Central Venous Catheter-associated Bloodstream Research Articles

Invasive device-associated hospital infection rates, etiological agents, and their antibiotic susceptibilities in the medical intensive care unit of a university hospital in Turkey

To determine the rate, etiological agents, antibiotic susceptibilities, and empirical treatment options of etiological agents of invasive device-associated hospital infections (IDAHIs) in the medical intensive care unit of a university hospital. Materials and methods: Between February 2007 and December 2009, 780 IDAHI cases were evaluated in 1650 patients. Results: Ventilator associated pneumonia, catheter-associated urinary tract infection, and central venous catheter-associated blood stream infection were observed in 415, 242, and 143 IDAHI cases, respectively. The most frequently isolated etiological agents were Acinetobacter spp. in ventilator-associated pneumonia, coagulase-negative staphylococci (CoNS) in central venous catheter-associated blood stream infection, and Candida spp. and E. coli in catheter-associated urinary tract infection. Conclusion: In our study, oxacillin resistance in coagulase-positive S. aureus and CoNS was high. Glycopeptides and linezolid should be considered as treatment options. Resistance of enteric bacteria is defined high against cephalosporin, aminoglycoside, and quinolone. Carbapenems can be considered in the empirical treatment of enteric bacterial infections. Colistin can be given in the treatment of resistant Acinetobacter infections as a therapeutic option. Since antifungal resistance is low, fluconazole should be the first drug of choice in the treatment of candidal infections.

Acesso venoso central guiado por ultrassom: qual a evidência?

In recent years, international health quality assurance organizations have been recommending ultrasound guidance for central venous punctures. This article reviews the evidence behind these recommendations. The MEDLINE, PubMed and SCIELO databases were searched for the following MeSH terms: central venous access, ultrasonography, and adults. The search was conducted on September 24, 2010, and selected meta-analyses, randomized clinical trials and reviews, retrieving 291 papers. The 21 most important papers were analyzed in this review. The internal jugular vein is the most studied ultrasound-guided puncture site, with meta-analysis showing lower relative risks of failure and complications. In addition, the largest available randomized clinical trial demonstrated a reduced central venous catheter-associated blood stream infection rate. There are few studies involving subclavian vein puncture; however, ultrasound was shown to be beneficial in two meta-analyses (however, with small numbers of patients). Regarding the femoral venous site, only one randomized clinical trial (20 patients) was identified, showing positive findings. In a British cost-effectiveness study, ultrasound use lead to resource savings for different sites of venous puncture. There is strong evidence for ultrasound benefit for internal jugular vein puncture. Although the method appears attractive for the other sites, the data are not sufficient to support any recommendation.

Catheter-Associated Bloodstream Infection Incidence and Risk Factors in Adults with Cancer: A Prospective Cohort Study.

Abstract 1382Poster Board I-404 Background:Central venous catheter-associated blood stream infections (CA-BSI) cause considerable morbidity in adult patients with hematologic cancers and solid tumors. A range of central venous access devices (CVAD) may be used across differing patient diagnoses and for varying indications. The aim of our study was to determine the incidence and risk factors for CA-BSI. Methods:A prospective observational cohort study of consecutive adult patients requiring a CVAD in a hematology-oncology unit (including autologous but not allogeneic transplantation) was performed. All CVADs were inserted under ultrasound guidance in a dedicated interventional radiology facility with peripherally inserted central venous catheters (PICCs) inserted in the basilic or cephalic vein and tunnelled lines, non-tunnelled lines and implantable ports inserted via the internal jugular vein. Standardized surveillance methods for CA-BSI were applied and data on CVAD complications were recorded. Results:1119 CVADs were assessed in 723 patients over 50,478 line days. Median patient age was 55yrs and 56% were male. Patient diagnoses included aggressive hematologic malignancies (48%, includes AML (17%), MDS (1%), NHL (22%) and MM (8%)), Hodgkin lymphoma (3%), other hematologic malignancies (3%), oesophageal/colon/rectal cancers (26%), and all other solid tumors (20%). CVAD types included PICCs (71%), non-tunnelled lines (14%), tunnelled lines (14%), and implantable ports (1%). 291 lines were removed due to a clinical suspicion of infection, 133 of these had CA-BSI and 34 of these had a positive tip culture in addition to meeting the definition of CA-BSI. The four most common bacterial isolates were S. epidermidis (n=23), S. aureus (n=15), Pseudomonas sp (n=12) and Stenotrophomonas sp (n=10). The rate of CA-BSI per 1,000 line days was 2.63. In multivariate analysis, factors associated with CA-BSI included: type of CVAD (greatest for non-tunnelled lines (HR 3.67, p<0.0001) and tunnelled lines (HR 1.83, p=0.0062) compared to PICC lines); patient diagnosis (greatest for aggressive haematological malignancies (HR 2.95, p=0.0031) and least for oesophageal, colon and rectal cancers (HR 0.26, p=0.014) compared to other solid tumours); side of insertion (greatest for right-sided lines (HR 1.61, p=0.024)); and number or prior line insertions (HR1.2, p=0.016). In a subgroup analysis of patients with aggressive hematologic malignancies, the association between CA-BSI and line type (greater infection for tunnelled (HR 1.46, p=0.09) and non-tunnelled lines (HR 3.73, p<0.001) compared to PICCs) and side of line insertion (more infection with right sided lines (HR1.66, p=0.035)) remained. 4.8% of lines were complicated by symptomatic thrombosis which was less common in patients with oesophageal, colon and rectal cancer (HR 0.43, p=0.027) and in lines inserted in the internal jugular vein (HR 0.2, p=0.0083) compared to PICC lines. Conclusions:Incidence of CA-BSI in an Australian adult cancer population is comparable to other reports in the literature. This study highlights the utility of a standardised CA-BSI surveillance strategy in adult patients with cancer, provides further data to support the use of PICC lines in such patient populations, including patients with hematological malignancies, and suggests that the side of line insertion may influence CA-BSI. Disclosures:No relevant conflicts of interest to declare.

Evidence-Based Practice, Rule-Following, and Nursing Expertise

Evidence-Based Practice, Rule-Following, and Nursing Expertise

Central Venous Catheter-Associated Blood Stream Infections Occurring in Canadian Intensive Care Units: A Six-Month Cohort Study

To determine the rate and risk factors associated with central venous catheter (CVC)-associated bloodstream infections (BSIs) in Canadian intensive care units (ICUs). A prospective, active six-month cohort with a nested case-control study. Forty-one ICUs located in 19 Canadian hospitals. Data were collected using a standardized format on all CVCs and patients when a CVC was inserted for more than 48 h. Results of microbiological studies and therapeutic interventions were recorded when a BSI occurred. There were 182 BSIs from 3696 CVC insertions in 2531 patients. Coagulase-negative staphylococci were responsible for 73% of the BSIs. Mean rates of CVC-associated BSIs per 1000 CVC days were 6.9, 6.8 and 5.0 in adult, neonatal and pediatric ICUs, respectively. Significant factors associated with BSI included duration of CVC insertion (OR=1.2, 95% CI 1.1 to 1.3), receiving total parenteral nutrition (OR=4.1, 95% CI 1.2 to 14.3) and having one or more CVCs (OR=3.1, 95% CI 1.5 to 6.5). In the case-control study, 80% of the variance in a backward elimination logistic regression analysis was explained by duration of CVC insertion (OR=1.2 per day), receiving chemotherapy (OR=6.1), more than one CVC insertion during the study (OR=3.5), insertion of a CVC with two or more lumens (OR=2.3), using the CVC to administer total parenteral nutrition (OR=1.6) and having a surgical wound other than a clean wound (OR=1.6). The present study identified risk factors explaining 80% of the variance associated with BSIs and is one of the largest reports on the rate of CVC-associated BSIs occurring in the ICU setting.

Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients

IntroductionCentral venous cannulation is crucial in the management of the critical care patient. This study was designed to evaluate whether real-time ultrasound-guided cannulation of the internal jugular vein is superior to the standard landmark method.MethodsIn this randomised study, 450 critical care patients who underwent real-time ultrasound-guided cannulation of the internal jugular vein were prospectively compared with 450 critical care patients in whom the landmark technique was used. Randomisation was performed by means of a computer-generated random-numbers table, and patients were stratified with regard to age, gender, and body mass index.ResultsThere were no significant differences in gender, age, body mass index, or side of cannulation (left or right) or in the presence of risk factors for difficult venous cannulation such as prior catheterisation, limited sites for access attempts, previous difficulties during catheterisation, previous mechanical complication, known vascular abnormality, untreated coagulopathy, skeletal deformity, and cannulation during cardiac arrest between the two groups of patients. Furthermore, the physicians who performed the procedures had comparable experience in the placement of central venous catheters (p = non-significant). Cannulation of the internal jugular vein was achieved in all patients by using ultrasound and in 425 of the patients (94.4%) by using the landmark technique (p < 0.001). Average access time (skin to vein) and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < 0.001). In the landmark group, puncture of the carotid artery occurred in 10.6% of patients, haematoma in 8.4%, haemothorax in 1.7%, pneumothorax in 2.4%, and central venous catheter-associated blood stream infection in 16%, which were all significantly increased compared with the ultrasound group (p < 0.001).ConclusionThe present data suggest that ultrasound-guided catheterisation of the internal jugular vein in critical care patients is superior to the landmark technique and therefore should be the method of choice in these patients.

A point well taken

A point well taken