric Hematopoietic Stem Cell Transplant Recipients: Does it Make a Difference in Reducing Catheter Related Blood Stream Infection Rates?

Central venous catheter related blood stream infections (CRBSI) increase morbidity and mortality in pediatric hematopoietic stem cell transplant (HSCT) recipients. There are limited data in the pediatric HSCT population regarding the incidence of CRBSI. Studies in adult oncology and HSCT patients have reported the average rate to be 2.5 CRBSI per 1000 patient-days. We hypothesized that adherence to evidence-based practices shown to reduce CRBSI in short term central venous lines (CVLs) would also reduce CRBSI in long term CVLs.

Catheter-related bloodstream infection according to central venous accesses

Which venous catheterization site is associated with the higher risk of infection remains controversial. In the CDC guidelines of 1996 and in the latest guidelines of 2002, central venous catheter (CVC) insertion at the subclavian site is recommended rather than a femoral or a jugular access to minimize infection risk. The objective of this study was to analyze the incidence of catheter-related bloodstream infection (CRBSI) of CVCs according to different accesses.

Intermittent Intravenous Administration Sets: Survey of Current Practices

The practice of using intravenous (IV) administration sets for intermittent infusion is subject to much controversy and there is no scientific data to validate the practice. To get an idea of this practice, an online survey was sent to approximately 4000 nurses, with 361 responding. The results highlight the vast differences in practice between the clinical settings of the available studies and how these sets are currently used. Although no recommendations for practice can be drawn from these data, they emphasize the urgent need for research on the use of intermittent administration sets and their contribution to the incidence of catheter-related bloodstream infection.

Central Venous Catheter Infections in Burn Patients with Scheduled Catheter Exchange and Replacement

Consensus in the general critical care patient population is that routine central venous catheter change is not necessary, and that central lines should not be rewired in the setting of possible infection. This concept has not carried over into the burn realm. In burn patients the rewiring of lines may lead to increased infection rates. Fifty-nine consecutive critically ill burn patients requiring central line placement were included: 277 central lines and 1691 catheter days. Standard care protocol was followed in all patients, with lines being placed initially by new site insertion, changed over a guidewire on day 6, and moved to a new site on day 12. New sites were used for all suspected or documented line infections. All other care was the same. New site placements were compared to guidewire exchanges. Pediatric patients (under the age of 18) were considered with and separate from adults. There was no difference in the incidence of catheter-related bloodstream infections (CRBSI) between lines placed by new site access (15.4/1000 catheter days) or by guidewire exchange (15.4/1000). Considering the 979 pediatric line days, there was a distinct difference, with new sites having 16.6/1000, and rewires 25.2/1000. Adults revealed the opposite trend, rewires having no occurrences of CRBSI, and new sites 13.7/1000. Children had a higher rate of CRBSI, 19.4/1000 days, compared to adults at 9.8/1000 days. Children had larger burns (P < 0.0001), more femoral lines (P = 0.0003), and lines closer to the burn wound (P = 0.001). In pediatric patients guidewire exchange increased the incidence of infection. This was not noted in adult patients. The utility of guidewire exchange needs to be further investigated in adults, although this data would imply that it may be safe to use routine rewire of lines in adult burn patients. Pediatric patients require an increase in vigilance to minimize CRBSI. Central venous catheters should be removed as soon as not needed and routine change of lines in burn patients needs continued evaluation.

Use of Ethanol Lock Therapy to Reduce the Incidence of Catheter‐Related Bloodstream Infections in Home Parenteral Nutrition Patients

Catheter-related bloodstream infection (CRBSI) is a serious complication for home parenteral nutrition (HPN) patients. To reduce the incidence of infection in frequently infected HPN patients, prophylactic ethanol lock therapy (ELT) was initiated. Nine patients were selected as candidates for ELT because of their history of recurrent CRBSI. Diagnosis of CRBSI was determined by symptoms correlating with positive peripheral and access device blood cultures. Medical-grade ethyl alcohol 25%-70% was instilled into the central venous access device and allowed to dwell for 2-4 hours. The incidence of CRBSI and catheter changes was compared before and after initiation of ELT. Nine patients experienced 81 CRBSIs (8.3 per 1,000 catheter-days) before starting ELT vs 9 infections (2.7 per 1,000 catheter-days: relative risk [RR], 0.325; confidence interval [CI] 95%, 0.17-0.64) after ELT. Catheter changes were also reduced from 69 (7.0 per 1000 days) before ELT to 1 (0.3 per 1,000 days: RR, 0.043; CI 95%, 0.01-0.25) after ELT. No significant adverse effects were noted, although some patients complained of transient dizziness and nausea. ELT shows promise in reducing the incidence of CRBSI in the frequently infected HPN population. Further studies are warranted.

Port-A-Cath Insertions in Acute Leukaemia and Childhood Malignancies

This retrospective case series sought to determine the incidence and profile of catheter-related complications associated with Port-A-Cath insertions in paediatric cancer patients, as well as predictive factors for infection-related port removals. Between January 2002 and December 2004, 175 consecutive Port-A-Cath insertions were followed for a total of 75,000 days (median, 407; range, 6-1,074). Incidence of catheter-related bloodstream infections (CRBSIs), other complications and CRBSI-related port removals were analysed for cases with acute leukaemia versus other malignancies. A total of 33 CRBSIs were encountered in 26 cases (18.9%), an infection rate of 0.44 episodes per 1,000 catheter days. While mean preoperative platelet count was 125.34 x 10(9)/L in children with acute leukaemia and 392.11 x 10(9)/L in those with other malignancies (p < 0.01), the incidence of all complications were similar between both subgroups. Staphylococcus epidermidis (23.1%) and Klebsiella spp. (19.2%) were most commonly isolated from infected ports. Median patient age and duration of implantation in CRBSI-related port removals was 1.5 years and 111 days respectively, and 10.0 years and 414 days respectively in CRBSIs without port removal. Minimal complications are associated with Port-A-Cath insertions, even in thrombocytopaenic leukaemic patients. The dominance of Gram-negative organisms in CRBSIs parallels the changing trend of nosocomial infectious agents involved in catheter-related infections.

Port-A-Cath insertions in acute leukemia: does thrombocytopenia affect morbidity?

Background Unnecessary delay of insertion of Port-A-Cath indwelling venous catheters in thrombocytopenic patients may result from fear of potential morbidity. This study sought to compare the morbidity of Port-A-Cath insertions in acute leukemic patients with platelet counts below and above 50 × 10 9/L. Method Incidence and profile of catheter-related bloodstream infections (CRBSIs) and other complications were determined in 80 consecutive Port-A-Cath insertions in pediatric patients with acute leukemia from January 2002 to December 2004. Subgroup analysis was performed for patients with platelet levels below and above the recommended safe level of 50 × 10 9/L. Results Twenty-two (27.5%) patients had insertions performed at platelet levels below the recommended level (median, 35.3; range, 10-49 × 10 9/L); postoperative counts were correspondingly higher (median, 66.0; range, 20-207 × 10 9/L) with perioperative platelet transfusion. Catheter-related bloodstream infection incidence was similar in patients with platelets less than and greater than the recommended threshold (18.2% vs 17.2%, respectively), and likewise for CRBSIs encountered in the immediate 30 postoperative days (4.6% and 5.2%, respectively). Only 2 episodes of postoperative bleeding occurred, both in the group with platelet counts greater than 50 × 10 9/L, with an equally low incidence of other local and mechanical complications in both subgroups. Patient demographics and other preoperative blood parameters did not differ significantly. Conclusion Preoperative thrombocytopenia was not associated with increased incidence of postoperative complications for Port-A-Cath insertions in acute leukemic children.

Incidence of Catheter-Related Bloodstream Infection Among Patients With a Needleless, Mechanical Valve–Based Intravenous Connector in an Australian Hematology-Oncology Unit

There are few Australian data on the incidence of catheter-associated bloodstream infection (BSI) among patients in hematology-oncology units. We found an increase in catheter-associated BSI rates coincident with the introduction of a mechanical valve connector (2.6 infections vs 5.8 infections per 1,000 catheter-days; incidence rate ratio, 2.2; P=.031).

Implementing Evidence-based Nursing Practice in the Pediatric Intensive Care Unit

With the widespread use of central venous catheters in children, the incidence of catheter-related bloodstream infections (CR-BSIs) is increasing. Current evidence-based practice strategies to decrease CR-BSIs include using maximum barrier techniques during insertion, practicing good hand hygiene, performing skin antisepsis with 2% chlorhexidine, using a chlorhexidine-impregnated patch (CIP) covered by a semipermeable polyurethane dressing, and promptly removing catheters when no longer needed. Implementation of evidence-based practice bundles, along with monthly monitoring of infection surveillance, has resulted in significant decreases in the average rates of CR-BSIs per 1,000 catheter days in many pediatric intensive care units.

Catheter related bloodstream infection following PICC removal in preterm infants

Describe the incidence of catheter-related blood stream infection (CRBSI), following removal of peripherally inserted central venous catheters (PICC) in preterm infants. A retrospective cohort study of infants <29 weeks gestational age with a PICC revealed 101 PICCs placed (2159 PICC days). Patients were hospitalized in a level III Neonatal Intensive Care Unit (NICU) between January 2002 and December 2003. Chi(2) analysis was performed. One infection was detected after the removal of a PICC (1 per 202 days). Ten infants had a CRBSI attributed to a PICC (1 per 216 PICC days). CRBSI during indwelling PICC was associated with increased risk for sepsis evaluation after PICC removal (P<0.05). The incidence of CRBSI in the 48 h following PICC removal was not different than the incidence of CRBSI while a PICC was in-dwelling. There was no evidence from this study to support antibacterial prophylaxis before PICC removal.

Antimicrobial Impregnated Catheters in the Prevention of Catheter-Related Bloodstream Infection in Hospitalized Patients

Catheter-related bloodstream infections have a significant impact on increasing health care costs and morbidity and mortality in hospitalized patients. Many technologies have been created in an attempt to decrease the incidence of catheter-related bloodstream infection. One of these is the impregnation of central venous catheters with antiseptics (e.g., chlorhexidine and silver sulfadiazine) or antibiotics (e.g., minocycline and rifampin). While studies evaluating the efficacy of impregnated catheters have been conducted, the data are limited and their use remains variable across institutions. This paper will discuss catheter-related factors that predispose patients to catheter-related bloodstream infection, the types of antimicrobial-impregnated catheters in use today, studies evaluating their efficacy, and common concerns associated with the use of these catheters. Issues related to the cost-effectiveness of impregnated catheters and future directions for the prevention of catheter-related bloodstream infection will also be presented.

Maximal barrier precautions, intensivist supervision, and catheter-related bloodstream infections

Catheter-related bloodstream infections (CR-BSI) have significant costs. Use of maximal barrier precautions (MBP) may reduce the incidence of CR-BSI. We studied MBP with/without intensivist supervision of residents on CR-BSI incidence.

An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU

Catheter-related bloodstream infections occurring in the intensive care unit (ICU) are common, costly, and potentially lethal. We conducted a collaborative cohort study predominantly in ICUs in Michigan. An evidence-based intervention was used to reduce the incidence of catheter-related bloodstream infections. Multilevel Poisson regression modeling was used to compare infection rates before, during, and up to 18 months after implementation of the study intervention. Rates of infection per 1000 catheter-days were measured at 3-month intervals, according to the guidelines of the National Nosocomial Infections Surveillance System. A total of 108 ICUs agreed to participate in the study, and 103 reported data. The analysis included 1981 ICU-months of data and 375,757 catheter-days. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention (P< or =0.002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002). The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% confidence interval [CI], 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months. An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.

Tunneled catheters' outcome optimization among diabetics on dialysis through antibiotic-lock placement

Efficacy and safety of antibiotic 'locks', in prevention of thrombotic and infectious complication-related morbidity and mortality, among diabetics dialyzed through tunneled-cuffed catheters (TCCs) has not been effectively investigated. This trial was designed to investigate the outcome of TCCs (n = 109), inserted among 96 diabetic end-stage renal disease patients (March 2002-February 2003), by comparing the catheter thrombosis, catheter-related bloodstream infections (CRBSI), catheter survival, and mortality rates, between the cohorts of 49 patients who had TCCs (n = 51) 'locked' with cefotaxime/heparin (group I) and 47 patients with TCCs (n = 58) filled with standard heparin (group II). Thrombosis was defined as the inability to use catheter at a blood flow of 200 ml/min despite intraluminal thrombolysis. Primary end points were catheter thrombosis and CRBSI; elective catheter removal and CRBSI-related death led to sensor of TCCs follow-up. Patients with intraluminal cefotaxime/heparin lock, on cumulative survival analysis, showed a superior thrombosis-free (86.3 vs 63.8%, P = 0.023, log rank), infection-free (72.9 vs 27.1%, P = 0.004, log rank), and thrombosis- and infection-free TCC survival (78.4 vs 37.9%, P = 0.001, log rank) at 365 days, besides having significantly lower incidence of CRBSI (1.56 vs 3.68 episodes/1000 catheter days, P < 0.0001) and CRBSI-related mortality (9.8 vs 23.4%, P = 0.015), compared with the heparin-alone group. Deployment of cefotaxime-heparin 'lock' enhances catheter survival; reduces thrombotic and infectious complications and ensuing mortality, among diabetics on dialysis. However, further studies are needed to define the long-term implications of antibiotic locks in terms of the risk of emergence of antimicrobial resistance.

Are antiseptic-coated central venous catheters effective in a real-world setting?

Catheter-related bloodstream infections are common, costly, and morbid. Randomized controlled trials indicate that antiseptic-coated central venous catheters reduce infection rates. To assess the clinical and economic effectiveness of antiseptic-coated catheters for critically ill patients in a real-world setting. Central venous catheters coated with chlorhexidine/silver-sulfadiazene were introduced in all patients requiring central venous access in adult intensive care units at the University of Michigan Health System, a large, tertiary care teaching hospital. A pretest-posttest cohort design measured the primary outcome of catheter-related bloodstream infection rate, comparing the 2 years prior to the intervention with the 2 years following the intervention. We also evaluated cost-effectiveness and changes in vancomycin use. The intervention was associated with a 4% per month relative reduction in the incidence of catheter-related bloodstream infection, after controlling for the effects of time. Overall, a 35% relative risk reduction (P < .0003) in the catheter-related bloodstream infection rate occurred in the posttest phase. The use of antiseptic-coated catheters reduced costs more than $100,000 annually. Vancomycin use was less in units in which antiseptic catheters were used compared with wards in which these catheters were not used. Antiseptic-coated catheters appear to be clinically effective and economically efficient in a real-world setting.

Recommendations and Reports about Central Venous Catheter-Related Infection

Central venous catheters (CVCs) are used to deliver a variety of therapies, as well as for measurement of hemodynamic parameters. The major associated complication is catheter-related blood stream infection (CRBSI). Review of the pertinent English-language literature. The incidence of CRBSI depends on how such infections are defined. Generally, the term includes all BSIs in patients with CVCs when other sources can be excluded, and if a culture of the catheter tip demonstrates a substantial number of colonies of the organism found in the blood stream. Important pathogenic determinants of catheter-related infection are the material of which the device is made and the intrinsic virulence of the organism. The site at which a catheter is placed influences the risk of infection. The types of organisms that most commonly cause hospital-acquired BSIs have changed over time. Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection. Good hand hygiene before catheter insertion, combined with proper aseptic technique during its manipulation, provides protection against infection; maximal sterile barrier precautions during insertion reduce the incidence of CRBSI. Catheters that are coated or impregnated with antimicrobial or antiseptic agents can decrease the risk and the associated hospital costs. No studies have demonstrated that oral or parenteral antibacterial or antifungal drugs reduce the incidence of CRBSI in adults. Use of anticoagulants might have a role in the prevention of CRBSI. Catheter replacement at scheduled intervals has not lowered rates of local or systemic complications. Central venous catheters are used commonly to deliver a variety of therapies, such as large amounts of fluid or blood products during surgery or in intensive care units, chemotherapy, and parenteral nutrition, as well as for measurement of hemodynamic variables. The major complication associated with CVCs is CRBSI.

The Importance of Leadership in Effecting Change: A Tale of 2 ICUs

ISSUE: A 2005 performance improvement goal for our Epidemiology Department (ED) was to decrease the incidence of catheter-related bloodstream infections (CR-BSIs). The leadership of 2 targeted, high-risk adult ICUs was presented with an initiative, which was met with enthusiasm in one and reservation in the other. PROJECT: A recommendation was made to the 2 ICUs to implement a central line bundle based on a peer reviewed, published study that demonstrated a decrease in CR-BSIs. The bundle consisted of 5 interventions: education on proper technique for central venous catheter (CVC) insertion, use of a CVC supply cart, daily questioning of the need for CVCs, a checklist to be completed by nurses to ensure sterility of CVC insertion, and empowering nurses to stop the procedure if breaches in sterility were identified. The ED brought the lead investigator of the study to our hospital as a consultant to kick off the implementation of the bundle; served as a resource for computer based education on CVC insertion; offered education to nursing and resourced the bundle policy development. Leadership in “ICU-A” was well informed of the initiative, obtained a CVC cart and completed education in March 2005. The unit educator wrote the policy and adapted a CVC insertion checklist, which was implemented July 1, 2005. Conversely, the leadership of “ICU-B” resisted adaptation of the bundle policy. It cited additional work for nurses, not wanting to “police” housestaff, and not wanting to utilize a bundle policy that was not designed specifically for ICU-B. Implementation was delayed until coaxed by hospital administration in October 2005. RESULTS: ICU-A maintains use of the femoral site for CVC below the CDC 10 th percentile. For the 6 months before and after the intervention, its CVC utilization decreased 24%, maintaining in the CDC 10 th -24 th percentile for the last 2 quarters of 2005. In ICU-B, the use of the femoral site for CVC increased 33% in the 3rd quarter of 2005, maintaining in the CDC 11 th -25 th percentile for the last 2 quarters of 2005. CVC utilization continued at the CDC 75 th -90 th percentile for 2005. LESSONS LEARNED: The same education produced 2 different outcomes. ICU-A has had 6 months of success with the bundle, and is now re-evaluating nursing processes to further decrease CR-BSIs. ICU-B strives to achieve compliance. Despite documented, evidence-based practice, it is imperative to achieve unit leadership “buy-in” in order to effect a practice change.