23 new highlights in central line- associated bloodstream infection and surgical-site infection...
TRANSCRIPT
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23
New Highlights in Central Line-
Associated Bloodstream Infection
and Surgical-Site Infection Prevention
Rabih O. Darouiche, MDVA Distinguished Service Professor
Director, Center of Prostheses Infectionat Baylor College of Medicine
Safe Practices WebinarFebruary 18, 2010
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• Co-invented antimicrobial-coated catheters that are licensed by Baylor College of Medicine to Cook Inc
• Received educational and research grants from CareFusion
• Do not plan to discuss off-label and investigational use of devices or drugs
Disclosure Statement
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• Address similarities and differences between CLABSI and SSI
• Assess the impact of these two infections
• Analyze potentially protective approaches
Overview of Presentation
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Similarities Between CLABSI and SSI
• Both infections result primarily from breaking skin integrity
• Both infections are caused mostly by skin organisms
• Both infections occur at unacceptably high rates, can be difficult to manage, may require future intervention(s), and are expensive to treat
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Differences Between CLABSI and SSI
• CLABSI manifests while the catheter is still in place, whereas SSI can manifest at any time after surgery, usually by 30 days post-op
• Microbiologic cause of CLABSI is almost always identified, whereas the microbiologic cause of SSI is unknown in many patients
• Occurrence of CLABSI can be attributed to various healthcare providers, whereas SSI is typically linked to the surgeon
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Clinical Manifestations of infected CVC
• Exit site infection
• Tunnel infection• Thrombophlebiti
s• BSI
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Impact of CLABSI
• Incidence: of the 6 million CVC inserted annually in the U.S., 250,000 result in BSI
• Management: cure often requires removal of the infected catheter and long antibiotic therapy
• Medical sequelae: attributable mortality 5%-25%
• Economic burden: cost of treatment is $10K-$56K; annual cost in U.S., $3 billion–$16.8 billion
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Annual Death Rates in the U.S. for Selected Infectious Diseases
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Nosocomial Infections in the ICU
PNEU27%
OTHER6%LRI
4%EENT
4%CVS4%
GI5%
BSI19%
UTI31%
National Nosocomial Infections Surveillance (NNIS) (97 hospitals)
87% central lines
86% Mechanical Ventilation95% Urinary Catheters
N= 14,177
< 55 = 33%55 – 70 = 32%>70 = 35%
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30%
70%
44%
56%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Non-CRBSI CRBSI Non-CRBSI CRBSI
Solid Tumor Malignancy Hematologic Malignancy
% o
f B
acte
rem
ia w
ith
C
VC
as
the
sou
rce
Gram-Positive Bacteremia in Cancer Patients: Role of the CVC
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Difference between Surveillance Definition
(by National Healthcare Safety Network: NHSN)
and Clinical/Microbiologic Definition of CLABSI
• Surveillance definition: includes all cases of BSI in patients with CVC in whom other sites of infection are excluded (catheter-associated BSI varies from from 1.3/1000 cath-days in medical surgical wards to 5.6/1000 cath-days in burn ICU)
• Clinical/microbiologic definition: includes only cases of BSI in patients with CVC in whom other sites of infection are excluded and microbiologic relationship of catheter to BSI exists (catheter-related BSI)
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Relationship between Catheter Colonization and Bloodstream
Infection
• Principle: catheter colonization is a prelude to catheter-related bloodstream infection
• Objective: to prevent infection by inhibiting catheter colonization
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IA Recommendations in Upcoming CDC Guidelines for Prevention of
CLABSI
• Staff education and training• Insert CVC in subclavian catheters• Place hemodialysis catheters in jugular or femoral veins• Promptly remove CVC when no longer essential• Hand wash with soap/water or alcohol-based hand rubs• Utilize 2% chlorhexidine-based preparation for skin
cleansing before inserting CVC, during dressing changes, and wiping access ports of needleless catheter systems
• Use sterile gauze or transparent semi-permeable dressings
• Use antimicrobial-impregnated CVC if expected duration of placement >5 days and CLABSI remains higher than goal set by institutions despite comprehensive strategyGuidelines for the Prevention of Intravascular Catheter-related Infections. Atlanta (GA): Centers for Disease Control and Prevention; 2010. [draft]
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Before insertion:• Educate healthcare personnel involved in the insertion, care, and
maintenance of central venous catheters (CVCs).At insertion:• Use a catheter checklist at the time of CVC insertion.• Perform hand hygiene prior to catheter insertion or manipulation.• Avoid using the femoral vein for central venous access in adult
patients.• Use a catheter cart or kit with components for aseptic catheter
insertion. • Use maximal sterile barrier precautions.• Use chlorhexidine gluconate 2% and isopropyl alcohol solution as
skin antiseptic preparation in patients over two months of age and allow appropriate drying time per product guidelines.
After insertion:• Use a standardized protocol to disinfect catheter hubs, needleless
connectors, and injection ports before accessing the ports.• Remove nonessential catheters. • Use a standardized protocol for non-tunneled CVCs in adults and
adolescents for dressing care.• Perform surveillance for CLABSI and report the data on a regular
basis.
NQF CLABSI Prevention Safe Practice Specifications: 2010
Update
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Comprehensive Protective Strategy
Infection Control Bundle
• Hand washing• Maximal barrier precautions• 2% chlorhexidine-based skin antisepsis• Avoiding femoral site if possible• Removing unnecessary catheters
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Although very essential, they: • Are not easily enforceable• Are not very durable• Do not completely prevent
infection• Save some, but not
enough, lives
Potential Limitations of Traditional Infection Control
Measures
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Reasons to Optimize Prevention of SSI
• Unacceptably high incidence: the 30 million annual surgical procedures in the U.S. result in 300,000-500,000 cases of SSI
• Difficult management: may require repeated surgical interventions
• Serious medical consequences: tremendous morbidity and occasional mortality
• Soaring economic burden: annual cost of treatment in the U.S. is >$7 billion
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Perioperative Approaches for Preventing SSI
• Non-antimicrobial approaches
•Normothermia
•Adequate oxygenation
•Tight glucose control
• Antimicrobial approaches
•Systemic antibiotic prophylaxis
•Nasal application of mupirocin
•Skin antisepsis40
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Impact of Timing of Systemic Antibiotic Prophylaxis on SSI
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A Prospective Randomized Trial of Nasal Mupirocin Plus Chlorhexidine
Wash
Rapid identification of nasal carriage by S. aureus followed by a 5-day course of nasal mupirocin plus chlorhexidine wash:• Reduces S. aureus infection (3.4% vs. 7.7%)• Decreases S. aureus SSI by almost 60%
Bode, et al. N Engl J Med 2010;362:9-17
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Importance of the Skin
• Largest bodily organ
• Protective barrier
• Skin flora most common cause of SSI (and CLABSI)
• 80% of bacteria reside in epidermis
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Factors that Support the Need for Optimal Skin
Antisepsis
• Most pathogens that cause SSI are skin flora
• At least 2/3 of cases of SSI are incisional
• Most SSI are considered preventable
• Other preventive measures reduce but do not eliminate SSI
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Commonly used Preoperative Antiseptics
• Povidone-iodine (Iodophor)• Chlorhexidine gluconate• Alcohol • Combination products: >2 active
agents
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Comparison of Antimicrobial Activity of Antiseptic
Preparations
Chlorhexidine-based preparations are better than alcohol or iodine-based products in:
• Reducing colonization of vascular catheters
• Preventing contamination of blood cultures
• Decreasing contamination of surgical tissues
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Pressing Need to Compare Clinical Efficacy of Antiseptic Preparations in
Preventing SSI
• CDC guidelines for prevention of infections related to vascular catheters recommend antiseptic cleansing of the skin with 2% chlorhexidine-containing products
O’Grady, et al. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 2002;51(RR-10):1-29
• CDC has not previously issued a preference as to type of preoperative skin antiseptics
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Prospective, Randomized, 6-Center Clinical Trial of 849 Patients
• Population: adult patients scheduled for abdominal or non-abdominal clean-contaminated surgery
• Randomization: hospital-stratified• Intervention: preoperative skin cleansing with:
• ChloraPrep® (2% chlorhexidine gluconate-70% isopropyl alcohol = CA) 26-ml applicators; OR
• 10% povidone-iodine (PI) scrub and paint• Evaluation: SSI was assessed by blinded
evaluators Darouiche, et al. N Engl J Med 2010;362:18-2648
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Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population).
Type of Infection
Chlorhexidine-Alcohol (N=409)no. (%)
Povidone- Iodine
(N=440)no. (%)
Relative Risk(95% CI) P-Value
Any surgical-site infection 39 (9.5) 71 (16.1) 0.59 (0.41-0.85)
0.004
Superficial incisional infection
17 (4.2) 38 (8.6) 0.48 (0.28-0.84)
0.008
Deep incisional infection 4 (1.0) 13 (3.0) 0.33 (0.11-1.01)
0.05
Organ-space infection 18 (4.4) 20 (4.6) 0.97 (0.52-1.80)
>0.99
Sepsis from surgical-site infection
11 (2.7) 19 (4.3) 0.62 (0.30-1.29)
0.26
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Kaplan-Meier Curves for Freedom from Surgical-Site Infection (Intention-to-Treat Population)
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Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population).
Chlorhexidine-Alcohol Povidone-Iodine
Type of Surgery Nno.
Infected
(%) Infected N
no. Infected
(%) Infected
Abdominal 297 37 (12.5) 308 63 (20.5)
Colorectal 186 28 (15.1) 191 42 (22.0)
Biliary 44 2 (4.6) 54 5 (9.3)
Small intestinal 41 4 (9.8) 34 10 (29.4)
Gastroesophageal26 3 (11.5) 29 6 (20.7)
Non-abdominal 112 2 (1.8) 132 8 (6.1)
Thoracic 44 2 (4.5) 57 4 (7.0)
Gynecologic 42 0 (0.0) 40 1 (2.5)
Urologic 26 0 (0.0) 35 3 (8.6)51
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Chlorhexidine-Alcohol (CA) vs. Povidone-Iodine (PI) for Prevention
of SSI
• CA significantly reduces SSI• Number of patients needed to receive
CA instead of PI to prevent one case of SSI: 17
• Delays onset of SSI • CA and PI have similar rates of
adverse events (including events related to study medication in 0.7% in each group) and serious adverse events
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New CMS Regulations (effective 10/08) Changes to Inpatient Prospective
Payment System
10 non-reimbursable conditions met these criteria:
• High cost• High volume• Triggers a high-paying MS-DRG• May be considered reasonably preventable
through application of evidence-based guidelines
Federal Register, Volume 73, No. 161; 08/19/08
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Non-reimbursable Infectious Conditions
• Catheter-associated urinary tract infection
• Vascular catheter-associated infection• Surgical-site infection-mediastinitis
after CABG• Surgery on various joints, including
shoulder, elbow, and spine
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Perspective
Optimal prevention of CLABSI and SSI can:
• Improve patient care• Incur cost-savings• Enhance infection control measures
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