Maximal Barrier Precautions Research Articles

Catheter-related bloodstream infections in children

Patient characteristics and system-level factors place children at increased risk for catheter-related bloodstream infection (CR-BSI). National Healthcare Safety Network data from 36 pediatric intensive care units (PICUs) demonstrate a pooled mean of 5.3 CR-BSIs per 1000 catheter-days and a median of 3.5 CR-BSIs per 1000 catheter-days. Almost 60% of CR-BSIs in children are caused by gram-positive bacteria. In the PICU setting, arterial catheterization, increased duration of catheterization, use of extracorporeal life support, and presence of a genetic abnormality are independent risk factors for CR-BSIs. ECONOMICS: In children, cost estimates range from $36,000 to $50,000 per CR-BSI. Empiric therapy should target gram-positive and gram-negative bacteria, with the choice of drug treatment based on local antimicrobial susceptibility patterns. Results from pediatric studies shows that catheter removal is indicated for all cases of candidemia and persistent bacteremia. Based on limited data, antimicrobial lock therapy may be appropriate in certain clinical situations, and multifaceted interventions are effective in reducing CR-BSIs in children. In one center, maximum barrier precautions during insertion, antimicrobial-impregnated catheters, annual hospital-wide handwashing campaigns, physical barriers between beds, and use of 2% chlorhexidine skin disinfectant decreased CR-BSIs.

Incidence of Blood Stream Infection Influenced by Dressing and Clinical Skin Care in a Patient with Neutropenia

Purpose For cancer-bearing patients, especially for patients with hematological malignancies, blood access is a ‘lifeline’ during chemotherapy, in three senses: administration of chemotherapy for the cancer treatment, intravenous supply of nutrients when a patient's oral intake is decreased, and injection of many agents for supportive care including antibiotics and G-CSF. For these purposes, we usually use a central venous catheter (CVC) at the subclavian portion. Dressing and skin care of the CVC are critical factors influencing the incidence of catheter-related blood stream infection (CRBSI). To clarify the association between preventative procedures and CRBSI rates, we summarize the effectiveness of annually instituted interventions for the prevention of CRBSI and present the result of surveillance of catheter infection in our hospital for a decade, from 1998 to the present.Method This is a prospective cohort study analyzing patients seen in our hospital for the treatment of cancer and predicting neutropenia by observation of catheter infection. All of the patients underwent CVC (Microneedle Seldinger Kit, Safe Guide II, Argyle) insertion with a subclavian approach except for patients with subclavian venous troubles such as embolism or occlusion. Each year for the first five years, we instituted new precautions for preventing CRBSI. Those interventions wereintroducing low-irritant skin tape from 1999,applying the maximal barrier precaution (MBP) procedure from 2000,applying closed injection-line system (Interlink system; Japan Beckton Dickinson, Tokyo, Japan) from 2001,once-a-week dressing using adherent transparent film (Tegaderm; Sumitomo 3M, Tokyo, Japan) from 2002, andusage of one pair of glove in each procedure for an individual patient from 2003.More than 2 sets (One set means blood samples from peripheral blood and CVC) of blood culture samples were drawn when a patient's body temperature (axillary) increased to more than 38.0 ºC. Multiple detection of the same isolate in the same individual during a series of febrile episode was considered as one infectious event. Bacteremia was defined as the isolation of at least one pathogen from at least one blood sample. BSI was defined as the recognition of a pathogen from one or more blood cultures that is not related to an infection at another site. CRBSI was defined as bacteremia in a patient with CVC with at least one positive pathogen obtained from a blood culture, and no apparent source for the BSI. We evaluated the duration of CVC insertion, episodes of febrile event, isolated bacteria and bacteremia.Results A total of 55,469 catheter-days were observed. The incidence of CRBSI per one thousand catheter-days was 8.08±2.76 before our interventions (before 1998), 4.18±2.59 after the low-irritant skin tape, 2.84±1.26 after the MBP procedure, 2.18±1.69 after the closed injection-line system, 2.84±2.17 after once-a-week dressing, and 2.53±2.63 after the individual-gloves intervention. After the introduction of MBP, the incidence of CRBSI was significantly decreased from before the start of interventions (P<0.001). Though the subsequent interventions (closed line system, once-a-week dressing and individual-gloves intervention) did not apparently influence the incidence of CRBSI, they were believed to keep the incidence of BSI low.Conclusion Applying MBP and low-irritant tape was significantly effective for decreasing the incidence of CRBSI. A concomitant use of MBP and valid taping might be most influential for preventing CRBSI.

Effectiveness of a central line bundle campaign on line-associated infections in the intensive care unit

Central line-associated bloodstream infections occur commonly and are a potentially preventable source of morbidity in the critical care setting. The purpose of this study was to find a way to decrease central line-associated bloodstream infections. Data were collected from February 1, 2005, to April 31, 2007, on all patients in the critical care unit who had a central venous catheter placed at New York Methodist Hospital in Brooklyn, which is a community teaching hospital with 628 beds. After 5 months of baseline data collection, a multidisciplinary team created a central line bundle to be used when placing central venous catheters. A bundle is a protocol put in place to ensure that a procedure is performed using the latest evidence-based techniques. In this case, it included maximal barrier precautions, hand washing, skin preparation with ChloraPrep (Enturia, Leawood, Kan), use of a central line cart, and avoidance of femoral lines. All central lines placed from the time of intervention were placed using the bundle provided. The variables included the number of central lines, number of central line days, and development of a line infection. The study period was 24 months, which included 9,938 central line days from a total of 1,395 central venous catheters. The average number of central line-associated bloodstream infections per 1000 catheter days decreased from 5.0 to 0.90 (P < .001) after the bundle intervention was initiated. The implementation of a central line bundle campaign resulted in a significant decrease in line-associated bloodstream infections. Based on our study, we recommend that this protocol be adopted nationwide.

External jugular venous catheterization with a Groshong catheter for central venous access

The Groshong catheter (GC) is commonly used as a peripherally inserted central catheter (PICC), and the external jugular vein (EJV) is not a common route for central venous access (CVA). Therefore, external jugular venous catheterization (EJVC) using a GC is rare. However, our experience has shown that this procedure is safe and simple for CVA. To assess the utility of EJVC using the GC for CVA. CVA was done using a GC via the EJV with a single puncture employing the maximal barrier precaution technique. Between March 2005 and June 2007, we attempted to perform EJVC using a GC via the EJV for 331 patients. Among of these patients, 301 patients received successful catheterization (success rate: 301/331 = 90.9%). The total period of catheter insertion was 4601 days, and the mean insertion period was 15.1 days (range 2-147 days). The main complications of catheter insertion were malposition (8/301; 2.7%) and, oozing or hematoma formation (8/301; 2.7%). There were no severe complications such as nerve injury, pneumothorax or arterial bleeding. Our experience demonstrates that EJVC using the GC is acceptable for CVA.

Risk Factors of Catheter‐Related Bloodstream Infections in Parenteral Nutrition Catheterization

Intravascular catheters are integral to the practice of modern medicine. Potential risk factors for catheter-related bloodstream infection (CRBSI) include underlying disease, method of catheter insertion, and duration and purpose of catheterization. The administration of parenteral nutrition (PN) through intravascular catheters increases CRBSI risks. The purpose of this study was to evaluate the risk factors of CRBSI in patients with PN administration. This study was conducted at the Karadeniz Technical University Hospital between October 2003 and November 2004. All the patients to whom PN was administered through intravascular catheters were prospectively monitored for the presence of CRBSI and risk factors. During the study period, 111 intravascular catheters through which PN was administered were monitored for a total of 1646 catheter-days. CRBSI was determined in 31 cases, a CRBSI rate of 18.8 per 1,000 catheter-days. When risk factors affecting CRBSI were investigated using logistic regression, an increase in APACHE II score (OR, 1.10; 95% CI, 1.01-1.21; p = .012), prolongation of catheterization (OR, 1.08; 95% CI, 1.02-1.14; p = .004), catheterization in emergent conditions (OR, 5.45; 95% CI, 1.20-24.82; p = .016), and poor patient hygiene (OR, 4.38; 95% CI, 1.39-13.78; p = .019) were all determined to be independent risk factors. Proper implementation of hand hygiene and maximal barrier precautions during the insertion of catheters reduced CRBSI levels (OR, 0.28; 95% CI, 0.09-0.88; p = .003 and OR, 0.26; 95% CI, 0.08-0.93; p = .017, respectively). It was concluded that the duration of catheterization should be shortened; that the intravascular catheter, which is inserted in urgent situations, should be removed as soon as possible; and that maximal sterile barrier precautions should be taken and due attention should be paid to hand hygiene.

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.

Using Evidence-Based Practice to Reduce Central Line Infections

Central venous catheters (CVCs) are used commonly in a variety of inpatient and outpatient healthcare settings. Catheterrelated bloodstream infections (CRBSIs) contribute to 2,400–20,000 deaths per year, with an estimated cost of $296 million to $2.30 billion (Hu, Veenstra, Lipsky, & Saint, 2004). CRBSIs can be reduced dramatically with maximal barrier precautions, chlorhexidine gluconate skin preparatory agents, and strict hand hygiene.

The 100,000 Lives Campaign: Crystallizing Standards of Care for Hospitals

The 100,000 Lives Campaign: Crystallizing Standards of Care for Hospitals

Central Venous Catheter Infections in Burn Patients: What is the Optimal Care for These Lines?

Burn patients have multiple central venous catheters (CVP) during their hospitalization. The best method of catheter care for CVP in this group of patients remains to be defined. We chose to re-examine our policy of CVP line care, determine the rate of catheter infection and to compare our data with the Centers for Disease Control and Prevention (CDC)-Catheter related blood stream infection project (CR-BSI). This was a prospective observational study to determine the incidence of catheter related infections in our burn patients. Rates of catheter infection were determined by utilizing the (CR-BSI) guidelines from the CDC. Our present method of CVP care includes the changing of the CVP over a guidewire every three days (day 3, 6 and 9 respectively). After three such lines have been placed, the fourth CVP was inserted in a new site. All CVP line changes were done using maximal barrier and sterile precautions. The CVP...

Mentors Decrease Compliance with Best Sterile Practices during Central Venous Catheter Placement in the Trauma Resuscitation Unit

In the academic trauma unit during initial evaluation and resuscitation of trauma victims, central venous catheters are often placed by multiple operators. There are few data on compliance with accepted, standard sterile practices during such procedures. Prospective data were tabulated from video capture of 144 consecutive central venous catheterizations in a trauma resuscitation unit, during peak hours, by a team of trained video technicians. The physicians were surgical and emergency medicine residents. The number of primary operators (trainees) and secondary operators (mentors) for each line was recorded from the video analysis, as well as physician adherence to the use of maximum barrier precautions (MBP; sterile gown, gloves, full operative drape, cap, and mask). Procedures were stratified by level of urgency: Emergent (n = 7), semi-emergent (n = 20), and elective (n = 113). The subclavian vein was used for 73% of the elective catheter placements. For elective central venous catheters, 99 of 113 primary operators (88%) observed MBP, whereas only 31 of 45 secondary operators (69%) did so (p < or = 0.01). Among the 45 elective central venous catheters placed with a secondary operator, there were four instances of frank contamination (9%). Secondary operators, typically trauma surgery attendings, trauma/critical care fellows, or senior surgical residents, function as mentors in academic institutions and act as role models. Secondary operators participated in many of the studied cases, yet failed to demonstrate consistent use of MBP. In elective central venous catheter placement, those where there was the greatest opportunity to follow MBP, we observed a statistically significant difference in compliance rate between the primary and secondary operators. The study suggests the need to address the performance of the secondary operators and to educate them, as although they may be technically experienced in placing central venous catheters, they may comply less consistently with MBP.

Why Is It That Internists Do Not Follow Guidelines for Preventing Intravascular Catheter Infections?

High morbidity of CVC-related infections has led to national guidelines for their prevention. Despite recommendations for the use of maximal barrier precautions (mask, sterile gloves, gown, and large drape) and skin antisepsis with 2% chlorhexidine gluconate during CVC insertion, internists in the United States are not implementing these practices frequently. This study sought to identify and characterize the obstacles to and potential opportunities for improving adherence. Cross-sectional survey. One thousand randomly selected physician-members of the American College of Physicians-American Society of Internal Medicine. Several potential determinants of adherence to maximal barrier precautions were assessed, including awareness of, agreement with, and ability to implement the recommendation, as well as the practice and training characteristics of the respondents. Factors influencing antiseptic selection were also recorded. Of 526 respondents, 178 (34%) had recently inserted CVCs. Clinician experience and subspecialty, awareness of CDC guidelines, and external influences (eg, time to collect equipment) did not affect maximal barrier precautions adherence. The only independent predictor of adherence was high outcome expectancy for the use of large sterile drapes (OR, 5.3; CI95, 2.2-12.6). Availability had the greatest influence on internists' selection of specific antiseptic agents, whereas cost was the least important determinant. Despite established efficacy, use of maximal barrier precautions and chlorhexidine gluconate is low among internists. Because improved adherence to these practices will require increased outcome expectancy for maximal barrier precautions and availability of chlorhexidine gluconate, targeting these areas through focused education and systems modifications is essential.

An increase in pediatric intensive care unit (PICU) catheter-related bloodstream infection (CR-BSI) rate temporally associated with change in intravenous (IV) port

ISSUE: In April 2004, the PICU switched from one mechanical valve (MV) IV port to a positive-displacement mechanical valve (PDMV) IV port. Associated with the switch, the NNIS defined CR-BSI rate increased fourfold. PROJECT: In February 2004, as part of a hospital-wide patient safety effort, the PICU instituted several measures to decrease the number of CR-BSIs: including implementation of a line cart to store supplies, preparation of skin with chlorhexidine, use of maximal barrier precautions, appropriate site selection, and use of an insertion checklist. In spite of these measures, the CR-BSI rate continued to climb. Several meetings were held with the children's center leaders to discuss possible reasons for the increased BSI rate and to develop a plan to reduce it. RESULTS: The CR-BSI rate increased from 4.1/1000 catheter days in the 1st quarter to 17.31/1000 catheter days in the 3rd quarter. Infections occurred from day 5 through day 157 post admission and involved both medical and surgical patients. No change in the case mix and acuity of patients admitted to the PICU was noted on investigation. Infections were caused by gram-positive and gram-negative organisms and Candida. Observations of central line insertions were made, and no infection control violations were noted. However, the PICU nurses reported that some of the PDMV leaked and were cracked. Because of the temporal association between introducing the PDMV and the increase in the CR-BSI rate, all PDMV were replaced with the MV that was previously used after re-education on the use of the antecedent valve. Since removing the PDMV in the 4th quarter, no further CR-BSIs have occurred. LESSONS LEARNED: Further studies need to be performed to define whether the PDMV is associated with an increase in CR-BSIs and to determine how the PDMV could contribute to an increase in CR-BSIs. Although "new and improved" products continue to flood the healthcare market, it is essential that appropriate trials be performed to demonstrate both efficacy and safety.

The Long-Term Effect of Antibiotic-Impregnated Catheters on Bloodstream Infection Rate in a PICU

BACKGROUND: Bloodstream infections are the most common reported healthcare-associated infections in pediatric facilities. To measure the effect, we compare catheter-related bloodstream infection (CR-BSI) rates for antibiotic-impregnated (rifampin/minocycline) catheters (AIC) to non-impregnated catheters (NAIC) in a PICU. Interventions such as the use of maximum barrier precautions (1998), handwashing compliance campaign (2000/2001), and chlorohexidine prep (2003) prior to catheter insertion also occurred. METHODS: Prospective, observational study conducted in a Pediatric Intensive Care Unit (PICU) of a children's hospital over 5-year period (1999–2003). CRBSI definitions are from National Nosocomial Surveillance System. Infection control professionals collected catheter days and reviewed medical record to determine if CR-BSI was present. The Intensivist determined type of catheter. Duration of catheterization, location of catheter, pediatric risk index (PRISM), and age of the patient were collected for analysis. RESULTS: The mean rate of CR-BSI in the study period has been 5.0/1000 (range = 3.8/1000–6.1/1000), which is significantly lower than the preceding 5-year period (mean 9.2, range = 7.2/1000 − 9.7/1000) [{ P=0.006]. The rate of CRBSI in AIC (4.6/1000) (range = 3.3 − 5.8/1000) is lower compared to NAIC (7.2/1000) (range = 5.4–9.1/1000) during this time period. This is in spite of the fact that AIC were placed for a longer duration (11 days versus 9 days), and placed in patients with higher mean PRISM scores (19.5 versus 13.3) and younger mean age (4 years versus 11 years) as compared to NAIC. CONCLUSION: The introduction of AIC has contributed significantly to a decline in the rate of CR-BSI in pediatric ICU patients.

Clinical review: New technologies for prevention of intravascular catheter-related infections

Intravascular catheters have become essential devices for the management of critically and chronically ill patients. However, their use is often associated with serious infectious complications, mostly catheter-related bloodstream infection (CRBSI), resulting in significant morbidity, increased duration of hospitalization, and additional medical costs. The majority of CRBSIs are associated with central venous catheters (CVCs), and the relative risk for CRBSI is significantly greater with CVCs than with peripheral venous catheters. However, most CVC-related infections are preventable, and different measures have been implemented to reduce the risk for CRBSI, including maximal barrier precautions during catheter insertion, catheter site maintenance, and hub handling. The focus of the present review is on new technologies for preventing infections that are directed at CVCs. New preventive strategies that have been shown to be effective in reducing risk for CRBSI, including the use of catheters and dressings impregnated with antiseptics or antibiotics, the use of new hub models, and the use of antibiotic lock solutions, are briefly described.

Line Sepsis in the ICU: Prevention, Diagnosis, and Management

Intravascular devices (IVDs) are universally employed in the intensive care unit. Although their use is essential for the administration of medications and IV fluids, they carry a substantial risk of infection, either from the device itself or from contamination of administered infusate. IVD-related infections lead to increased patient morbidity and mortality and excess costs, but they are preventable. The highest rates of IVD-related infection occur with central venous catheters (CVCs). Immunosuppression and other underlying illnesses further increase the risk of IVD-related infection. Coagulase-negative staphylococci, Staphylococcus aureus, and Candida spp. are the most frequent infecting organisms. The incidence of IVD-related infections may be minimized by simple measures, including maximal barrier precautions during CVC placement, specialized training for personnel placing IVDs, and use of chlorhexidine for cutaneous antisepsis. Management of line sepsis should include blood cultures, treatment with appropriate antibiotics or antifungals, and, in most cases, removal and culture of the IVD.

New technologies to prevent intravascular catheter-related bloodstream infections.

Most intravascular catheter-related infections are associated with central venous catheters. Technologic advances shown to reduce the risk for these infections include a catheter hub containing an iodinated alcohol solution, short-term chlorhexidine-silver sulfadiazine- impregnated catheters, minocycline-rifampin-impregnated catheters, and chlorhexidine- impregnated sponge dressings. Nontechnologic strategies for reducing risk include maximal barrier precautions during catheter insertion, specialized nursing teams, continuing quality improvement programs, and tunneling of short-term internal jugular catheters.

Infusion therapy team and dressing changes of central venous catheters.

To determine whether central venous catheter (CVC) dressing changes could be performed by ward nurses rather than by the infusion therapy team (ITT) nurses without increasing the risk of catheter-related infection. Retrospective cohort study using prospectively collected data. The study extended from January 1995 to June 1996. The University of Texas M.D. Anderson Cancer Center, a referral cancer center. The study group was a random sample of 483 patients who received CVC dressing changes by ward nurses during the study period. A random sample of 483 patients who received CVC dressing changes by the ITT constituted the control group. The risks of catheter-related septicemia were 1.7% among cases and 1.4% among controls (risk ratio, 1.14; 95% confidence interval [CI95], 0.26-6.42; P=.70). There also were no significant differences between the two groups in the risks of catheter-related site infection (risk ratio, 0.50; CI95, 0.02-4.12; P=.25) or any catheter-related infection (risk ratio=1.00; CI95, 0.27-3.64; P=.59). Provided that aseptic techniques (including maximal barrier precautions during insertion) are maintained, the responsibility of CVC dressing changes could be delegated to the ward nurses without increasing the low risk of CVC-related infection, resulting in an estimated cost saving in excess of $90,000 per year.

Yes, Virginia, Aseptic Technique Is Very Important: Maximal Barrier Precautions during Insertion Reduce the Risk of Central Venous Catheter-Related Bacteremia

Yes, Virginia, there is a Santa Claus. -Frances Pharcellus Church There long has been controversy over the level of sterile barrier precautions that should be used during the insertion of a short-term, noncuffed central venous catheter. Most authorities stress the need for good aseptic technique, stringent asepsis, or asepsis, and many explicitly advocate use of maximal sterile barriers,1-9 namely the use of sterile gloves, a long-sleeved surgical gown, a large sterile drape, and possibly a surgical cap and mask as well. However, most authors have not addressed the issue explicitly or endorsed the widespread practice of using only sterile gloves and drapes.1~19 Even the expert panel that wrote the first Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Intravascular Infections could not bring itself to recommend sterile barriers beyond gloves and drapes.20 No cardiologist performing a cardiac catheterization would use less than complete barrier precautions, despite the fact that the catheter remains in place for only an hour or two in most cases and rarely for more than 24 hours, even when the introducer is left in place for a percutaneous transcoronary angioplasty the following day. Realizing that a short-term, percutaneously inserted, noncuffed central venous catheter is the intravascular device most likely to cause nosocomial bloodstream infection,8,21,22 I have long believedadmittedly without conclusive supportive data-that maximal sterile barrier precautions should be mandat ry during the insertion of any central venous catheter (realizing that such precautions are unnecessary and would not be cost-effective for insertion of peripheral venous catheters or intraarterial catheters used for hemodynamic monitoring in an ICU).8 The problem with imposing such a standard on the 5 million short-term central venous catheters placed in U.S. hospitals each year has been the lack of scientific data affirming clearcut benefits in terms of reduction of device-related infection and, in the maelstrom of impending healthcare reform, economic cost-benefit. As a consequence, central venous catheters currently are inserted by physicians who wear sterile gloves, but often use little else in terms of barrier precautions. Personally having inserted hundreds of central venous catheters and supervised the insertion of several thousand over the past 20 years using a long floppy guidewire (as is the common practice), I would submit that without maximal sterile barriers-including a longsleeved gown and a large sterile sheet-drape-touch contamination of the guidewire, the catheter, or both is very common (but rarely appreciated).

Yes, Virginia, Aseptic Technique Is Very Important: Maximal Barrier Precautions During Insertion Reduce the Risk of Central Venous Catheter-Related Bacteremia

Yes, Virginia, Aseptic Technique Is Very Important: Maximal Barrier Precautions During Insertion Reduce the Risk of Central Venous Catheter-Related Bacteremia