Roma, 8 aprile 2008
Linea Guida
PREVENZIONE DELLE INFEZIONI ASSOCIATE AI CATETERI
VENOSI CENTRALI (CVC)
Scilla Pizzarelli, Settore Documentazione, SIDBAE, ISS (tel: 2520)
Referente: Cristina Morciano
Anni: 2000-2008
Lingua: Inglese ed italiano
Base dati: PUBMED
N. Record: 51
Quesito 1: Quanto incide sull’insorgenza delle infezioni associate a
CVC l’adesione del personale medico e infermieristico alle corrette
procedure di igiene delle mani?
NB: Non avendo reperito un numero eccessivo di articoli, in questa fase
preliminare, non ho ritenuto opportuno limitare la ricerca al personale
medico e infermieristico per non correre il rischio di perdere riferimenti
pertinenti.
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1: J Hosp Infect. 2008 Mar 6 [Epub ahead of print]
Strategies for the prevention of hospital-acquired infections in the neonatal
intensive care unit.
Borghesi A, Stronati M.
Neonatal Intensive Care Unit, Fondazione IRCCS–Policlinico San Matteo, Pavia,
Italy.
Nosocomial infections are among the leading causes of mortality and morbidity in
neonatal intensive care units. Prevention of healthcare-associated infections is
based on strategies that aim to limit susceptibility to infections by enhancing
host defences, interrupting transmission of organisms by healthcare workers and
by promoting the judicious use of antimicrobials. Several strategies are
available and include: hand hygiene practices; prevention of central venous
catheter-related bloodstream infections; judicious use of antimicrobials for
therapy and prophylaxis; enhancement of host defences; skin care; and early
enteral feeding with human milk.
PMID: 18329134 [PubMed - as supplied by publisher]
2: J Hosp Infect. 2007 Jun;65 Suppl 2:3-9.
The Lowbury Lecture. The United States approach to strategies in the battle
against healthcare-associated infections, 2006: transitioning from benchmarking
to zero tolerance and clinician accountability.
Jarvis WR.
Jason and Jarvis Associates, Hilton Head Island, SC 20029, USA.
Approximately 2,000,000 healthcare-associated infections (HAIs) annually occur in
US healthcare facilities and lead to approximately 60,000 90,000 deaths and cost
$17 29 billion dollars. Such HAIs are an equal, if not more common problem,
worldwide. Many evidence-based HAI prevention guidelines exist. However, despite
knowing what to do, the challenge remains of getting clinicians to comply with
these recommendations. In the USA, a variety of forces, including the public and
legislators, are demanding HAI prevention. This is illustrated by the Consumers
Union's effort to get legislation in every state for public HAI rate reporting.
In addition, a number of profit-making and non-profit-making organizations have
initiated major HAI prevention interventions. At least three common themes for
these interventions exist. First, no single intervention prevents any HAI; rather
a "bundle" approach, using a package of multiple interventions based on evidence
provided by the infection control community and implemented by a
multidisciplinary team is the model for successful HAI prevention. Second,
benchmarking is inadequate and a culture of zero tolerance is required. Third, a
culture of accountability and administrative support is required. Such
interventions have illustrated that much greater levels of HAI prevention can be
accomplished than ever estimated in the past. Implementation of evidence-based
HAI prevention interventions should be a high priority for all healthcare
facilities to reduce preventable HAIs to the greatest extent possible.
Publication Types:
Lectures
PMID: 17540232 [PubMed - indexed for MEDLINE]
3: Curr Opin Crit Care. 2007 Aug;13(4):411-5.
Prevention of catheter-related blood stream infection.
Byrnes MC, Coopersmith CM.
Department of Surgery, Washington University School of Medicine, St. Louis,
Missouri, USA.
PURPOSE OF REVIEW: Catheter-related blood stream infections are a morbid
complication of central venous catheters. This review will highlight a
comprehensive approach demonstrated to prevent catheter-related blood stream
infections. RECENT FINDINGS: Elements of prevention important to inserting a
central venous catheter include proper hand hygiene, use of full barrier
precautions, appropriate skin preparation with 2% chlorhexidine, and using the
subclavian vein as the preferred anatomic site. Rigorous attention needs to be
given to dressing care, and there should be daily assessment of the need for
central venous catheters, with prompt removal as soon as is practicable.
Healthcare workers should be educated routinely on methods to prevent
catheter-related blood stream infections. If rates remain higher than benchmark
levels despite proper bedside practice, antiseptic or antibiotic-impregnated
catheters can also prevent infections effectively. A recent program utilizing
these practices in 103 ICUs in Michigan resulted in a 66% decrease in infection
rates. SUMMARY: There is increasing recognition that a comprehensive strategy to
prevent catheter-related blood stream infections can prevent most infections, if
not all. This suggests that thousands of infections can potentially be averted if
the simple practices outlined herein are followed.
Publication Types:
Review
PMID: 17599011 [PubMed - indexed for MEDLINE]
4: JPEN J Parenter Enteral Nutr. 2007 Jul-Aug;31(4):284-7.
Risk factors of catheter-related bloodstream infections in parenteral nutrition
catheterization.
Yilmaz G, Koksal I, Aydin K, Caylan R, Sucu N, Aksoy F.
Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical
University School of Medicine, Trabzon, Turkey. gurdalyilmaz53@hotmail.com
BACKGROUND: 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.
METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
PMID: 17595436 [PubMed - indexed for MEDLINE]
5: J Infus Nurs. 2007 Mar-Apr;30(2):105-12; quiz 120-1.
Implementing evidence-based nursing practice in the pediatric intensive care
unit.
Morgan LM, Thomas DJ.
Nova Southeastern University, Miami, FL, USA. Anchoredsoul@aol.com
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.
PMID: 17413495 [PubMed - indexed for MEDLINE]
6: J Hosp Infect. 2007 Apr;65(4):314-8. Epub 2007 Mar 12.
Effect of neonatal intensive care unit environment on the incidence of
hospital-acquired infection in neonates.
Von Dolinger de Brito D, de Almeida Silva H, Jose Oliveira E, Arantes A, Abdallah
VO, Tannus Jorge M, Gontijo Filho PP.
Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, CEP
38400-902, Uberlândia, MG, Brazil. denisebrito@terra.com.br
The influence of the inanimate hospital environment and hospital design on
nosocomial infection is a topic for discussion. This study evaluated the impact
of the neonatal intensive care unit (NICU) environment on the risk of
hospital-acquired infection (HAI). HAI surveillance was performed during a
four-year period when the NICU was moved initially from an old facility to
temporary accommodation and then eventually to a new and better-designed
facility. The rate of HAI rose significantly from 12.8 to 18.6% (P<0.01) after
moving to the temporary unit, which had a lower sink:cot ratio and a higher
monthly admission rate. In contrast, the rates of catheter-associated
staphylococcal bacteraemia decreased significantly after moving to the new NICU
(P<0.0001). Since peripherally inserted central catheters (PICCs) were introduced
concomitantly with the move to the new unit, however, the catheter type may have
contributed towards this reduction in CVC-related staphylococcal bacteraemias.
Moving to a temporary NICU with poor handwashing facilities and higher admission
activity resulted in higher rates of HAI.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 17350722 [PubMed - indexed for MEDLINE]
7: J Hosp Infect. 2007 Feb;65 Suppl 1:S1-64.
epic2: National evidence-based guidelines for preventing healthcare-associated
infections in NHS hospitals in England.
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SR, McDougall C,
Wilcox MH.
Richard Wells Research Centre, Faculty of Health and Human Sciences, Thames
Valley University, London. robert.pratt@tvu.ac.uk
National evidence-based guidelines for preventing healthcare-associated
infections (HCAI) in National Health Service (NHS) hospitals in England were
commissioned by the Department of Health (DH) and developed during 1998-2000
by a
nurse-led multi-professional team of researchers and specialist clinicians.
Following extensive consultation, they were published in January 2001. These
guidelines describe the precautions healthcare workers should take in three
areas: standard principles for preventing HCAI, which include hospital
environmental hygiene, hand hygiene, the use of personal protective equipment,
and the safe use and disposal of sharps; preventing infections associated with
the use of short-term indwelling urethral catheters; and preventing infections
associated with central venous catheters. The evidence for these guidelines was
identified by multiple systematic reviews of experimental and non-experimental
research and expert opinion as reflected in systematically identified
professional, national and international guidelines, which were formally assessed
by a validated appraisal process. In 2003, we developed complementary national
guidelines for preventing HCAI in primary and community care on behalf of the
National Collaborating Centre for Nursing and Supportive Care (National Institute
for Healthand Clinical Excellence). A cardinal feature of evidence-based
guidelines is that they are subject to timely review in order that new research
evidence and technological advances can be identified, appraised and, if shown to
be effective in preventing HCAI, incorporated into amended guidelines.
Periodically updating the evidence base and guideline recommendations is
essential in order to maintain their validity and authority. Consequently, the DH
commissioned a review of new evidence published following the last systematic
reviews. We have now updated the evidence base for making infection prevention
and control recommendations. A critical assessment of the updated evidence
indicated that the original epic guidelines published in 2001 remain robust,
relevant and appropriate but that adjustments need to be made to some guideline
recommendations following a synopsis of the evidence underpinning the guidelines.
These updated national guidelines (epic2) provide comprehensive recommendations
for preventing HCAI in hospitals and other acute care settings based on the best
currently available evidence. Because this is not always the best possible
evidence, we have included a suggested agenda for further research in each
section of the guidelines. National evidence-based guidelines are broad
principles of best practice which need to be integrated into local practice
guidelines. To monitor implementation, we have suggested key audit criteria for
each section of recommendations. Clinically effective infection prevention and
control practice is an essential feature of protecting patients. By incorporating
these guidelines into routine daily clinical practice, patient safety can be
enhanced and the risk of patients acquiring an infection during episodes of
healthcare in NHS hospitals in England can be minimised.
Publication Types:
Practice Guideline
PMID: 17307562 [PubMed - indexed for MEDLINE]
8: BMJ. 2007 Feb 17;334(7589):362-5.
Reduction of bloodstream infections associated with catheters in paediatric
intensive care unit: stepwise approach.
Bhutta A, Gilliam C, Honeycutt M, Schexnayder S, Green J, Moss M, Anand KJ.
Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas
Children's Hospital, 800 Marshall Street, Slot 512-3, Little Rock, AR 72202, USA.
bhuttaadnant@uams.edu
PROBLEM: Bloodstream infections associated with catheters were the most common
nosocomial infections in one paediatric intensive care unit in 1994-7, with rates
well above the national average. DESIGN: Clinical data were collected
prospectively to assess the rates of infection from 1994 onwards. The high rates
in 1994-7 led to the stepwise introduction of interventions over a five year
period. At quarterly intervals, prospective data continued to be collected during
this period and an additional three year follow-up period. SETTING: A 292 bed
tertiary care children's hospital. KEY MEASURES FOR IMPROVEMENT: We
aimed to
reduce our infection rates to below the national mean rates for similar units by
2000 (a 25% reduction). STRATEGIES FOR CHANGE: A stepwise introduction of
interventions designed to reduce infection rates, including maximal barrier
precautions, transition to antibiotic impregnated central venous catheters,
annual handwashing campaigns, and changing the skin disinfectant from
povidone-iodine to chlorhexidine. Effects of change Significant decreases in
rates of infection occurred over the intervention period. These were sustained
over the three year follow-up. Annual rates decreased from 9.7/1000 days with a
central venous catheter in 1997 to 3.0/1000 days in 2005, which translates to a
relative risk reduction of 75% (95% confidence interval 35% to 126%), an absolute
risk reduction of 6% (2% to 10%), and a number needed to treat of 16 (10 to 35).
LESSONS LEARNT: A stepwise introduction of interventions leading to a greater
than threefold reduction in nosocomial infections can be implemented
successfully. This requires a multidisciplinary team, support from hospital
leadership, ongoing data collection, shared data interpretation, and introduction
of evidence based interventions.
PMID: 17303886 [PubMed - indexed for MEDLINE]
9: Contrib Nephrol. 2007;154:84-96.
Hemodialysis catheter exit site care.
Astle CM.
WC McKenzie Center, University of Alberta Hospital, Edmonton, Canada.
Tunneled, cuffed central venous catheters are used extensively throughout the
hemodialysis patient population as a permanent arterio-venous access. One of the
major complications associated with these devices is infection. The strategies
aimed at reducing catheter-related infection include nurse-patient ratio, use of
barrier precautions, hand washing, ointments, dressings, and skin antiseptics.
The intent of this paper is to examine the types of skin antiseptics and compare
their effectiveness.
PMID: 17099303 [PubMed - in process]
10: AACN Adv Crit Care. 2006 Oct-Dec;17(4):446-54; quiz 456.
Elimination of central line-associated bloodstream infections: application of the
evidence.
Posa PJ, Harrison D, Vollman KM.
Keystone ICU, St. Joseph Mercy Hospital, 5301 E Huron, Ann Arbor, MI 48106,
USA.
patposa@comcast.net
Central line-associated bloodstream infections are considered to be an avoidable
complication of care delivery. In addition to considerable morbidity and use of
resources, central line-associated bloodstream infections carry an attributable
morality between 12% and 25%. The estimated cost per infection is approximately
25,000 US dollars. Research over the last decade has focused on a number of care
activities that have been shown to reduce the incidence of bloodstream infections
related to central line placement in the critically ill patient. A significant
reduction or elimination of central line-associated bloodstream infections can
occur with implementation of a comprehensive central line-associated bloodstream
infection prevention program that includes staff education, hand hygiene, use of
maximal sterile barrier precautions, chlorhexidine gluconate skin antisepsis,
avoidance of femoral lines, empowerment of staff to stop the procedure if sterile
technique is broken, and daily assessment of the continued need for a central
line. This article focuses on strategies for implementing a comprehensive central
line-associated bloodstream infections prevention program and a tool and process
for defect analysis as part of a statewide collaborative in Michigan.
Publication Types:
Review
PMID: 17091045 [PubMed - indexed for MEDLINE]
11: Annu Rev Nurs Res. 2006;24:75-99.
Hospital-acquired infections as patient safety indicators.
Peterson AM, Walker PH.
CNS Nursing Department, NIH Clinical Center, National Institutes of Health,
Bethesda, Maryland, USA.
Transmission of infection in the hospital has been identified as a patient safety
problem adversely affecting patients, visitors, and health care workers.
Prevention of infection should not be limited to the hospital epidemiology staff
but also must involve the entire multidisciplinary team, including nurses. This
chapter reviews the literature related to patient safety of nursing-authored
studies of infection control in the hospital. The review indicated that there
were key areas of research interest including drug resistance; hand hygiene
products, procedures, and surveillance; preoperative skin preparations; health
care worker transmission of infection; common procedures associated with an
increased risk of transmission; and organizational issues.
Publication Types:
Review
PMID: 17078411 [PubMed - indexed for MEDLINE]
12: Hosp Health Netw. 2006 Sep;80(9):32-6, 38-40, 2.
Republished in:
Mater Manag Health Care. 2006 Nov;15(11):27-32, 34.
Save lives now. 30 things you can do to eliminate infections.
Scalise D.
More than 2 million Americans a year acquire infections during a hospital stay,
often with deadly results. These infections are costly to treat and difficult to
rationalize to patients and the public. And most of them can be prevented. Here
are 30 simple and low-cost things that you can do right now to eliminate
infections in your hospital. Well outline additional steps in upcoming issues of
H&HN as part of the 2006 Save Lives Now series.
PMID: 17036764 [PubMed - indexed for MEDLINE]
13: Am J Infect Control. 2006 Oct;34(8):537-9.
Measurement and feedback of infection control process measures in the intensive
care unit: Impact on compliance.
Berhe M, Edmond MB, Bearman G.
Division of Infectious Diseases, Department of Internal Medicine, Virginia
Commonwealth University School of Medicine, Richmond, VA, USA.
BACKGROUND: Infection control process measures provide actionable and
measurable
indicators for performance improvement. OBJECTIVE: To determine the relationship
between the measurement and feedback of selected infection control process
measures and compliance with infection control practices. METHODS: We measured
selected infection control process measures (hand hygiene, femoral catheter use
as a proportion of all central venous catheter (CVC) days and proportion of head
of bed elevations) in the medical respiratory intensive care unit (ICU) (MRICU)
and the surgical trauma ICU (STICU). All data were collected by trained infection
control practitioners. Baseline data were obtained April through June 2004.
Baseline hand hygiene data were obtained from May to June. Follow-up observations
were obtained from July 2004 through March 2005. Both baseline and follow-up
observations were reported to the units' leadership. The data were reviewed for
improvement in compliance with process measures. Differences in proportions were
analyzed for statistical significance by the chi(2) test. RESULTS: There was a
statistically significant improvement in the head of bed elevation rates: 54.9%
versus 98.4% (P < .001) for the MRICU and 46.5% versus 77.2% (P < .001) for the
STICU, respectively. There was also a statistically significant decline in
femoral catheter rates in both ICUs: 17.8% versus 10% (P = .001) in the MRICU and
8.4% versus 3% (P < .001) in the STICU, respectively. There was no significant
improvement in hand hygiene rates in either ICU: 31.8% versus 39.3% (P = .1) in
the MRICU and 50% versus 50.3% (P = .9) in the STICU, respectively.
CONCLUSION:
Feedback of process measures lowered the use of femoral catheters and improved
the proportion of elevated head of beds in 2 ICUs, but there was no significant
improvement in hand hygiene.
PMID: 17015162 [PubMed - indexed for MEDLINE]
14: Clin Infect Dis. 2006 Oct 15;43(8):971-8. Epub 2006 Sep 14.
Comment in:
Clin Infect Dis. 2007 Mar 1;44(5):766; author reply 766-7.
Impact of routine intensive care unit surveillance cultures and resultant barrier
precautions on hospital-wide methicillin-resistant Staphylococcus aureus
bacteremia.
Huang SS, Yokoe DS, Hinrichsen VL, Spurchise LS, Datta R, Miroshnik I, Platt R.
Channing Laboratory, Brigham and Women's Hospital, Boston, MA 02115, USA.
sshuang@partners.org
BACKGROUND: Serial interventions are often used to reduce the risk of health
care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections. To
our knowledge, the relative impact of these interventions has not previously been
ascertained. METHODS: We conducted a retrospective study of 4 major infection
control interventions using an interrupted time series design to evaluate their
impact on MRSA bacteremia in an 800-bed hospital with 8 intensive care units
(ICUs). Interventions were introduced 1 at a time during a 9-year period and
involved the promotion of compliance with maximal sterile barrier precautions
during central venous catheter placement, the institution of alcohol-based hand
rubs for hand disinfection, the introduction of a hand hygiene campaign, and the
institution of routine nares surveillance cultures for MRSA in all ICUs for
patients on ICU admission and weekly thereafter while in the ICU. Positive
cultures resulted in the initiation of contact isolation precautions.Using
segmented regression analyses, we evaluated changes in monthly incidence and
prevalence of MRSA bacteremia from their predicted values.
Methicillin-susceptible Staphylococcus aureus bacteremia was monitored as a
control. RESULTS: Routine surveillance cultures and subsequent contact isolation
precautions resulted in substantial reductions in MRSA bacteremia in both ICUs
and non-ICUs. In 16 months, the incidence density of MRSA bacteremia decreased
by
75% in ICUs (P=.007) and by 40% in non-ICUs (P=.008), leading to a 67%
hospital-wide reduction in the incidence density of MRSA bacteremia (P=.002).
Methicillin-susceptible S. aureus bacteremia rates remained stable during this
time. The other interventions were not associated with a statistically
significant change in MRSA bacteremia. CONCLUSIONS: Routine surveillance for
MRSA
in ICUs allowed earlier initiation of contact isolation precautions and was
associated with large and statistically significant reductions in the incidence
of MRSA bacteremia in the ICUs and hospital wide. In contrast, no similar
decrease was attributable to the other infection control interventions.
Publication Types:
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.
PMID: 16983607 [PubMed - indexed for MEDLINE]
15: Surg Infect (Larchmt). 2006;7 Suppl 2:S65-7.
Recommendations and reports about central venous catheter-related infection.
Bacuzzi A, Cecchin A, Del Bosco A, Cantone G, Cuffari S.
Anaesthesia and Palliative Care, Ospedale di Circolo e Fondazione Macchi, Varese,
Italy. bacuzzi@tin.it
BACKGROUND: 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).
METHOD: Review of the pertinent English-language literature. RESULTS: 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. CONCLUSIONS: 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.
Publication Types:
Review
PMID: 16895510 [PubMed - indexed for MEDLINE]
16: Arch Pediatr Adolesc Med. 2006 Aug;160(8):832-6.
Impact of staffing on bloodstream infections in the neonatal intensive care unit.
Cimiotti JP, Haas J, Saiman L, Larson EL.
Center for Health Outcomes and Policy Research, School of Nursing, University of
Pennsylvania, Philadelphia, 19104-6096, USA. jcimiott@nursing.upenn.edu
OBJECTIVE: To examine the association between registered nurse staffing and
healthcare-associated bloodstream infections in infants in the neonatal intensive
care unit (NICU). DESIGN: Prospective cohort study. SETTING: Two level III-IV
NICUs in New York, NY, from March 1, 2001, through January 31, 2003.
PARTICIPANTS: A total of 2675 infants admitted to the NICUs for more than 48
hours and all registered nurses who worked in the same NICUs during the study
period.Intervention Hours of care provided by registered nurses.Main Outcome
Measure Time to first episode of healthcare-associated bloodstream infection.
RESULTS: A total of 224 infants had an infection that met the study definition of
healthcare-associated bloodstream infection. In a multivariate analysis, after
controlling for infants' intrinsic and extrinsic risk factors, a greater number
of hours of care provided by registered nurses in NICU 2 was associated with a
decreased risk of bloodstream infection in these infants (hazard ratio, 0.21; 95%
confidence interval, 0.06-0.79). CONCLUSION: Our findings suggest that registered
nurse staffing is associated with the risk of bloodstream infection in infants in
the NICU.
Publication Types:
Research Support, N.I.H., Extramural
PMID: 16894083 [PubMed - indexed for MEDLINE]
17: Br J Nurs. 2006 Apr 13-26;15(7):362, 364-8.
Central venous catheter infection in adults in acute hospital settings.
Jones CA.
King's College London.
As well as the human cost, central venous catheter (CVC)-related bloodstream
infections significantly inflate hospital costs, mainly through increased length
of stay in hospital, particularly in intensive care. This literature review
appraises recent research on measures used to minimize CVC-related infection and
compares it with current best practice. Randomized controlled trials and
systematic reviews published on the subject between 2000 and 2005 were reviewed,
concentrating on non-tunnelled, short-term CVCs in the acute hospital setting.
The new evidence mainly backs up current best practice. However, skin
disinfection could be improved by using alcoholic chlorhexidine followed by
aqueous povidone-iodine before CVC insertion. Also, alcoholic chlorhexidine is
the preferred solution for cleaning the hubs/connectors before accessing the CVC.
Good hand hygiene and quality control and education programmes are vital to
improve patient care. More research is needed to clarify the effectiveness of
certain interventions and technologies, such as antimicrobial CVCs.
Publication Types:
Review
PMID: 16723935 [PubMed - indexed for MEDLINE]
18: Curr Opin Pediatr. 2006 Apr;18(2):101-6.
Strategies for prevention of nosocomial sepsis in the neonatal intensive care
unit.
Saiman L.
Columbia University, Department of Pediatrics, Division of Infectious Diseases,
New York 10032, USA. LS5@columbia.edu
PURPOSE OF REVIEW: Infants hospitalized in the neonatal intensive care unit,
particularly preterm infants, have very high rates of nosocomial sepsis (also
referred to as late onset sepsis or healthcare-associated sepsis). Today's
preventive strategies for nosocomial sepsis focus on augmenting the immunologic
and functional immaturities of premature infants and ameliorating the risks of
extrinsic factors by the use of prophylactic antibiotics and best clinical
practices. RECENT FINDINGS: Topical emollients improved neonatal skin
condition,
but were associated with an increased risk of nosocomial bacterial sepsis and
coagulase negative staphylococcal infections, and thus should not be used in
extremely-low-birth-weight infants. Single-center studies have shown that
probiotics containing anaerobic bacteria may reduce the rate of necrotizing
enterocolitis, the severity of necrotizing enterocolitis, and/or bacterial
sepsis. Single-center studies have shown that prophylactic fluconazole reduces
the rates of invasive candidiasis and/or colonization of
extremely-low-birth-weight infants. Quality improvement projects to improve
adherence to appropriate hand hygiene and best practices for central venous
catheter insertion and maintenance can reduce rates of nosocomial sepsis.
SUMMARY: The safety and efficacy of probiotics and prophylactic fluconazole
require large multicenter trials. Quality improvement initiatives, however, can
be performed now and can reduce the rates of nosocomial sepsis in the neonatal
intensive care unit.
Publication Types:
Review
PMID: 16601486 [PubMed - indexed for MEDLINE]
19: Aust Crit Care. 2006 Feb;19(1):15-21.
Handwashing practice and policy variability when caring for central venous
catheters in paediatric intensive care.
Morritt ML, Harrod ME, Crisp J, Senner A, Galway R, Petty S, Maurice L, Harvey
A,
Hardy J, Donnellan R.
Sydney Children's Hospital, Randwick, NSW.
It has been estimated that there may be as many as 150,000 healthcare associated
infections (HCAI) in Australia each year, contributing to 7,000 deaths, many of
which could be prevented through the implementation of appropriate infection
control practices. Contact with contaminated hands is a primary source of HCAI.
Intensive care staff have been identified as one of the least adherent groups of
health care professionals with handwashing; they are less likely to practise hand
antisepsis before invasive procedures than staff working in other patient care
specialties. The study examined the self-reported clean and aseptic handwashing
practices of nurses working in paediatric intensive care units (PICUs) across
Australia and New Zealand, the patterns in variation between nurses' reported
handwashing practices and the local policies, and patterns in the duration of
procedural handwashing for specific procedures. A survey was undertaken in 2001
in which participating tertiary paediatric hospitals provided copies of their
infection control policies pertaining to central venous catheter (CVC)
management; five nurses on each unit were asked to provide information in
relation to their handwashing practices. Seven hospitals agreed to participate
and 30 nurses completed the survey. The study found an enormous level of
variation among and between nurses' reported practices and local policies. This
variation extended across all aspects of handwashing practices - duration and
extent of handwash, type of solution and drying method used. The rigour of
handwashing varied according to the procedure undertaken, with some evidence that
nurses made their own risk assessments based on the proximity of the procedure to
the patient. In conclusion, this study's findings substantiate the need for
standardisation of practice in line with the current Centers for Disease Control
and Prevention Guidelines, including the introduction of alcohol handrub.
PMID: 16544674 [PubMed - indexed for MEDLINE]
20: Pediatr Infect Dis J. 2006 Feb;25(2):113-7.
Comment in:
Pediatr Infect Dis J. 2006 Jul;25(7):663-4; author reply 664.
Risk factors for late onset gram-negative sepsis in low birth weight infants
hospitalized in the neonatal intensive care unit.
Graham PL 3rd, Begg MD, Larson E, Della-Latta P, Allen A, Saiman L.
Department of Pediatrics, Columbia University, New York-Presbyterian Hospital,
New York, NY, USA. pg143@columbia.edu
BACKGROUND: Gram-negative bloodstream infections (BSIs) cause 20-30% of
late
onset sepsis in neonatal intensive care unit (NICU) patients and have mortality
rates of 30-50%. We investigated risk factors for late onset Gram-negative sepsis
in very low birth weight (<1500 g) NICU patients. METHODS: We performed a
case-control study as part of a larger 2-year clinical trial that examined the
effects of hand hygiene practices on hospital-acquired infections. In this
substudy, a case was a very low birth weight infant with a hospital-acquired
Gram-negative BSI; control subjects, matched on study site and hand hygiene
product, were chosen randomly from the patients who did not have Gram-negative
BSIs. Potential risk factors were analyzed by Mantel-Haenszel methods and
conditional logistic regression. RESULTS: There were 48 cases of Gram-negative
BSI. In multivariate analysis, we found that the following variables were
significantly associated with Gram-negative BSI: central venous catheterization
duration of >10 days; nasal cannula continuous positive airway pressure use; H2
blocker/proton pump inhibitor use; and gastrointestinal tract pathology.
CONCLUSIONS: These analyses provide insights into potential strategies to reduce
Gram-negative BSIs. Catheters should be removed as possible and H2
blockers/proton pump inhibitors should be used judiciously in NICU patients. The
association between nasal cannula continuous positive airway pressure and
Gram-negative BSIs requires further investigation. The association of
gastrointestinal tract pathology with Gram-negative BSIs identifies a high risk
group of neonates who may benefit from enhanced preventative strategies.
Publication Types:
Clinical Trial
Research Support, N.I.H., Extramural
PMID: 16462286 [PubMed - indexed for MEDLINE]
21: Infect Control Hosp Epidemiol. 2006 Jan;27(1):8-13. Epub 2006 Jan 6.
Comment in:
Infect Control Hosp Epidemiol. 2006 Jan;27(1):3-7.
Preventing catheter-associated bloodstream infections: a survey of policies for
insertion and care of central venous catheters from hospitals in the prevention
epicenter program.
Warren DK, Yokoe DS, Climo MW, Herwaldt LA, Noskin GA, Zuccotti G, Tokars
JI,
Perl TM, Fraser VJ.
Division of Infectious Diseases, Washington University School of Medicine, Saint
Louis, MO 63110, USA. dwarren@im.wustl.edu
OBJECTIVE: To determine the extent to which evidence-based practices for the
prevention of central venous catheter (CVC)-associated bloodstream infections are
incorporated into the policies and practices of academic intensive care units
(ICUs) in the United States and to determine variations in the policies on CVC
insertion, use, and care. DESIGN: A 9-page written survey of practices and
policies for nontunneled CVC insertion and care. SETTING: ICUs in 10 academic
tertiary-care hospitals. PARTICIPANTS: ICU medical directors and nurse managers.
RESULTS: Twenty-five ICUs were surveyed (1-6 ICUs per hospital). In 80% of the
units, 5 separate groups of clinicians inserted 24%-50% of all nontunneled CVCs.
In 56% of the units, placement of more than two-thirds of nontunneled CVCs was
performed in a single location in the hospital. Twenty units (80%) had written
policies for CVC insertion. Twenty-eight percent of units had a policy requiring
maximal sterile-barrier precautions when CVCs were placed, and 52% of the units
had formal educational programs with regard to CVC insertion. Eighty percent of
the units had a policy requiring staff to perform hand hygiene before inserting
CVCs, but only 36% and 60% of the units required hand hygiene before accessing a
CVC and treating the exit site, respectively. CONCLUSION: ICU policy regarding
the insertion and care of CVCs varies considerably from hospital to hospital.
ICUs may be able to improve patient outcome if evidence-based guidelines for CVC
insertion and care are implemented.
Publication Types:
Comparative Study
Multicenter Study
Research Support, N.I.H., Extramural
PMID: 16418980 [PubMed - indexed for MEDLINE]
22: J Hosp Infect. 2005 Oct;61(2):162-7.
Prospective evaluation of a multi-factorial prevention strategy on the impact of
nosocomial infection in very-low-birthweight infants.
Andersen C, Hart J, Vemgal P, Harrison C.
Deparetment of Paediatrics, Mercy Hospital for Women, 126 Clarendon Street East
Melbourne, Melbourne, Victoria 3002, Australia. candersen@mercy.com.au
The aim of this study was to examine the impact of a multi-factorial intervention
on nosocomial infection in very-low-birthweight infants. Consecutive infants with
a birth weight less than 1500 g, born between February 2002 and February 2003,
were included in this prospective study. The first six-month period (control)
included surveillance of current practice. The intervention began in the seventh
month and included: (i) changes to handwashing solutions with hand hygiene
education; (ii) standardization of intravascular device (IV) insertion with
specialized packs; (iii) changes to skin antiseptic solutions (2% aqueous
chlorhexidine and 1% chlorhexidine in ethanol); and (iv) mandatory removal or
replacement of peripheral IV after 48 hours and removal once enteral intake was >
120 mL/kg/day. Demographic data and details of every device were collected
prospectively. Bloodstream infections (BSIs), length of stay (LOS), length of
ventilation (LOV) and death were recorded and the rate of nosocomial BSI was
calculated. Overall, 174 newborns required 1359 devices. The two cohorts were
similar for birth weight and gestation. There was a reduction in nosocomial BSIs
from 21% to 9% (control vs. intervention) (P = 0.05, confidence intervals
0.19-1.0). There was no significant difference in LOS, LOV, or mortality. Four
infants had complications from 2% chlorhexidine. In conclusion, implementation of
the multi-factorial prevention strategy reduced nosocomial BSIs. Alternative
antiseptic solutions are needed to reduce the complications caused by 2% aqueous
chlorhexidine.
PMID: 16240469 [PubMed - indexed for MEDLINE]
23: Am J Infect Control. 2005 Sep;33(7):392-7.
Comment in:
Am J Infect Control. 2006 Jun;34(5):329. Am J Infect Control. 2006
Sep;34(7):467.
Reduction in nosocomial infection with improved hand hygiene in intensive care
units of a tertiary care hospital in Argentina.
Rosenthal VD, Guzman S, Safdar N.
Section of Infectious Diseases and Hospital Epidemiology, Colegiales Hospital,
Buenos Aires, Argentina. victor_rosenthal@fibertel.com.ar
BACKGROUND: Hand hygiene is a fundamental measure for the control of
nosocomial
infection. However, sustained compliance with hand hygiene in health care workers
is poor. We attempted to enhance compliance with hand hygiene by implementing
education, training, and performance feedback. We measured nosocomial infections
in parallel. METHODS: We monitored the overall compliance with hand hygiene
during routine patient care in intensive care units (ICUs); 1 medical surgical
ICU and 1 coronary ICU, of 1 hospital in Buenos Aires, Argentina, before and
during implementation of a hand hygiene education, training, and performance
feedback program. Observational surveys were done twice a week from September
2000 to May 2002. Nosocomial infections in the ICUs were identified using the
National Nosocomial Infections Surveillance (NNIS) criteria, with prospective
surveillance. RESULTS: We observed 4347 opportunities for hand hygiene in both
ICUs. Compliance improved progressively (handwashing adherence, 23.1%
(268/1160)
to 64.5% (2056/3187) (RR, 2.79; 95% CI: 2.46-3.17; P < .0001). During the same
period, overall nosocomial infection in both ICUs decreased from 47.55 per 1000
patient-days (104/2187) to 27.93 per 1000 patient days (207/7409) RR, 0.59; 95%
CI: 0.46-0.74, P < .0001). CONCLUSION: A program consisting of focused
education
and frequent performance feedback produced a sustained improvement in compliance
with hand hygiene, coinciding with a reduction in nosocomial infection rates in
the ICUs.
PMID: 16153485 [PubMed - indexed for MEDLINE]
24: Crit Care Med. 2005 Sep;33(9):2022-7.
Comment in:
Crit Care Med. 2005 Sep;33(9):2133-4.
The effect of process control on the incidence of central venous
catheter-associated bloodstream infections and mortality in intensive care units
in Mexico.
Higuera F, Rosenthal VD, Duarte P, Ruiz J, Franco G, Safdar N.
General Hospital, Mexico City, Mexico.
PURPOSE: To ascertain the effect of an infection control program including
process control on intensive care unit (ICU) rates of intravascular device
(IVD)-associated bloodstream infection (BSI). SETTING: Two level III adult ICUs
in one public university hospital in Mexico: one medical surgical ICU and one
neurosurgical ICU. POPULATION STUDY: All adult patients admitted to study
units
who had a central venous catheter (CVC) in place for at least 24 hrs. METHODS: A
prospective before/after trial in which rates of IVD-associated BSI are
determined during a period of active surveillance without process control (phase
1) were compared with rates of IVD-associated BSI after implementing an infection
control program applying process control (phase 2). RESULTS: Six hundred five
IVD-days were accumulated in phase 1, and 2824 IVD-days were accumulated
during
phase 2. Compliance with CVC site care and hand hygiene improved significantly
from baseline during the study period: placing a gauze dressing over the catheter
insertion site (99.24% vs. 86.69%, respectively; relative risk [RR] = 1.14; 95%
confidence interval [CI] = 1.07-1.22; p = .0000), proper use of gauze for
vascular catheter insertion site (97.87% vs. 84.21%, respectively; RR = 1.16; 95%
CI = 1.09-1.24; p = .0000), documentation of the duration of the administration
set of the vascular catheter (93.85% vs. 40.69%, respectively; RR = 2.34; 95% CI
= 2.14-2.56; p = .0000), and hand hygiene before contact with the patient (84.9%
vs. 62%, respectively; RR = 1.37; 95% CI = 1.21-1.51; p = .0000). Overall rates
of IVD-associated BSI were lowered significantly from baseline rates after
implementation of process control (19.5 vs. 46.3 BSIs per 1000 IVD-days,
respectively; RR = 0.42; 95% CI = 0.27-0.66; p = .0001). Overall rates of crude
unadjusted mortality were lowered significantly from baseline rates (48.5% vs.
32.8% per 100 discharges, respectively; RR = 0.68; 95% CI = 0.50-0.31; p = .01).
CONCLUSION: Implementation of an infection control program utilizing education,
process control, and performance feedback was associated with significant
reductions in rates of IVD-associated BSI and mortality.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 16148475 [PubMed - indexed for MEDLINE]
25: Infect Control Hosp Epidemiol. 2004 Sep;25(9):747-52.
Survey of knowledge, beliefs, and practices of neonatal intensive care unit
healthcare workers regarding nosocomial infections, central venous catheter care,
and hand hygiene.
Kennedy AM, Elward AM, Fraser VJ.
Department of Internal Medicine, Washington University School of Medicine, 660
South Euclid Avenue, St. Louis, MO 63110, USA.
OBJECTIVE: To assess the knowledge, beliefs, and practices of neonatal intensive
care unit (NICU) healthcare workers (HCWs). DESIGN: Self-administered survey.
SETTING: A 55-bed NICU. PARTICIPANTS: NICU HCWs (N = 215). RESULTS:
The response
rate was 68%. Ninety-two percent knew central venous catheters (CVCs) should be
capped, clamped, or connected to running fluids at all times. Ninety-five percent
knew when to change gloves. Thirty-one percent knew the recommended duration for
handwashing. Most HCWs believed sterile technique in CVC care (96%), gloves
(91%), and handwashing (99%) prevent nosocomial infection (NI). Sixty-seven
percent used sterile barriers to insert CVCs, 76% reported wearing gloves, 81%
reported routine handwashing, 35% knew that bacterial hand counts are higher with
rings, 30% knew that long fingernails are associated with higher gram-negative
bacterial hand contamination, and 35% knew that artificial fingernails are
associated with higher gram-negative bacterial hand contamination. Most (93%)
believed HCWs can affect outcomes of patients with NIs. Fewer believed rings
(40%), artificial fingernails (61%), and long fingernails (48%) play a role in
NIs, or that policies concerning number of rings (50%), cutting fingernails
(35%), or prohibiting artificial fingernails (47%) would prevent NIs. Sixty-one
percent of HCWs regularly wore at least one ring to work, 56% wore their
fingernails shorter than the fingertip, and 8% wore artificial fingernails.
CONCLUSIONS: A disconnect existed between CVC knowledge and beliefs and
practice.
HCWs did not know the relationship between bacterial hand counts and rings and
fingernails, and did not believe rings or long or artificial fingernails
increased the risk of NIs.
Publication Types:
Research Support, U.S. Gov't, P.H.S.
PMID: 15484799 [PubMed - indexed for MEDLINE]
26: Med Mycol. 2004 Aug;42(4):333-9.
Invasive fungal infections in Chile: a multicenter study of fungal prevalence and
susceptibility during a 1-year period.
Silva V, DÃaz MC, Febré N; Chilean Invasive Fungal Infections Group.
Microbiology and Mycology Program, Biomedical Sciences Institute, School of
Medicine, University of Chile, Santiago, Chile. vsilva@med.uchile.cl
During the first year of an ongoing surveillance program of invasive fungal
infections (IFI) a total of 130 patients (56% male) with fungal strains isolated
from blood and other sterile sites were reported from 13 hospitals in Chile.
Significant yeast isolates were obtained from 118 patients, and molds affected 12
patients. The main patient groups affected were neonates, children less than 1
year old and adults aged 50-79 years. All fungal bloodstream infections (BSI)
were due to yeasts; 79 patients (61%) were affected. The main risk factors
recorded were antibiotic therapy (76%), stay in the intensive care unit (ICU)
(70%) and presence of a central venous catheter (65%). Nosocomial infections were
represented in 83.5% of BSI. Overall, Candida albicans (40.8%), C. parapsilosis
(13.1%), C. tropicalis (10%) and Cryptococcus neoformans (10%) were the most
common species. Aspergillus fumigatus (3.1%) was the most frequent mold. C.
albicans (48.1%) and C. parapsilosis (17.7%), were the most frequent agents
recovered from blood. Saccharomyces cerevisiae and Trichosporon mucoides, two
emerging pathogens, were also isolated. All yeasts tested were susceptible to
amphotericin B with minimal inhibitory concentration (MIC) < or = 1 microg/ml.
Resistance to itraconazole (MIC > or = 1 microg/ml) and fluconazole (MIC > or =
64 microg/ml) was observed in 4 and 6% of cases, respectively. C. glabrata was
the least susceptible species, with 50% of isolates resistant to itraconazole and
33% resistant to fluconazole, with one strain showing combined resistance.
Reduction of BSI requires greater adherence to hand-washing and related infection
control guidelines.
Publication Types:
Multicenter Study
PMID: 15473358 [PubMed - indexed for MEDLINE]
27: J Clin Microbiol. 2004 Oct;42(10):4468-72.
Epidemiologic and molecular characterization of an outbreak of Candida
parapsilosis bloodstream infections in a community hospital.
Clark TA, Slavinski SA, Morgan J, Lott T, Arthington-Skaggs BA, Brandt ME,
Webb
RM, Currier M, Flowers RH, Fridkin SK, Hajjeh RA.
Epidemic Intelligence Service, Epidemiology Program Office, Division of Applied
Public Health Training, Centers for Disease Control and Prevention, Atlanta,
Georgia 30333, USA. tnc4@cdc.gov
Candida parapsilosis is an important cause of bloodstream infections in the
health care setting. We investigated a large C. parapsilosis outbreak occurring
in a community hospital and conducted a case-control study to determine the risk
factors for infection. We identified 22 cases of bloodstream infection with C.
parapsilosis: 15 confirmed and 7 possible. The factors associated with an
increased risk of infection included hospitalization in the intensive care unit
(adjusted odds ratio, 16.4; 95% confidence interval, 1.8 to 148.1) and receipt of
total parenteral nutrition (adjusted odds ratio, 9.2; 95% confidence interval,
0.9 to 98.1). Samples for surveillance cultures were obtained from health care
worker hands, central venous catheter insertion sites, and medical devices.
Twenty-six percent of the health care workers surveyed demonstrated hand
colonization with C. parapsilosis, and one hand isolate was highly related to all
case-patient isolates by tests with the DNA probe Cp3-13. Outbreak strain
isolates also demonstrated reduced susceptibilities to fluconazole and
voriconazole. This largest known reported outbreak of C. parapsilosis bloodstream
infections in adults resulted from an interplay of host, environment, and
pathogen factors. Recommendations for control measures focused on improving hand
hygiene compliance.
PMID: 15472295 [PubMed - indexed for MEDLINE]
28: Haemophilia. 2004 Sep;10(5):629-48.
Consensus recommendations for use of central venous access devices in
haemophilia.
Ewenstein BM, Valentino LA, Journeycake JM, Tarantino MD, Shapiro AD,
Blanchette
VS, Hoots WK, Buchanan GR, Manco-Johnson MJ, Rivard GE, Miller KL, Geraghty
S,
Maahs JA, Stuart R, Dunham T, Navickis RJ.
Baxter BioScience, Westlake Village, California 91362, USA.
bruce_ewenstein@baxter.com
Venous access is essential for delivery of haemophilia factor concentrate.
Wherever possible, peripheral veins remain the route of choice, and the use of
central venous access devices (CVADs) should be limited to cases of clear need in
patients with caregivers able to exercise diligence in CVAD care and should
continue no longer than necessary. CVADs are of recognized value for repeated
administration of coagulation factors in haemophilia, particularly for
prophylaxis and immune tolerance therapy and in young children. Evidence to guide
best practices has been fragmentary, and standardized methods for CVAD usage have
yet to be established. We have developed management recommendations based upon
available published evidence as well as extensive clinical experience. These
recommendations address patient and CVAD selection; CVAD placement, care and
removal; caregiver/patient guidance; and complications, including infection and
thrombosis. In the absence of inhibitors, ports are recommended, primarily
because of fewer associated infections than with external catheters. For patients
with inhibitors, ports also appear to be associated with fewer infections.
Infection is the most frequent complication, and recommendations to prevent and
treat infections are supported by extensive clinical data and experience. Strict
adherence to handwashing and aseptic technique are essential elements of catheter
care. Evidence-based data regarding the detection and treatment of CVAD-related
thrombotic complications are limited. Caregiver education is an integral part of
CVAD use and the procedural practices of users should be regularly re-assessed.
These recommendations provide a basis for sound current CVAD practice and are
expected to undergo further refinements as new evidence is compiled and clinical
experience is gained.
Publication Types:
Consensus Development Conference
Review
PMID: 15357790 [PubMed - indexed for MEDLINE]
29: Infect Control Hosp Epidemiol. 2004 Aug;25(8):675-7.
Prevention of central venous catheter-related bloodstream infections using
non-technologic strategies.
Gnass SA, Barboza L, Bilicich D, Angeloro P, Treiyer W, Grenóvero S, Basualdo J.
Sanatorio Adventista del Plata and Facultad de Ciencias de la Salud, Universidad
Adventista del Plata, Libertador San Martin, Entre Rios, Argentina.
OBJECTIVE: To evaluate the incidence of nosocomial bacteremias related to the use
of non-impregnated central venous catheters (CVCs) when only non-technologic
strategies were used to prevent them. DESIGN: This was a prospective study of
infectious complications of CVCs placed in intensive care unit (ICU) patients
from April 1997 to December 2001. SETTING: The medical-surgical ICU of a
tertiary-care, university-affiliated hospital in Argentina. METHODS: We studied
all patients admitted to the ICU using non-impregnated CVCs. Maximal sterile
barrier precautions (ie, use of cap, mask, sterile gown, sterile gloves, and
large sterile drape), strict handwashing, preparation of the patients' skin with
antiseptic solutions, insertion and management of catheters by trained personnel,
and continuing quality improvement programs aimed at appropriate insertion and
maintenance of catheters were employed. RESULTS: During the study period, 2,525
patients were admitted to the ICU. Eight hundred sixty-eight patients had 1,037
CVCs inserted. The number of CVC-related bloodstream infections (BSIs), acquired
in the ICU, was 2.7 per 1,000 CVC-days (13 nosocomial CVC-related BSIs during
4,770 days of CVC use). Microorganisms isolated included methicillin-susceptible
Staphylococcus aureus (n = 6), methicillin-resistant S. aureus (n = 2),
coagulase-negative methicillin-resistant Staphylococcus (n = 2), Escherichia coli
(n = 1), Klebsiella pneumoniae (n = 1), and Enterobacter cloacae (n = 1).
CONCLUSIONS: A low rate of catheter-related BSI was achieved without
antimicrobial-impregnated catheters. The incidence of CVC-associated bacteremias
corresponded to the 10th to 20th percentile range of the National Nosocomial
Infections Surveillance System hospitals for the same type of ICU.
PMID: 15357160 [PubMed - indexed for MEDLINE]
30: Br J Nurs. 2004 Jul 8-21;13(13):806-12.
Nosocomial bloodstream infections in a neonatal intensive care unit.
Apostolopoulou E, Lambridou M, Lambadaridis I.
Nursing Department, University of Athens.
A study was performed to assess the incidence density of, and to identify the
risk factors associated with, nosocomial bloodstream infection (BSI) in a
neonatal intensive care unit (NICU) in Athens. Twenty-four of 105 patients
developed nosocomial BSI (22.9%). The incidence density of BSI was 10.9 per 1000
patient-days. A multivariate model showed that only two factors were
significantly and independently responsible for nosocomial BSI: central venous
catheter use and umbilical catheter use. Results showed that the incidence
density rate was high and the factors that had most influence on the development
of nosocomial BSI were associated with the treatment received by neonates during
their stay in the NICU. Therefore, surveillance of nosocomial BSI and strategies
such as infection control, nursery design and staffing should be implemented to
reduce the incidence of these infections. This effort should be
multidisciplinary, involving staff who insert and maintain intravascular
catheters, and healthcare managers who allocate resources.
PMID: 15284665 [PubMed - indexed for MEDLINE]
31: Ig Sanita Pubbl. 2004 Jan-Apr;60(1-2):75-80.
[Prevention of intravascular catheter-related infections: a multidisciplinary
strategy]
[Article in Italian]
Cortesi E, Caldès MJ, Briani S.
UO Direzione Sanitaria, P.O. SS Cosma e Damiano, Pescia.
e.cortesi@mail.vdn.usl3.toscana.it
Crucial points in the prevention of intravascular catheter-related infections
include scrupulous handwashing combined with the use of proper aseptic technique.
Growing awareness of the importance of these factors has highlighted the need for
multidisciplinary strategies involving healthcare workers, who insert and
maintain intravascular catheters, as well as patients, who should be trained in
the adoption of appropriate personal hygiene measures essential for proper
catheter care.
Publication Types:
English Abstract
PMID: 15213762 [PubMed - indexed for MEDLINE]
32: Am J Infect Control. 2004 May;32(3):135-41.
Prospective study of the impact of open and closed infusion systems on rates of
central venous catheter-associated bacteremia.
Rosenthal VD, Maki DG.
Infection Control and Infectious Diseases Department, Bernal Medical Center and
Colegiales Medical Center, Arengreen 1366, (1405) Buenos Aires, Argentina.
victor_rosenthal@fibertel.com.ar
OBJECTIVE: We sought to ascertain the effect of switching from an open infusion
system to a closed system on rates and sequelae of central venous catheter
(CVC)-associated bloodstream infection in the intensive care department (ICU) of
2 hospitals in Argentina. METHODS: A prospective, controlled, time-series, cohort
trial was undertaken in adult patients admitted to 4 level-III adult ICUs in
Buenos Aires, Argentina, who had a CVC in place for at least 24 hours. Rates of
CVC-associated bloodstream infection during a period of active surveillance with
an open system (baseline; externally vented, semirigid, noncollapsible, 1-port
plastic bottles) were compared with rates after switching to a closed system
(intervention; nonvented, collapsible, 2-port plastic bags). RESULTS: Between
August 1999 and March 2002, 992 patients in the ICU with CVCs were enrolled.
Patients during each study period (open system, 608; closed system, 384) were
similar with respect to sex, severity-of-illness score, and prevalence of
diabetes and cancer. Compliance with handwashing and CVC site care was also
similar during the 2 study periods. The incidence of CVC-associated bacteremia
during use of the closed system was significantly lower than during use of the
open system (2.36 vs 6.52/1000 catheter-days, relative risk=0.36, 95% confidence
interval=0.14-0.94, P=.02); bacteremias caused by gram-negative bacilli declined
by 64%. In all, 17 patients with catheter-associated bacteremia died during the
period when the open system was in use (2.8%), versus only 1 (0.2%) during use of
the closed system (relative risk 0.09, P=.003). The calculated cost savings in
the 20 hospital-month intervention period was $53,768 and 130.9 ICU days.
CONCLUSION: Adoption of a closed infusion system resulted in major reductions in
the incidence of catheter-associated bacteremia, related mortality, and cost.
Because most Latin American hospitals still use externally vented fluid
containers, switching to nonvented bags could substantially reduce rates of
nosocomial bacteremia.
Publication Types:
Multicenter Study
Research Support, Non-U.S. Gov't
PMID: 15153924 [PubMed - indexed for MEDLINE]
33: J Infus Nurs. 2004 May-Jun;27(3):175-80.
Incidence and nature of epidemic nosocomial infections.
Gura KM.
Division of Gastroenterology and Clinical Nutrition at Children's Hospital in
Boston, USA. kathleen.gura@tch.harvard.edu
Nosocomial bloodstream infections continue to be a major cause of morbidity and
mortality. Approximately 8% of all nosocomial infections reported in the United
States are primarily bloodstream infections. These infections prolong hospital
length of stay, increase mortality, and raise the overall cost of healthcare. A
contaminated infusate administered through a central venous catheter is one of
the commonly identified causes of nosocomial bacteremia. In most cases,
contamination of the infusate occurs extrinsically during manipulation of the
fluid before its administration to the patient. Failure to use aseptic technique
and poor hand washing often are the cause. In addition to improved staff
education, surveillance for nosocomial bloodstream infections continues to be the
cornerstone of prevention.
Publication Types:
Review
PMID: 15118456 [PubMed - indexed for MEDLINE]
34: Infection. 2003 Dec;31 Suppl 2:4-9.
Hospital infection control in Italy.
Ippolito G, Nicastri E, Martini L, Petrosillo N.
National Institute for Infectious Disease, Lazzaro Spallanzani-IRCCS, Via
Portuense, 292, I-00149 Rome, Italy. ippolito@inmi.it
In 1998, the National Health Plan identified the reduction of hospital infection
(HI) incidence as a priority. This article reviews the main activities set up in
Italy on infection control in the hospital setting. In 1983, the first national
prevalence survey reported 6.8% and 7.6% prevalence rates of patients with HI and
of HIs, respectively. The high point prevalence found in the intensive care units
(ICU) (12.5%), prompted a national incidence study in 1985. This study found an
incidence of 29.5 HIs per 100 patients in the ICUs: lower respiratory tract
infections (LRTI) were the most common HIs (47.8%), followed by urinary tract
infections (UTI) (19.9%) and blood stream infections (BSI) (4.8%). A 1999 survey
showed that in 463 Italian hospitals only 40.5% had protocols on the use of
disinfectants, 32.3% on sterilization, 30.8% on occupational risk management,
18.3% on isolation measures, 17.7% on hand-washing, 14.3% on antibiotic
prophylaxis in surgery, 9.4% on the prevention of surgical site infections and
8.5% on the management of CVC. A national forum to consider surveillance systems
using standardized definitions and methodologies is urgently needed.
Publication Types:
Review
PMID: 15018466 [PubMed - indexed for MEDLINE]
35: Arch Surg. 2004 Feb;139(2):131-6.
The impact of bedside behavior on catheter-related bacteremia in the intensive
care unit.
Coopersmith CM, Zack JE, Ward MR, Sona CS, Schallom ME, Everett SJ, Huey
WY,
Garrison TM, McDonald J, Buchman TG, Boyle WA, Fraser VJ, Polish LB.
Department of Surgery, Washington University School of Medicine, St Louis, MO,
USA. coopersmithc@msnotes.wustl.edu
HYPOTHESIS: The success of an educational program in July 1999 that lowered the
catheter-related bloodstream infection (CRBSI) rate in our intensive care unit
(ICU) 3-fold is correlated with compliance with "best-practice" behaviors.
DESIGN: Before-after trial. SETTING: Surgical ICU in a referral hospital.
PATIENTS: A random sample underwent bedside audits of central venous catheter
care (n = 187). All ICU admissions during a 39-month period (N = 4489) were
prospectively followed for bacteremia. INTERVENTIONS: On the basis of audit
results in December 2000, a behavioral intervention was designed to improve
compliance with evidenced-based guidelines of central venous catheter management.
MAIN OUTCOME MEASURES: Compliance with practices known to decrease
CRBSI.
Secondary outcome was CRBSI rate on all ICU patients. RESULTS: Multiple
deficiencies were identified on bedside audits 18 months after the previous
educational program. After the implementation of a separate behavioral
intervention in July 2001, a second set of bedside audits in December 2001
demonstrated improvements in documenting the dressing date (11% to 21%; P<.001)
and stopcock use (70% to 24%; P<.001), whereas nonsignificant trends were
observed in hand hygiene (17% to 30%; P>.99) and maximal sterile barrier
precautions (50% to 80%; P =.29). Appropriate practice was observed before and
after the behavioral intervention in catheter site placement, dressing type,
absence of antibiotic ointment, and proper securing of central venous catheters.
Thirty-two CRBSIs occurred in 9353 catheter-days 24 months before the behavioral
intervention compared with 17 CRBSIs in 6152 catheter-days during the 15 months
after the intervention (3.4/1000 to 2.8/1000 catheter-days; P =.40). CONCLUSIONS:
Although a previous educational program decreased the CRBSI rate, this was
associated with only modest compliance with best practice principles when bedside
audits were performed 18 months later. A behavioral intervention improved all
identified deficiencies, leading to a nonsignificant decrease in CRBSIs.
Publication Types:
Comparative Study
Evaluation Studies
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.
PMID: 14769568 [PubMed - indexed for MEDLINE]
36: Paediatr Nurs. 2003 Dec;15(10):14-8.
Central venous access and handwashing: variability in policies and practices.
Galway R, Harrod ME, Crisp J, Donnellan R, Hardy J, Harvey A, Maurice L, Petty S,
Senner A.
University of New South Wales, Sydney Children's Hospital.
GalwayR@sesahs.nsw.gov.au
This study examined variability in handwashing policy between hospitals,
variability in handwashing practices in nurses and how practice differed from
policy in tertiary paediatric hospitals in Australia and New Zealand. Eight of
the possible nine major paediatric hospitals provided a copy of their handwashing
and/or central venous access device (CVAD) policies, and 67 nurses completed a
survey on their handwashing practices associated with CVAD management. A high
degree of variability was found in relation to all the questions posed in the
study. There was little consistency between policies and little agreement between
policies and clinical practice, with many nurses washing for longer than required
by policy. Rigour of handwashing also varied according to the procedure
undertaken and the type of CVAD with activities undertaken farther from the
insertion site of the device more likely to be performed using a clean rather
than an aseptic handwashing technique. As both patients and nursing staff move
within and between hospitals, a uniform and evidence-based approach to
handwashing is highly desirable.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 14705353 [PubMed - indexed for MEDLINE]
37: Nursing. 2003 Nov;33(11):17.
Is your skin-prep technique up-to-date?
Moureau NL.
PICC Excellence, Inc., Hartwell. GA, USA.
PMID: 14650378 [PubMed - indexed for MEDLINE]
38: Am J Infect Control. 2003 Nov;31(7):405-9.
Effect of an infection control program using education and performance feedback
on rates of intravascular device-associated bloodstream infections in intensive
care units in Argentina.
Rosenthal VD, Guzman S, Pezzotto SM, Crnich CJ.
Department of Infectious Diseases and Hospital Epidemiology, Bernal Medical
Center, Buenos Aires, Argentina.
OBJECTIVE: Our aim was to ascertain the effect of an infection control program,
using education and performance feedback on intensive care units, for
intravascular device (IVD)-associated bloodstream infection (BSI). METHODS:
Within 4 level III, adult, intensive care units in Argentina, all admitted, adult
patients with a central vascular catheter in place for at least 24 hours were
included. This was a prospective before-and-after trial in which rates of
IVD-associated BSI determined during a period of active surveillance without
education or performance feedback (phase 1) were compared after sequential
implementation of an infection control program using education (phase 2) and
performance feedback (phase 3). RESULTS: A total of 1219 IVD days were
accumulated in phase 1; 586 during phase 2; and 4140 during phase 3. Compliance
with central vascular catheter--site care improved significantly from baseline
during the study period. Overall rates of IVD-associated BSI were lowered
significantly from baseline after sequential implementation of education and
performance feedback (11.10 vs 46.63 BSI/1000 IVD days; relative risk=0.25; 95%
confidence interval=0.17-0.36; P<.0001). Rates of IVD-associated BSI decreased
significantly after implementation of an educational program (phase 1 to phase 2)
(relative risk 0.37; confidence interval 0.19-0.73; P=.0026) and further
reductions were seen after implementation of a performance feedback program
(phase 2 to phase 3), although the reduction did not reach statistical
significance (9.9 vs 17.06 BSI/1000 IVD days; relative risk 0.58; confidence
interval 0.29-1.18; P=.11). Additional analysis of the data using chi2 for trends
demonstrated that sequential implementation of an education and performance
feedback program resulted in a significant trend toward reduced rates of
IVD-associated BSI (P<.001). CONCLUSION: Implementation of an infection
control
program, using education and performance feedback, resulted in significant
reductions in rates of IVD-associated BSI.
Publication Types:
Multicenter Study
Research Support, Non-U.S. Gov't
PMID: 14639436 [PubMed - indexed for MEDLINE]
39: FEMS Immunol Med Microbiol. 2003 Sep 22;38(2):153-8.
Strict infection control measures do not prevent clonal spread of coagulase
negative staphylococci colonizing central venous catheters in neutropenic
hemato-oncologic patients.
van Pelt C, Nouwen J, Lugtenburg E, van der Schee C, de Marie S, Schuijff P,
Verbrugh H, Löwenberg B, van Belkum A, Vos M.
Department of Medical Microbiology and Infectious Diseases, Erasmus MC,
University Medical Center Rotterdam, Molewaterplein 40, 3015 GD Rotterdam, The
Netherlands.
Coagulase negative staphylococci (CoNS) are a main cause of catheter related
infections (CRI). Earlier studies (1994-1996) revealed a high incidence of CRI (6
per 1000 catheter days) among neutropenic hemato-oncologic patients in the
Erasmus MC Hematology Department (Rotterdam, The Netherlands). This was
mainly
explained by expansion of two methicillin resistant Staphylococcus epidermidis
(MRSE) clones (Nouwen et al., J. Clin. Microbiol. 36 (1998) 2696-2702). In a new,
16-bed unit in the same institution, we investigated the effect of strict
clinical isolation measures on the incidence of CRI. During two 6-month screening
periods (period I: April 1998-December 1998 and period II: April 1999-October
1999) all patients receiving a central venous catheter were prospectively
monitored for the development of CRI. During period I every visitor of the
cubicles had to wear hair caps, masks, gowns and gloves. During period II these
procedures were abolished, but hands were cleansed using alcohol and masks were
worn during both periods in case of coughing and sneezing. All CoNS strains
isolated from blood cultures were genetically classifies by pulsed field gel
electrophoresis (PFGE). The incidence of CRI during period I was 13.0 per 1000
catheter days, in comparison to 9.6 in period II (P=0.84). During this latter
period, 19 CRI were diagnosed, 14 catheter related bacteremia episodes (CRB) and
five local infections. Seventy-two percent (n=9) of CRB were due to a CoNS. The
mean catheter survival until appearance of a CRI increased from 43 days during
period I to 78 days in period II (P=0.39). The mean catheter survival until
infection related removal was increased from 43 days to 133 days (P=0.12). During
period I less experienced intervention radiologists introduced the catheters,
which may have limited the efficacy of the strict hygiene measures. Thus,
abolishing strict isolation precautions had no negative effect on the incidence
of CRI. After genotyping of 38 MRSE strains isolated from blood and central
venous catheter cultures of 12 patients in period II, eight PFGE types were
found. Three types were found in more than one patient, but based on
epidemiological data patient-to-patient spread could not be proven. No genotypic
identity between patient and personnel CoNS isolates was shown and the two major
clonal types that were present between 1994 and 1996 were not encountered.
However, from December 1998 onwards new MRSE clones could be identified
(types E
and J). In conclusion, despite a constant rate of CRI and implementation of
optimal patient care, clonal spread of MRSE strains was not prevented by strict
hygiene measures.
PMID: 13129649 [PubMed - indexed for MEDLINE]
40: Minerva Anestesiol. 2003 Apr;69(4):302-7.
[Infection prevention and control in intravascular devices]
[Article in Italian]
Colombo D, Russolillo C.
Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Luigi Sacco, Polo
Universitario, Milano, Italy.
Intravascular devices (IVD) are indispensable in the care of the critical
patient; even so, their use can be complicated by infection, which is generally
associated with longer hospital stay and ensuing higher hospital costs. It is
therefore imperative that guidelines are applied that constitute a basis of
information upon which the individual facility can develop its own strategy. The
strategy can be outlined under the following points: a) staff training, b)
surveillance of IVD-associated infections, c) hand washing, d) barrier measures
during catheter introduction and management, e) insertion site management and
medication systems for the insertion site, f) choice and replacement of the IVD,
g) replacement of intravenous administration devices and liquids, h)
antimicrobial prophylaxis. In the management of central venous catheters (CVC),
recommendations call for: 1) the use of a single lumen CVC, unless multiple
accesses are needed; 2) the peripheral placement of CVCs, both in the use of
tunneled catheters and/or implantable vascular devices in patients over 4 years
of age in which long-term vascular access (> 30 days) is planned; 3) the use of
completely implantable devices in pediatric patients less than 4 years of age
requiring long-term vascular access; 4) the use of the subclavian artery as the
site of CVC insertion unless clinically contraindicated (e.g. coagulopathy,
anatomic alterations); 5) the application of barrier precautions during CVC
introduction and in the management of the catheter and the insertion site.
Publication Types:
English Abstract
Review
PMID: 12766724 [PubMed - indexed for MEDLINE]
41: Pediatrics. 2003 Apr;111(4 Pt 2):e504-18.
Evaluation and development of potentially better practices to prevent neonatal
nosocomial bacteremia.
Kilbride HW, Powers R, Wirtschafter DD, Sheehan MB, Charsha DS, LaCorte M,
Finer
N, Goldmann DA.
Children's Mercy Hospitals and Clinics, University of Missouri, Kansas City
School of Medicine, Kansas City, Missouri 64108, USA. hkilbride@cmh.edu
OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the
Vermont Oxford National Evidence-Based Quality Improvement Collaborative for
Neonatology collaborated to reduce infection rates. There were 7 centers in the
original focus group, but 1 center left the collaborative after 1 year. The
objective of this study was to develop strategies to decrease nosocomial
infection rates in NICUs. METHODS: The process included a comprehensive
literature review, internal practice analyses, benchmark studies, and development
of practical experience through rapid-cycle changes, subsequent analysis, and
feedback. This process led to 3 summary statements on potentially better
practices in handwashing, approach to nosocomial sepsis evaluations, and central
venous catheter management. RESULTS: These statements provide a basis for an
evidence-based approach to lowering neonatal intensive care unit nosocomial
infection rates. CONCLUSIONS: The 2-year process also led to changes in the
culture and habits of the institutions involved, which should in turn have
long-term effects on other aspects of quality improvement.
PMID: 12671171 [PubMed - indexed for MEDLINE]
42: J Hosp Infect. 2003 Feb;53(2):97-102.
Healthcare-associated outbreak due to pan-drug resistant Acinetobacter baumannii
in a surgical intensive care unit.
Wang SH, Sheng WH, Chang YY, Wang LH, Lin HC, Chen ML, Pan HJ, Ko WJ,
Chang SC,
Lin FY.
Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
Acinetobacter baumannii is ubiquitous and has recently become one of the most
important healthcare-associated (HA) pathogens in hospitals. Infection caused by
this organism often leads to significant morbidity and mortality. Outbreaks of
pan-drug resistant Acinetobacter baumannii (PDRAB) have rarely been reported.
During a two-month period, an outbreak of PDRAB colonization and infection
affecting 7 patients occurred in our surgical intensive care unit (SICU). The
colonized sites were respiratory tract (N = 7) and central venous catheter (N =
2). One of the patients had a surgical wound infection. Extensive environmental
contamination was identified, including sites such as bed rails, bedside tables,
surface of ventilators and infusion pump, water for nasogastric feeding and
ventilator rinsing and sinks. All of the isolates were analysed by pulsed-field
gel electrophoresis (PFGE) and showed an identical pattern. After use of strict
cohort nursing, hand hygiene environmental cleaning, and replacement of a
dysfunctional high-efficiency particulate air filter (HEPA), the outbreak was
controlled. Copyright 2003 The Hospital Infection Society
PMID: 12586567 [PubMed - indexed for MEDLINE]
43: Am J Infect Control. 2002 Dec;30(8):476-89.
Guidelines for the prevention of intravascular catheter-related infections.
O'grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur
H,
McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA;
Healthcare Infection Control Practices Advisory Committee.
Clinical Center, National Institutes of Health, Bethesda, MD, USA.
BACKGROUND: Although many catheter-related bloodstream infections (CR-BSIs)
are
preventable, measures to reduce these infections are not uniformly implemented.
OBJECTIVE: To update an existing evidenced-based guideline that promotes
strategies to prevent CR-BSIs.Data Sources: The MEDLINE database, conference
proceedings, and bibliographies of review articles and book chapters were
searched for relevant articles.Studies Included: Laboratory-based studies,
controlled clinical trials, prospective interventional trials, and
epidemiological investigations.Outcome Measures: Reduction in CR-BSI, catheter
colonization, or catheter-related infection. SYNTHESIS: The recommended
preventive strategies with the strongest supportive evidence are education and
training of healthcare providers who insert and maintain catheters; maximal
sterile barrier precautions during central venous catheter insertion; use of a 2%
chlorhexidine preparation for skin antisepsis; no routine replacement of central
venous catheters for prevention of infection; and use of antiseptic/antibiotic
impregnated short-term central venous catheters if the rate of infection is high
despite adherence to other strategies (i.e. education and training, maximal
sterile barrier precautions and 2% chlorhexidine for skin antisepsis).
CONCLUSION: Successful implementation of these evidence-based interventions
can
reduce the risk for serious catheter-related infection.
Publication Types:
Guideline
Review
PMID: 12461511 [PubMed - indexed for MEDLINE]
44: Anaesth Intensive Care. 2002 Jun;30(3):338-40.
Washing of gloved hands in antiseptic solution prior to central venous line
insertion reduces contamination.
Kocent H, Corke C, Alajeel A, Graves S.
Intensive Care Unit, The Geelong Hospital, Barwon Heath, Victoria.
Glove contamination at the time a central venous catheter is handled is highly
undesirable and likely to increase the risk of subsequent line infection. This
study was designed to determine how frequently gloves become contaminated during
central venous line insertion and to demonstrate the value of glove
decontamination immediately prior to handling of the central venous catheter
During twenty routine internal jugular catheter insertions the sterility of the
operator's gloved fingertips (just prior to handling the intravenous catheter)
was assessed by touching the fingertips onto blood agar plates. The gloved hands
were then rinsed in chlorhexidine/alcohol and after drying were placed onto a
further plate. Contamination was detected in 55% of the prewash plates but in
none of the postwash plates. Procedures performed by less experienced resident
staff had a higher contamination rate despite there being no evident breach of
sterile technique. It is likely that glove contamination results from the
persistance of bacteria within the deeper layers of the skin, despite surface
disinfection. These bacteria may be released by manipulation of the skin when
identifying landmarks. This hypothesis was supported by a subsequent observation
that gloves were more highly contaminated after firm touching of the skin rather
than light touching. Glove contamination during central line insertion is
frequent. Catheter contamination rates could be reduced (without risk or
additional cost) by rinsing gloved hands in a solution of chlorhexidine (0.5%) in
alcohol (70%) prior to handling the catheter.
Publication Types:
Comparative Study
PMID: 12075642 [PubMed - indexed for MEDLINE]
45: Curr Opin Pediatr. 2002 Apr;14(2):157-64.
Prevention of nosocomial infections in the neonatal intensive care unit.
Adams-Chapman I, Stoll BJ.
Department of Pediatrics, Division of Neonatology, Emory University School of
Medicine, Atlanta, Georgia 30322, USA. ira_adams-chapman@oz.ped.emory.edu
Nosocomial infections are responsible for significant morbidity and late
mortality among neonatal intensive care unit patients. The number of neonatal
patients at risk for acquiring nosocomial infections is increasing because of the
improved survival of very low birthweight infants and their need for invasive
monitoring and supportive care. Effective strategies to prevent nosocomial
infection must include continuous monitoring and surveillance of infection rates
and distribution of pathogens; strategic nursery design and staffing; emphasis on
handwashing compliance; minimizing central venous catheter use and contamination,
and prudent use of antimicrobial agents. Educational programs and feedback to
nursery personnel improve compliance with infection control programs.
Publication Types:
Review
PMID: 11981284 [PubMed - indexed for MEDLINE]
46: Clin Microbiol Infect. 2001;7 Suppl 4:91-9.
Nonantibibiotic measures for the prevention of Gram-positive infections.
Eggimann P, Pittet D.
Medical Intensive Care Unit, Department of Internal Medicine, University of
Geneva Hospitals, Switzerland. philippe.eggimann@hcuge.ch
While Gram-negative bacteria remain a leading cause of nosocomial infections such
as ventilator-associated pneumonia and catheter-associated urinary tract
infections, Gram-positive cocci are now responsible for a large majority of
surgical site and bloodstream infections. A shift has occurred during the last
decade and multidrug-resistant micro-organisms have become predominant in most
referral centers. Severe infections with Gram-positive micro-organisms such as
methicillin-resistant Staphylococcus aureus, coagulase-negative staphylococci,
vancomycin-resistant enterococci, penicillin-resistant Streptococcus pneumoniae
and, more recently, glycopeptide intermediate S. aureus are now regularly
reported to be associated with increased morbidity and represent a true health
problem in many institutions. The importance of nonantimicrobial measures to
prevent infections and further spread is reviewed in this paper. New evidence of
the effectiveness of basic infection control measures that have been regarded of
little importance during the last two decades by the exponential progress of
technologically sophisticated medicine, is discussed.
Publication Types:
Review
PMID: 11688540 [PubMed - indexed for MEDLINE]
47: Crit Care Nurs Clin North Am. 2000 Jun;12(2):165-74.
Risks and complications of peripherally and centrally inserted intravenous
catheters.
Schmid MW.
School of Nursing, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin,
USA.
Increased nursing vigilance is needed while caring for critically ill patients
who have i.v. catheters. All i.v. sites should be selected based upon the i.v.
therapy needs of the patient, using the shortest catheter and smallest size
possible to meet the treatment needs of the patient while avoiding excessive
repeated insertions of peripheral IVs. Meticulous handwashing, site preparation,
and the use of sterile technique during insertion and maintenance are essential
to minimize the risk of infection. Use multilumen catheters only when necessary
because these catheters have an increased manipulation and associated infection
risk. Observe for signs and symptoms of localized, systemic, mechanical, and
metastatic (e.g., vertebral osteomyelitis and endocarditis) foci of infection.
Additionally, remove all unnecessary or poorly performing i.v. catheters. I.v.
sites that do not yield a blood return but will accept i.v. solutions are in the
process of becoming occluded. Most likely, there is a fibrin sheath that is
developing along the catheter's inner lumen and opening, decreasing the
catheter's effectiveness. Accommodate the need to replace a catheter into the
patient's plan of care rather than allowing the catheter to occlude and then
replacing it under emergent or rushed conditions.
Publication Types:
Review
PMID: 11249361 [PubMed - indexed for MEDLINE]
48: J Hosp Infect. 2001 Jan;47 Suppl:S3-82.
Comment in:
J Hosp Infect. 2001 Aug;48(4):320-1. J Hosp Infect. 2001 Jul;48(3):242-3. J
Hosp Infect. 2001 Oct;49(2):145-6. J Hosp Infect. 2005 Apr;59(4):375-6.
The epic project: developing national evidence-based guidelines for preventing
healthcare associated infections. Phase I: Guidelines for preventing
hospital-acquired infections. Department of Health (England).
Pratt RJ, Pellowe C, Loveday HP, Robinson N, Smith GW, Barrett S, Davey P,
Harper
P, Loveday C, McDougall C, Mulhall A, Privett S, Smales C, Taylor L, Weller B,
Wilcox M; Department of Health (England).
Richard Wells Research Centre, Wolfson Institute of Health Sciences, Thames
Valley University, London. robert.pratt@tvu.ac.uk
In 1998, the Department of Health (England) commissioned the first phase of
national evidence-based guidelines for preventing healthcare associated
infections. These focused on developing a set of standard principles for
preventing infections in hospitals together with guidelines for preventing
hospital-acquired infections (HAI) associated with the use of short-term
indwelling ureteral catheters in acute care and with central venous catheters in
acute care. These guidelines are systematically developed broad statements
(principles) of good practice that all practitioners can use and which can be
incorporated into local protocols. A nurse-led, multi-professional team composed
of infection prevention practitioners, clinical microbiologists/retrovirologist,
epidemiologists, and researchers developed the guidelines. A rigorous guideline
development process was used to inform the systematic reviews, the clinical and
critical appraisal of relevant evidence, and linking that evidence to evolving
guidelines. Both general and specialist clinical practitioners were involved in
all stages of developing these guidelines, as were representatives from relevant
Royal Colleges, learned societies, other professional organisations and key
stakeholders. The introduction to these guidelines describes a robust and
validated guideline development model that can be used by others to develop
future guidelines. This model is described in more detail in the associated
technical reports that can be found on the project web site
http://www.epic.tvu.ac.uk. Locating and appropriately using good quality evidence
to inform guideline development in this field is challenging. Evidence from
rigorously conducted experimental studies was frequently limited and consequently
a range of other types of evidence were systematically retrieved and carefully
appraised. The concluding discussion on implementation highlights potential
issues for clinical governance and areas for future research and suggests issues
that need to be addressed to allow practitioners to successfully incorporate
these guidelines into routine clinical practice.
Publication Types:
Guideline
Practice Guideline
Research Support, Non-U.S. Gov't
PMID: 11161888 [PubMed - indexed for MEDLINE]
49: Postgrad Med J. 2001 Jan;77(903):16-9.
The health professional's role in preventing nosocomial infections.
Saloojee H, Steenhoff A.
Department of Paediatrics and Child Health, University of the Witwatersrand, PO
Wits, Johannesburg 2050, South Africa.
Despite their best intentions, health professionals sometimes act as vectors of
disease, disseminating new infections among their unsuspecting clients. Attention
to simple preventive strategies may significantly reduce disease transmission
rates. Frequent hand washing remains the single most important intervention in
infection control. However, identifying mechanisms to ensure compliance by health
professionals remains a perplexing problem. Gloves, gowns, and masks have a role
in preventing infections, but are often used inappropriately, increasing service
costs unnecessarily. While virulent microorganisms can be cultured from
stethoscopes and white coats, their role in disease transmission remains
undefined. There is greater consensus about sterile insertion techniques for
intravascular catheters-a common source of infections-and their care. By
following a few simple rules identified in this review, health professionals may
prevent much unnecessary medical and financial distress to their patients.
Publication Types:
Review
PMID: 11123387 [PubMed - indexed for MEDLINE]
50: Ann Intern Med. 2000 Dec 19;133(12):974-80.
Update in critical care medicine.
Fromm R Jr, Guntupalli K.
Emergency Medicine, Methodist Hospital, 6565 Fannin Street, Room 196, Houston,
TX
77030, USA.
Publication Types:
Review
PMID: 11119399 [PubMed - indexed for MEDLINE]
51: Lancet. 2000 May 27;355(9218):1864-8.
Impact of a prevention strategy targeted at vascular-access care on incidence of
infections acquired in intensive care.
Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D.
Department of Internal Medicine, University of Geneva Hospitals, Switzerland.
BACKGROUND: Intravascular devices are a leading cause of nosocomial infection.
Specific prevention strategies and improved guidelines for the use of
intravascular devices can decrease the rate of infection; however, the impact of
a combination of these strategies on rates of vascular-access infection in
intensive-care units (ICUs) is not known. We implemented a multiple-approach
prevention programme to decrease the occurrence of vascular-access infection in
an 18-bed medical ICU at a tertiary centre. METHODS: 3154 critically ill
patients, admitted between October, 1995, and November, 1997, were included in a
cohort study with longitudinal assessment of an overall catheter-care policy
targeted at the reduction of vascular-access infections and based on an
educational campaign for vascular-access insertion and on device use and care.
Incidence of ICU-acquired infections was measured by means of on-site
surveillance. FINDINGS: 613 infections occurred in 353 patients (19.4 infections
per 100 admissions). The incidence density of exit-site catheter infection was
9.2 episodes per 1000 patient-days before the intervention, and 3.3 episodes per
1000 patient-days afterwards (relative risk 0.36 [95% CI 0.20-0.63]).
Corresponding rates for bloodstream infection were 11.3 and 3.8 episodes per 1000
patient-days, respectively (0.33 [0.20-0.56]) due to decreased rates of both
microbiologically documented infections and clinical sepsis. Rates of respiratory
and urinary-tract infections remained unchanged, whereas those of skin or
mucous-membrane infections decreased from 11.4 to 7.0 episodes per 1000
patient-days (0.62 [0.41-0.93]). Overall, the incidence of nosocomial infections
decreased from 52.4 to 34.0 episodes per 1000 patient-days (0.65 [0.54-0.78]).
INTERPRETATION: A multiple-approach prevention strategy, targeted at the
insertion and maintenance of vascular access, can decrease rates of
vascular-access infections and can have a substantial impact on the overall
incidence of ICU-acquired infections.
Publication Types:
Comparative Study
Research Support, Non-U.S. Gov't
PMID: 10866442 [PubMed - indexed for MEDLINE]