Open to CLOSED

System

Dr. Jayant R. Giri MD

Associate Director – Clinical Services

April 11th , 2018

JAKARTA,
Today, we’ll talk about!
Sources of Infections
 Microbiology of the Skin

 80% of the resident bacteria exist

within the first 5 layers of the
stratum corneum

 20% are found in biofilms

within hair follicles and sebaceous
glands

©ETHICON, Inc 2005

Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice
Nursing eJournal. 2005;5(3) Posted 08/18/2005 . http://www.medscape.com/viewarticle/508109.
RISK along the IV Therapy Continuum
 Microbial Source of CrBSIs

EXTRALUMINAL COLONIZATION INTRALUMINAL COLONIZATION

Hub
Catheter

Skin
Skin

Vein

Extraluminal biofilm is the major source Intraluminal biofilm is the major source of
of CLA-BSI within the first week of CLA-BSI after 1 week in both short- and
catheterization in short-term catheters. long-term catheters.

Extraluminal biofilm is the major source

of tunnel infections in long-term
catheters.

Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing
eJournal. 2005;5(3) ©2005 Medscape. Posted 08/18/2005 . http://www.medscape.com/viewarticle/508109.
Air and Road Accidents
• Most published studies focus on thrombophlebitis and address the issue of scheduled
catheter change.

• Although PVC-associated catheter-related bloodstream infections (PVC-BSI) are far

more serious than thrombophlebitis.

• Current data available on PVC-BSI suggest incidence density rates of 0.2–0.7

episodes per 1000 device days
PVC - BSI

• Although rates are low, especially when compared

with central venous lines,
• Studies have reported that absolute PVC-BSI numbers
may approach absolute CLABSI rates outside the ICU.
• The finding of low rates but high absolute numbers,
raises the question of whether PVC-BSI can be
neglected.
• (looking at the high absolute numbers). If the number
of absolute PVC-BSI episodes is indeed as high as
CLABSI episodes
 A Review of 200 Published Studies

Mayo Clin Proc. • September 2006;81(9):1159-1171 • www.mayoclinicproceedings.com

Rates of IVCs – Related BSI’s

# bloodstream infections
Per 100 catheters Per 1000 catheter days
Type of catheter Mean 95% CI Mean 95% CI
Peripheral IV 0.2 0.1 – 0.3 0.6 0.3 – 1.2
Arterial 1.5 0.9 – 2.4 2.9 1.8 – 4.5
Short -term CVC 3.3 3.3 – 4.0 2.3 2.0 – 2.4
Pulmonary artery 1.9 1.1 – 2.5 5.5 3.2 – 12.4
Hemodialysis
Noncuffed 16.2 13.5 – 18.3 2.8 2.3 – 3.1
Cuffed 6.3 4.2 – 9.2 1.1 0.7 – 1.6
PICC 1.2 0.5 – 2.2 0.4 0.2 – 0.7
Long -term CVC 20.9 18.2 – 21.9 1.2 1.0 – 1.3
Implanted port 5.1 4.0 – 6.3 0.2 0.1 – 0.2

Mayo Clin Proc. • September 2006;81(9):1159-1171 • www.mayoclinicproceedings.com

How to Prevent?
Lifecycle of an Intra-Venous Line

Diagnostics
&
Treatment

Prevention Removal Insertion SEPSIS!

Patient
Catheter complications
Care
Bundles Resistant
MDRO’s

Maintenance Limited
Antibiotics
Options
Lifecycle of an Intra-Venous Line

Diagnostics
&
Treatment

Prevention SEPSIS!
Removal Insertion
Patient
Catheter complications
Care
Bundles Resistant
MDRO’s
Limited
Maintenance Antibiotics
Options
Insertion and Maintenance
Catheter Care Bundles
Bundle

Institute for Healthcare Improvement (IHI)

describes a “Bundle” as “Group of best
practices that individually improve care, but
when applied Together result in substantially
Greater improvement.”
INICC Care Bundles

• Expert reviewed – 26
co-authors from 22
emerging countries

• Elaborates on all
vascular access lines

• Comprehensive and
latest (2017)

http://www.inicc.org
 Care bundles have two (2) components

BEHAVIOR TECHNOLOGY
1. Clorhexidine skin antisepsis
1. Hand hygiene 6. 7. Don’t Replace CL /
2. Use single use device for
PL at fixed intervals
2. Maximal barrier flushing
precautions upon 7. 8. Scrub and disinfect
catheter hub, ports 3. Sterile chlorhexidine
insertion
and needleless impregnated dressing at
3. Optimal catheter site connectors insertion site
selection, with
avoidance of the 8. 9. Replace IV 4. Needleless connectors as IV
femoral vein for CV administration sets connection devices
access in adult every 96 hs
5. PL with integrated extension
patients 9. 10. Don’t use of and needleless access ports
4. Sterile dressings to multi-dose vials as
cover the VAD source for flushing 6. Closed IV fluid containers
insertion site and locking
7. Daily bath with 2%
5. Remove CL / PL when chlorhexidine-impregnated
is not needed wash cloth in patients with CL
Care Bundle to Prevent Central Line
Associated BSIs (CLABSI)
Insertion
1. Hand Hygiene Before Insertion
2. Max precaution barrier
3. Chlorhexidine skin antisepsis
4. Avoid Femoral as Insertion site
5. Assess need of Catheter
6. Presence of sterile dressing
7. Good condition of dressing
8. Chlorhexidine Impregnated dressing
9. Administration set with date
10. Closed System Needle Free IV Set Connector
11. Collapsible IV Container
Maintenance
1. Hand Hygiene Before Manipulation
2. Use Aseptic Technique
3. Chlorhexidine skin antisepsis
4. Assess need of Catheter
5. Don’t Routinely Replace it
6. Presence of sterile dressing
7. Good condition of dressing
8. Chlorhexidine Impregnated dressing
9. Scrub and Disinfect Catheter Hub, Ports and
Needle Free connectors
10. Administration set with date
11. Closed System Needle Free IV Set Connector
12. Collapsible IV Container
13. Single Use Flushing
14. Daily bathing with a 2% chlorhexidine-
impregnated washcloth
Components of Bundle to prevent Peripheral
Line Associated BSI (PLABSI)
Insertion
1. Hand Hygiene Before Insertion
2. Use Appropriate Personal Protective
Equipment and Aseptic Technique
3. Chlorhexidine skin antisepsis
4. Check if Catheter is necessary
5. Insertion Place and Type of Catheter with
lowest risk
6. Presence of sterile dressing
7. Good condition of dressing
8. Closed System Needle less IV Set Connector
9. Collapsible IV Container
10. Administration set with date
Maintenance
1. Hand Hygiene Before Manipulation
2. Use Appropriate Personal Protective Equipment
and Aseptic Technique
3. Chlorhexidine skin antisepsis
4. Check if Catheter is necessary
5. Don’t Replace it Routinely
6. Presence of sterile dressing
7. Good condition of dressing
8. Scrub and Disinfect Catheter Hub, Ports and
Needle-less Connectors
9. Closed System Needle less IV Set Connector
10. Collapsible IV Container
11. Single Use Flushing
12. Administration set with date
 Clinical Evidence

BEHAVIOR TECHNOLOGY
 JUL
2014
JOURNAL OF
PEDIATRICS -
OCT 2012
 INICC Care Bundles to Prevent Central and Peripheral
Line-Related Bloodstream Infections

• Use VAD systems that minimize manipulations and reduce components (PLs
with integrated extension and needleless access ports)
• Closed catheter access systems are associated with fewer infections than
open systems and should be used preferentially
Peripheral
catheter

integrated extension
and needleless
access ports

*International Nosocomial Infection Control Consortium (INICC)

http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
INICC Care Bundles to Prevent Central and
Peripheral Line-Related Bloodstream Infections
• Integration of Needleless Connectors as IV Connection Devices
(quality of evidence: II)2, 79, 80, 87, 105-108, 185, 240-244
• “Three Ways Stopcocks” should be avoided, as they represent a potential
portal of entry for microorganisms into vascular access catheters and IV
fluids.
• Use needleless connectors (NC) as IV connection devices.2, 87, 105-108, 185, 240-243
• Avoid three way-stop cocks as IV connection devices.2, 87, 185, 240-243, 252
• Disinfect NC prior to each entry into the device.
• Access NC connectors only with a sterile device.2, 87, 185, 240-243, 252
• Consider the use of an extension set between the line and needleless
connector to reduce line manipulation.239

*International Nosocomial Infection Control Consortium (INICC)

http://www.jointcommission.org/preventing_clabsi/. Accesed on August 12th 2012
INICC Care Bundles to Prevent Central and
Peripheral Line-Related Bloodstream Infections

• Scrub and Disinfect Catheter Hub, Ports and Needleless Connectors (quality of
evidence: II)1-4, 185, 253-266
• A single-use application 70 % isopropyl alcohol alone or with 2 % chlorhexidine
gluconate (or povidone iodine in alcohol for patients with sensitivity to
chlorhexidine) should be used to decontaminate the access port, catheter hub, and
needleless connectors.
• The access port, catheter hub, and needleless connectors should be cleaned for a
minimum of 15 seconds and allowed to dry before accessing the system.

*International Nosocomial Infection Control Consortium (INICC)

JAN
2014
Products overview: NC+SUF vs. 3 WSC
Closed IV system Open IV system
Needle Less Connector (NCs) Three-Way Stopcocks (3WSC)
• Simple needleless • A valve or tuning plug that
connector with a pre- controls the flow of fluid from a
pierced septum that container through a tube. Open
can be of a blunt to the air when the cover is not
cannula or luer-lock in place
design

Single-use Prefilled Flushing Devices Multiple use Container with

(SUF) manual admixture (MUC)
• A prefilled • A 100 to 500 ml
single use vial container as a
for IV lines common source of
when drugs are fluids
not compatible

Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock
on central line-associated bloodstream infection rates in India: a randomized clinical trial. Am J Infect Control 2015;43:1040-5
 Study Overview

Study Design:
• A Randomized controlled trial (RCT)
• 5 ICUs of 2 centers, 2 Cities in India;

Outcomes:
• Clinical impact and cost effectiveness analysis

Patient Groups:
• 1,096 ICU adult patients those needed a central line

Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock
on central line-associated bloodstream infection rates in India: a randomized clinical trial. Am J Infect Control 2015;43:1040-5
 CLABSI rate
Cost Effectivennes Analysis:
For each US$ 1 invested
US$ 124 were saved
CLABSI Rate per 1000 CL-days CLABSI Rate per 100 patients, %
7.00 5 4.7
6.40
4.5
6.00
4
5.00 RR: 0.35 3.5 RR: 0.31

CLABSI Rate (%)

CLABSI x 1000 CL-days

P value: 0.006 P value: 0.002

3
4.00
2.5
3.00 2
2.21 1.5
1.5
2.00
1
1.00 0.5
0
0.00 SS+SUF Group 3 WSC Group
SS+SUF group 3WSC group
CLABSIs per 1000 CL- CLABSI rate per 100
2.21 6.40 1.5 4.7
days, n patients, %

CLABSI incidence rate is significantly lower in NC + SUF group than in 3WSC + MUC group

Rosenthal VD, Udwadia FE, Kumar S, et al. Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock
on central line-associated bloodstream infection rates in India: a randomized clinical trial. Am J Infect Control 2015;43:1040-5
INICC Care Bundles to Prevent Central and Peripheral
Line-Related Bloodstream Infections

• Use Sterile Dressings to Cover the VAD Insertion Site (quality of evidence: I)1-4, 185, 245-248
• Sterile transparent, semi-permeable polyurethane dressings (with or without
chlorhexidine) should be routinely changed every 7 days, or sooner, if they are no
longer intact or if moisture collects under the dressing.1-4, 185
• Use sterile gauze if a patient has profuse perspiration or if the VAD insertion site is
bleeding or leaking, and change when inspection of the insertion site is necessary
or when the dressing becomes damp, loosened or soiled.
• Replace sterile gauze with a transparent semi-permeable dressing as soon as
possible.4
• Sterile gauze dressings should be routinely changed every 2 days, or sooner, if they
are no longer intact or if moisture collects under the dressing.1-4, 185

*International Nosocomial Infection Control Consortium (INICC)

 CHG impregnated dressings

• Consider the use of a chlorhexidine

impregnated sponge dressing or
chlorhexidine-impregnated transparent
dressing in adult patients.1-4, 75, 185, 249-251
• Randomized controlled trials evaluating the efficacy of a
chlorhexidine-impregnated dressing compared with
conventional dressings for prevention of catheter
colonization and catheter-related bloodstream infection.
• Use of a chlorhexidine-impregnated dressing resulted in a
reduced prevalence of catheter-related bloodstream
infection (random effects relative risk, 0.60; 95% CI, 0.41-
0.88, p = 0.009).
• The prevalence of catheter colonization was also markedly
reduced in the chlorhexidine-impregnated dressing group
(random effects relative risk, 0.52; 95% CI, 0.43-0.64; p <
0.001).
Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-
analysis*. Safdar et al. Crit Care Med. 2014 Jul;42(7):1703-13
 JUL
2014
INICC Care Bundles to Prevent Central and Peripheral
Line-Related Bloodstream Infections

• Flushing and Locking of VADs

• Use single-dose systems (eg, single-dose vials or prefilled labeled syringes) for
all VAD flushing and locking.
• Do not use intravenous (III) solution containers (eg, bags or bottles) as a
source for obtaining flush solutions.5, 106, 175, 200, 201 (III)
• Prefilled syringes may reduce the risk of CR-BSI and save staff time for
syringe preparation.5, 106, 267, 268 (III)

• Perform disinfection of connection surfaces

(i.e., needleless connectors, injection ports)
before flushing and locking procedures.
• Flush all VADs with preservative-free 0.9%
sodium chloride (USP).

JANUARY 1st 2017 Copyright © 2017 International Nosocomial Infection Control Consortium (INICC)
Single use flushing device is
recomended by following Gudeilines

* CDC 2011. Center for Diseases Control

* JCI 2012. Joint Commission International
* JCAHO 2015. Joint Commission on
Accreditation of Healthcare Organizations
* INS 2016. Infusion Nurse Society
* INICC 2017. International Nosocomial
Infection Control Consortium
 Single use flushing device

• Contamination rates when saline is

drawn up manually
• 8% (Calop1)
• 7.8% (Trautmann2)
• 6-16% (Slucki3)
• Hepatitis C in the (multi-dose) vial.
A report from a children’s cancer
ward in Malmo, Sweden 3

1- Calop J, Bosson J, Croize J, Laurent P. Maintenance of peripheral and central intravenous infusion devices by 0.9%
sodium chloride with or without heparin as a potential source of catheter microbial contamination. J Hosp Infect.2000;
46:161-162
2- Trautmann M, Zauser B, Wiedeck H. Bacterial colonisation and endotoxin contamination of intravenous infusion
fluids. J Hosp Inf 1997;37:225-236.
3.- Stucki C et al. Am J Health Syst Pharm 2009;56:2032-6.
4- Widell A, et al. Epidemiologic and molecular investigation of outbreaks of hepatitic C virus infection on a pediatric
oncology service. Ann Int Med 1999; 130:130-134.
MAY
2013
 Performance Improvement
Use hospital-specific or collaborative-based performance
improvement initiatives in which multifaceted strategies are
"bundled" together to improve compliance with evidence- based
recommended practices.
- Category IB
1. Rosenthal. 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. Am J Infect Control. 2003 Nov;31(7):405-9.
2. Rosenthal. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico.
Crit Care Med. 2005 Sep;33(9):2022-7
3. Rosenthal. Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care
units of 15 developing countries. Infect Control Hosp Epidemiol 2010;31:1264-72.
4. Rosenthal. Impact of a Multidimensional Infection Control Strategy on Central Line-Associated bloodstream Infections Rates in Pediatric Intensive Care Units of Five
Developing Countries: Findings of the International Nosocomial Infection Control Consortium (INICC). Infection 2012.
5. Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of
infections acquired in intensive care. Lancet 2000; 355:1864–8.
6. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725–32.
7. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004; 32:2014–20.
8. Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora TJ, Laussen PC. Systematic intervention to reduce central line-associated bloodstream infection rates
in a pediatric cardiac intensive care unit. Pediatrics 2008; 121:915–23.
9. Frankel HL, Crede WB, Topal JE, Roumanis SA, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of
catheter-related bloodstream infections in a surgical ICU. J Am Coll Surg 2005; 201:349–58.
10. Galpern D, Guerrero A, Tu A, Fahoum B, Wise L. Effectiveness of a central line bundle campaign on line- associated infections in the intensive care unit. Surgery 2008;
144:492–5; discussion 495.
11. McKee C, Berkowitz I, Cosgrove SE, et al. Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality. Pediatr Crit Care
Med 2008; 9:40–6.
12. Pronovost PJ, Berenholtz SM, Goeschel CA. Improving the quality of measurement and evaluation in quality improvement efforts. Am J Med Qual 2008; 23:143–6.
Summary
• CRBSI – Catheter Related Blood Stream Infections
• CaRe - Bundles Stop Infections
• Bundles has two elements
• Behavior and Technology
• Closed systems are preferred
• Proven with clinical data
• When adopting technology
• Review scientific data
• Cost-effectiveness
• Patients Safety!