ESSENTIAL PRE-REQUISITE FOR

CENTRAL-LINE ASSOCIATED
INFECTIONS (CLABSI) PREVENTION
Anucha Apisarnthanarak, M.D.
Division of Infectious Diseases
Thammasat University Hospital
Pratumthani, Thailand
OUTLINES
 Guidelines and Recommendations

 Implementation Gaps

 What pre-requisites are needed?

GUIDELINES AND RECOMMENDATIONS
 JCI RECOMMENDATIONS
CVC insertion CVC maintenance bundle
o Hand hygiene before  Catheter locked solution
catheter insertion  Disinfect the catheter hubs
o Use of full barrier or connector
precautions  CHG bahting
o Chlorhexidine skin
preparation
o Avoidance of the femoral
vein for inserting CVCs
(except in children)
o Prompt removal of CVCs
ROLE OF TECHNOLOGY

 Use antibiotic/antimicrobial impregnated catheters, if duration

of catheterization was anticipated to be 1-3 weeks.

 Use of CHG-impregnated dressing for temporary short-term

catheter, if CLABSI rates fail to decline despite successful
adherence to basic measure.
SHEA RECOMMENDATIONS
Before insertion
 Provide easy access to
indication of CVC (III)
 Education (II)
 Bath ICU patients with
CHG (I)
At insertion
 Checklist (II)
 Hand hygiene (II)
 Avoid femoral vein (I)
 Use of catheter kits (II)
 Use of MSB (II)
 Use >0.5% alc-CHG (I)
After insertion
 Adequate nurse-to-patient
ratio (I)
 Disinfect catheter hub (II)
 Remove non-essential
catheter (II)
 Change transparent dressing
and performed site care with
CHG-based antiseptic q5-7
days (II)
 Use of antibiotic ointment
for dialysis catheter (I)
 Perform CLABSI
surveillance (I)
SPECIAL APPROACHES
Antiseptic/antibiotic  CHG containing dressing
impregnated catheter for CVC in pts> 2mo (I)
 Units that had CLABSI rates  Use of antiseptic
above the goal, despite good containing hub (I)
compliance to basic measure  Use of antibiotic lock for
 Pt w limited access or CVC (I)
history of recurrent CLABSI
 Pt w high risk of severe
sequelae (e.g, graft,
prosthesis valave)
UNRESOLVED ISSUES
APSIC GUIDELINE FOR CLABSI PREVENTION!
IMPLEMENTATION GAP!
Only 38% of those that monitor bundle implementation reported full compliance!
PRE-REQUISITE
Education, Implementation Science, Monitor Process and
Feedback
THE ROLE OF LEADERSHIP
ROLE OF LEADERSHIP IN DEVELOPING
COUNTRY…
 During January 2010-October 2010, 254 tertiary
care centers in Thailand were surveyed on Infection
Control Processes on 3 main sites (CA-BSI, CA-
UTI, VAP).

 Using TRIP 5 survey tool that was previously

validated by Sanjay Saint and colleagues, we send
people to interview chief of IC in 254 hospitals.

 204 hospitals response to our survey

Apisarnthanarak A, et al. National survey of practices to prevent HAIs. ICHE 2012
Bundle was performed in only 6%
 FOLLOW-UP NATIONAL SURVEY 2014
(UNDER PREPARATION)
Predictors for practice
Frequency (%)
CLABSI practice
80.00%
Variables aOR Factor P
70.00%
73.60%
60.00% Use of CHG 2.1 Have ID specialist 0.02
antiseptic

50.00% 63.20%
Use of MSB 1.7 Have ID specialist 0.06
40.00%
Have Hospital Epi 0.05
58%

30.00% Routine change CVC 1.06 No. of bed 0.05

48.60%

20.00%

Use CHG Antiseptic 3.3 Have ID Specialist 0.02

10.00% 20% Dressing 2.7 Involve in collaborative 0.004
3.03 Support from leader 0.03
0.00%
Use of Use of Avoid Use of Routine Avoid femoral site 1.9 Have ID specialist 0.02
CHG MSB femoral CGH change of 2.3 Involve in collaborative 0.002
Antiseptic site CVC
 ANALYSIS OF BUNDLE COMPONENTS
 Overall, 34% of hospital implement all CLABSI care bundle.
 Predictors for successful CLABSI reduction
- Have ID specialist (P=0.0007)
- Involve in collaborative network (P=0.0005)
- Support from leadership (P=0.03)
- Lead IP certified in IC training (P=0.003)
 De-construct CLABSI care bundle
Bundle Component Reduction 95% CI Reduethen P
Use of CHG antiseptic 130% 60%-204% 0.002

Anti-microbial dressing with CHG 103% 41%-165% 0.01

Avoid femoral site inserting 120% 58%-183% 0.002

High compliance to all bundle component 185% 65%-278% <0.001

(>90%)
 Leadership: At All Levels

• Applies not only to the Director…

• Examples: Infection preventionists, charge

nurses, hospital epidemiologists, hospitalists,
patient safety officers, CMOs, intensivists,
nurse managers…

• Works well with other disciplines

ANOTHER FACILITATOR:
COLLABORATION
 Ensuring the support of the boss

 Spotlighting an issue

 Identifying a champion within the

organization

 Implementing “bundles”
CHAMPION?
VDO Clip
 IDENTIFYING THE “CHAMPION”

 Successful champions tend to be intrinsically

motivated and enthusiastic about the practices
they promote. Even when broad implementation
is stymied, champions can implement change
within their own sphere of influence.

(Damschroder et al., Qual and Safety in Healthcare 2009)

THE ROLE OF CHAMPION IN INFECTION
PREVENTION

“It was possible for a single well-placed champion to

implement a new technology, but more than one champion was
needed when an improvement required people to change
behaviours. Although the behavioural change itself may
appear to be inexpensive and simple, implementation was
often more complicated than changing technology because
behavioural changes required interprofessional coalitions
working together. Champions in hospitals with low-quality
working relationships had a challenging time implementing
behavioural change.”

(Damschroder et al., Qual and Safety in Healthcare 2009)

CONCLUSIONS
 Several CLABSI guidelines have been available and
Infection Preventionist need to adopt, adapt and
implement the guideline to fit the institutional culture.
 Understand factors associated with success or failure to
implement CLABSI bundles may be important to
improve your program.
 Basic pre-requisite for successful program include:
education, implementation, feedback, leadership (at all
levels), collaboration and champion.
Thank you!
Anucha Apisarnthanarak
SUBOPTIMAL PRACTICES STILL
COMMONLY SEEN

Rosenthal VD. CID 2009

Unneccessary and Protective factor Adjusted odds ratio P
suboptimal practice (95%confidence interval)

Not disinfecting connectors Having a designated CVC insertion team 0.17)0.06-0.49) 0.001
/hubs before accessing

Use of multi-dose vial Having a designated CVC insertion team 0.40(0.17-0.95) 0.04

Use of PICC 0.37(0.18-0.75) 0.006

Participation in a collaorative prevention effort 0.26(0.11-0.60) 0.002

Use of central venous cutdown Having Infection Diseases-trained ICC Chair 0.18(0.08-0.40) <0.001

Having a designated CVC insertion team 0.26(0.11-0.61) 0.002

Use of PICC 0.36(0.17-0.78) 0.009

Good to excellent infection control support 0.13(0.03-0.53) 0.004

Use of 3-way stopcock Having Infection Diseases-trained ICC Chair 0.18(0.08-0.40) <0.001

Having a designated CVC insertion team 0.30(0.13-0.70) 0.005

Use of PICC 0.47(0.21-1.04) 0.06

Having a hospital epidemiologist 0.28(0.10-0.81) 0.02

Routine submission of catheter Having Infection Diseases-trained ICC Chair 0.12(0.04-0.32) <0.001

tip for culture Having a designated CVC insertion team 0.18(0.06-0.52) 0.002

Use of PICC 0.16(0.06-0.48) 0.001

Good to excellent infection control support 0.14(0.02-0.96) 0.04

Routine central venous catheter None --- ---

change

Apisarnthanarak A, et al. A national survey of suboptimal and unnecessary IC practices AJIC 2013
UNDERSTAND MORE ABOUT
BEHAVIORAL SCIENCE
Area that need more studies
 Behavioral Science
 The behavior Theorem
The Transtheoretical Model of Health Behavior Change (TTM)
Termination
Maintenance
Action
Preparation
Contemplation
Precontemplation
 Hand Hygiene Compliance Differential by
Stage of Change

Hand hygiene compliance by TTM Stages of Change

Compliance to five
moments hand
hygiene (mean; %)

90 83.5 84.4
80 73.5
71.5 Observed
70 64.7
hand hygiene
60 compliance
50 P = 0.04
40
28.4 Self-reported
30 hand hygiene
20 16.7 compliance
11.1
7.6 P = 0.01
10
0
0
Precontemplation Contemplation Preparation Action Maintenance
Stage of Change
 Evidence-Based Practice of
CLABSI and Bundle Approach

Wang-Huei Sheng
Center of Infection Control &
Division of Infectious Diseases
National Taiwan University Hospital
Outlines
 Impact of CLABSI
 CLABSI Bundle care: elements &
evidences
 Cost-benefits of CLABSI bundle care
 Experiences of CLABSI bundle
promotion at NTUH
 Impact of Catheter-associated
Bloodstream Infections
In US:
• CLABSI: 350,000 patients per year
• Mortality rate: 12% to 25%
• Extra-hospital stay: 5 to 20 days per CLABSI
• Extra-costs: $34,000- $56,000 per CLABSI
• Annual costs: $2.3 billion
Stone PW, et al. Am J Infect Control. 2005;33:542-547.
Perencevich EN, et al. Infect Control Hosp Epidemiol 2007; 28:1121-33.

In Taiwan: CLABSI prolong 15 days of hospital stay and

has 4800 USD extra-cost per event.
Sheng WH, et al. J Hosp Infect 2005;59:205-14.

• More than 50% of CLABSI may be preventable.

Harbarth S, et al. J Hosp Infect. 2003;54:258-266.
Incidence and Cost of HAI, US data

Magill SS, et al. N Engl J Med. 2014;370:1198-1208.

Sievert DM, et al. NHSN data. Infect Control Hosp Epidemiol. 2013;34:1-14.
 Preventing Central Line–Associated Bloodstream
Infections: A Global Challenge, A Global Perspective

http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf
 Factors with increase risk of CLABSI
• Prolonged hospitalization before catheterization
• Prolonged duration of catheterization
• Heavy microbial colonization at insertion site
• Femoral catheterization
• Neutropenia, prematurity
• Total parenteral nutrition
• Substandard care of the catheter (excessive
manipulation, reduced nurse-to-patient ratio…)
Marschall J, et al. Infect Control Hosp Epidemiol 2008; 29:S22–S30
 The First Bundle Develop in IHI
CLR-BSI Prevention Strategy “Key Best Practice“ Issues

Hand hygiene

Transparent
dressing q7d
Gauze q2d

Replace iv set in 96 hrs

 blood/lipid in 24 hrs
Early removal of nonessential catheter

Close system
Skin prepare 2% CHG-Alc Aseptic procedure

CHG Selective catheter site

Maximum aseptic barrier MMWR.2002;51:RR-10.
Prevention of CLABSI; One or
Two element are not Enough!
 Bundle Design Guidelines
• Three to five elements with strong clinician agreement
• Each bundle element is relatively independent.
• Defined patient population in one location
• Multidisciplinary care team
• Allow for local customization and appropriate clinical
judgment
• Compliance using all-or-none measurement (>95%)

Each element (90% x 90% x 90% x 90% x 90%) =59% reliability

Using Care Bundles to Improve Health Care Quality 2012
 Strategies to Prevent Central Line–
Associated Bloodstream Infections in
Acute Care Hospitals: 2014 Update.
• Society for Healthcare Epidemiology of America (SHEA)
• Infectious Diseases Society of America (IDSA)
• American Hospital Association (AHA)
• Association for Professionals in Infection Control and
Epidemiology (APIC)
• Joint Commission, USA

Marschall J, et al. Infection Control and Hospital Epidemiology 2014;35(7):753-771.

 CLABSI Care Bundle
Before insertion (quality of evidence)
• Provide easy access to an evidence-based list
of indications for CVC use to minimize
unnecessary CVC placement (III).
• Require education of healthcare personnel
involved in insertion, care, and maintenance of
CVCs about CLABSI prevention (II)
• Bathe ICU patients over 2 months of age with a
chlorhexidine preparation on a daily basis (I)

Marschall J, et al. Infect Contr Hosp Epidemiol 2014;35:753-71.

 Indications for insertion of
a central venous catheter
• Administration of medications that could cause
harm if given through a peripheral vein
• The need to provide large volumes of blood
products or fluids
• Inability or difficult to obtain a peripheral vein
• Unstable vital signs need intensive monitoring
• Special medical intervention (e.g. dialysis)

Taiwan CDC, CLABSI bundle Campaign

 Education
• All involved HCW
• Indications for catheter use
• Involved in catheter insertion,
care, and maintenance
• Periodically assess
adherence of HCW

Confucius B.C. 551- B.C. 479

Marschall J, et al. Infect Control Hosp Epidemiol 2008; 29:S22–S30.

Pronovost P, et al. N Engl J Med 2006;355:2725-32.
McGee Dc, et al. N Engl J Med 2003;348:1123-33.
 CLABSI Care Bundle
During insertion
• Ensure and document adherence to aseptic
technique at the time of CVC insertion (II)
- Checklist
• Hand hygiene prior to catheter insertion or
• manipulation (II)
- Use an alcohol-based waterless product or
antiseptic soap and water.
Design Checklist to ensure adherence
• Aseptic technique observed by nurse or physician
• Empowered to stop procedure if breaches in aseptic
technique observed

中心靜脈導管置入操作流程查檢表 (checklist)
1.手部衛生(酒精性或濕洗手)戴口罩及髮帽
2.病人皮膚清潔：□酒精 □生理食鹽水 □其他_____
3.消毒劑洗手或刷手
4.穿戴無菌衣及無菌手套
5.病人皮膚以2％Chlorhexidine消毒
5-1 消毒範圍應大於洞巾洞口(直徑至少大於10cm)
5-2 應等待消毒液至自然乾
Evidence Support Hand Hygiene
Semmelweis （1846）

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Maternal Mortality at Lying-In Women’s Hospital, Vienna
Before and After Hand Hygiene in Chlorinated Lime

Pittet D, et al. Lancet Infectious Diseases 2001; April: 9–20

 Hand Hygiene
Hand hygiene before catheter insertion
 Alcohol-based waterless product
 Antiseptic soap and water
• Use of gloves does not obviate hand hygiene

WHO 5 moments

WHO Guidelines on Hand Hygiene in Health Care

Effectiveness and Limitations of Hand
Hygiene Promotion on Decreasing HAI

Hospital-wide (change in trends, p = 0.04)

Hand hygiene Promotion

Predicted incidence
Actual incidence

Chen YC, Sheng WH, et al. PLoS ONE 2011; 6(11): e27163.
Effectiveness and Limitations of Hand
Hygiene Promotion on Decreasing HAI

Intensive care units (change in trends, p<0.001)

Hand hygiene Promotion
Chang in levels and trends of infection due to
methicillin-resistant S. aureus

Hand hygiene Promotion

Predicted

Observed
levels, p=0.0309
trends, p=0.0373
Effectiveness and Limitations of Hand
Hygiene Promotion on Decreasing HAI

Hematology ward (p = 0.21)

Chang in levels and trends of infection
due to E. coli
Hand hygiene Promotion

P=0.33
 Economic evaluation of Hand Hygiene
Item Data
Healthcare-associated infection (HAI), April 2004-Dec 2007
Predicted episodes 16,805
Observed episodes 15,301
Total reduction (%) 1,504 (8.9%)
Cost of hand hygiene program, 2004-2007
Total cost 244,470 USD
Average cost to prevent per episode of
162.5 USD
HAI
Average extra cost per episode of HAI 5,335±13,872 USD

Estimated financial benefit through reduction

of HAI 8,023,840 USD
Estimated net financial benefit through hand
hygiene program 7,779,370 USD
Chen YC, Sheng WH, et al. PLoS ONE 6(11): e27163.
 Catheter Insert Sites
Avoid femoral vein for CVC (A-I)
• Risk of infection and deep venous thrombosis
• Limited to overweight adult (BMI >28.4) or children
• Lower risk in subclavian v. than internal jugular v.

McGee Dc, et al. N Engl J Med 2003;348:1123-33.

 Site of Central Venous Access
During insertion
• Avoid using the femoral vein for central
venous access (I).
- Controversy : insertion sites must be
considered on an individual basis with regard
to infectious and noninfectious complications
(e.g. jugular access may have a higher
infection risk if they have a concurrent
tracheostomy ; risk of bleeding tendency and
pneumothorax by subclavian access).
 Infectious Complications of Central Venous
Catheters, Different selected sites at ICU
Patients with one catheter at one site

Subclavian v. Int. jugular v. Femoral v.

Incidence
(n =221) (n=191) (n=139)

Catheter infection /1000 catheter-days (p = 0.26)

0.881 0 2.98

Bacterial colonization /1000 catheter-days (p = 0.13)

0.881 2.00 5.96

Deshpande KS et al. Crit Care Med. 2005;33(1):13-20.

Patients Clinical Data.

Connor AO, et al. J Clin Med Res 2013;5(1):18-21.

Connor AO, et al. J Clin Med Res 2013;5(1):18-21.
 CLABSI Care Bundle
During insertion
• Use ultrasound guidance for internal jugular
catheter insertion (II)
- Reduce non-infectious complications of
internal jugular vein insertion.

Sonography-guide CVC insertion

: photo of education at NTUH
 All in One Cart
During insertion
• Use an all-inclusive catheter cart or kit (II).
- A catheter cart or kit that
contains all necessary
components for aseptic
catheter insertion has to
be available and easily
accessible in all units
where CVCs are inserted.

CVC cart at NTUH

 Maximum Sterile Barrier
During insertion
• Use maximum sterile barrier precautions
during CVC insertion (II).
 A mask, cap, sterile gown, and sterile
gloves are to be worn by all healthcare
personnel involved in the catheter insertion
procedure.
 The patient is to be covered with a large
(“fullbody”) sterile drape during catheter
insertion.
 Maximal sterile barrier precaution
• For all involved HCW: mask, cap, sterile gown, gloves
• For patient: covered with a large sterile drape from
head to toe with a small opening for site of insertion
.

A full length sterile drape (by 3M)

 After
Maximum sterile
barrier precautions
Before
 Skin Antisepsis with Alc-CHG
During insertion
• Use alcoholic chlorhexidine (CHG)
antiseptic for skin preparation (I).
 Before catheter insertion,
apply an Alc-CHG solution
(>0.5% CHG) to insertion site.
 Antiseptic solution must be
allowed to dry before skin
puncture.
Disinfection, Sterilization, and Preservation. 5th ed.
Philadelphia: Lippincott Williams & Wilkins; 2001:159-183.
CHG-Antiseptic vs Alc-Pov-Iodine for CVC Care

P=.006 by the log-rank test

Alc-CHG decrease
the risk of Bacterial
colonization

Mimoz O, et al. Arch Intern Med. 2007;167(19):2066-2072

 Dressing Changes
After insertion
• For nontunneled CVCs in adults
and children, change transparent
dressings and perform site care
with a chlorhexidine-based
antiseptic every 5–7 days or
immediately if the dressing is
soiled, loose, or damp; change
gauze dressings every 2 days or
earlier if the dressing is soiled,
loose, or damp (II).
CLABSI Care Bundle: Maintenance
After insertion
• Ensure appropriate nurse-to-patient ratio (I).
• Disinfect catheter hubs, needleless connectors,
and injection ports before accessing catheter (II).
• Remove nonessential catheters (II).
• Replace administration sets not used for blood,
blood products, or lipids at intervals not longer
than 96 hours (II).
• Perform surveillance for CLABSI in ICU and non-
ICU settings (I).
Biofilm
Remove nonessential catheters!
 Special Approach
• Daily bathe ICU patients (II)
• Antiseptic- or antimicrobial-impregnated CVC (I)
(chlorhexidine-silver sulfadiazine, minocycline-rifampin)
• Use chlorhexidine-containing sponge dressings (I)
• Use antimicrobial locks for CVCs (I)
i. Units or patient populations have high CRBSI rates
ii. Limited difficult venous access or recurrent CRBSI
iii. Risk for severe sequela from CRBSI
(recently implant device, prosthetic valve or graft)
 Control Antiseptic RR p
N=122 N=113
Deaths due to CRBSI 2 (1.6%) 0 (0) 0.27
Catheter-related infection 6 1 0.17 0.07
BSI 2 1 (0.03-1.15) 0.53
SSI 4 0 0.71
Colonization 25 (20.5%) 9 (7.1%) 0.34 0.006
Gram-positive cocci 14 6 (0.15-0.74) 0.06
Gram-negative bacilli 1 2 0.84
Fungi 7 1 0.04
Sheng WH, et al. Diagn Microb Infect Dis 2000;38:1–5.
Antimicrobial CVC Commercially Available

Casey AL, et al. Lancet Infect Dis 2008; 8: 763-76.

Measure and Feedback to the Units, Physician,
Nursing leadership & Hospital Administrators

Rosenthal VD, et al. Am J Infect Control 2003;31:405-9.

National Experiences of BSI Prevention Bundle
National Association of Children’s and Related Institutions
(NACHRI) PICU CA-BSI Collaborative
- Reduce 43% (5.4 vs. 3.1 CA-BSIs per 1,000 central line-days).
Pediatrics. 2010;125(2):206–213.

New York State NICU CLABSI Study

- Decreased 40%, from 3.5 to 2.1 CLABSIs per 1,000 CVC-days
Pediatrics. 2011;127(3):436-444.

University Hospital of Zurich Impact Study, Switzerland

- Decrease CABSI rate from 3.9 to 1.0 per 1,000 catheter-days.

Crit Care Med. 2009;37(7):2167-2173.

Pennsylvania ICU CLABSI Intervention
- CLABSI rates decreased by 68%, from 4.31 to 1.36 per 1,000
central line-days.
MMWR Morb Mortal Weekly Rep. 2005;54(40):1013-1016.
 CLABSI Care Bundle at NTUH
Before & during insertion
• Avoid femoral vein for CVC insertion
• Hand hygiene and aseptic technique
• Use maximal sterile barrier precautions.
• Skin preparation with alcohol-chlorhexidine

After insertion
• Daily evaluation and remove unnecessary CVC

Taiwan CDC, CLABSI bundle Campaign

 Bundle Adherence of Dr/Nurse

(%) 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4

選 96.9 94.4 89.9 92 97.3 100 100 100

手 100 100 100 100 100 100 100 100

大 99.4 100 100 100 100 100 100 100

消 99.1 100 100 100 100 100 100 100

除 100 100 100 100 100 100 100 100

Total 95.5 94.4 89.9 92 97.3 100 100 100

 CLABSI, CRBSI Rates, All ICUs, 2011-2014
12 12
CRBSI CABSI Michigan, USA CRBSI

Infection density/1000 catheter days

Infection density/1000 catheter days

Average 7.4 ‰ Average 6.5 ‰

10 Average 6.7 ‰ 10
Average 5.5 ‰
8 8

6 6

4 Average 0.94 ‰ 4
Average 1.16 ‰
Average 0.83 ‰ Average 0.7 ‰
2 2

0 0

Pronovost P, et al., Sustaining reductions in catheter related

bloodstream infections in Michigan intensive care units,2010
 Zero Tolerance of CRBSI caused by Skin
flora at ICUs, Jan 2010~ Dec 2014
10 5

9 Skin flora Number of skin flora CRBSI 4.5

• CoNS & S. aureus

Infection density/1000 catheter days

8 4
• Corynebacterium skin flora CRBSI density
• Bacillus
CRBSI case number

7 3.5

6
• Viridans streptococcus 3
• Propionebacterium
5
5 • Micrococcus 2.5

4 2
3
3 1.5
2 2 2 2 2
2 1
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 0.5
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0

50
 Annual Healthcare-associated
Infection Density NTUH, 2008- 2014
‰ Infection Density = HAI episodes/1000 patient-days
10
9 Hand hygiene promotion
8 6.8
7 6.3
5.8
6 5.1 4.9
5 4.2
3.8
4
3 BSI
2
1
Bundle care VAP
UTI
0
2008 2009 2010 2011 2012 2013 2014
 Methicillin-resistant Staphylococcus
aureus (MRSA) HAI Infection Density
2011-2014
HAI
HAIMRSA ‰(HAI菌株數/住院總人日)
Density, MRSA infection /1000 patient-days
0.35

0.30

0.25

P=0.03
0.20

0.15

0.10

0.05

0.00
 Summary
• CLABSI: a burden on patients, families,
health insurance payers & society.
• Good performance of bundle care rely on:
 Design an appropriate bundle
 Leadership commitment
 Physician-nurse alignment (compliance)
 Systematic education
 Rewards and performance feedback
• Implementing evidence-based practices
 Zero Tolerance of CLABSI
“Near zero” catheter-related bloodstream
infections: Turning dreams into reality!

台灣
蘭嶼
GETTING TO ZERO:

PARTNERSHIPS FOR SUCCESS

TECHNOLOGY ADVANCEMENTS

Patrick J Parks MD PhD

Medical Director, 3M Critical and Chronic Care Solutions Division
Adjunct Associate Professor, Experimental and Clinical Pharmacology
University of Minnesota, Minneapolis
 Biofilms are the source of bloodstream catheter infection
Aslam, S, (2008) Effect of antibacterials on biofilms. Am J Infect Control 36:S175.e9-S175.e11.

 Biofilms
― Sugars (Extracellular polysaccharides)
― Proteins (Bacterial and Host)

Planktonic bacteria
Kint CI et al, Trends in Microbiology
2 (2012) 20:577-585.
Needlestick injuries can
be costly!
 Needleless connectors were designed to avoid needlestick injuries, not
reduce infection!
SPLIT SEPTUM: POSITIVE PRESSURE
Lower infection rate Higher infection rate
Higher thrombotic rate Lower thrombotic rate

Btaiche IF, Kovacevich DS, Khalidi N, Papke LF. J Infus Nursing (2011) 34:89-95.
4
Modified connectors and caps hold promise for reduced infections
111 infections 22 infections 16 infections 1 infection
24459 catheter days (cd) 25621 catheter days (cd) 6851 catheter days (cd) 3005 catheter days (cd)
5.4 per 1000 cd 1.1 per 1000 cd 2.3 per 1000 cd 0.3 per 1000 cd
Alcohol
containing
caps

Positive/Negative Neutral Neutral pressure connectors

connectors connectors

5
 Organisms at the insertion site are source of infection in the majority of
cases.

Mermel LA, McCormick RD, Springman SR, Maki DG.

Am J Med 1991; 91:197S–205S.

Tao C, Hu B, Rosenthal VD, Gao X and He L.

Intl J Infect Dis (2011) 15:e774-e780.

6 6
 Bloodstream infections: Chlorhexidine Gluconate (CHG) reduces infection
rate by 50% compared to aqueous Povidone Iodine (PI)

FAVORS FAVORS
chlorhexidine povidone
gluconate iodine

7 Chaiyakunapruk et al, Ann Intern Med 2002

CHG 2% 70% Isopropyl alcohol is superior for preventing biofilms.

Prepare clean skin with a >0.5%

chlorhexidine preparation with alcohol
before central venous catheter and
peripheral arterial catheter insertion and
during dressing changes. If there is a
contraindication to chlorhexidine, tincture This study supports the recommendation of
of iodine, an iodophor, or 70% alcohol can a chlorhexidine in alcohol product. Indeed, the
be used as alternatives Category IA in vitro results suggest that 2% (w/v) CHG in
70% (v/v) IPA offers an improved antimicrobial
effect compared with all three standard preparations of
O’Grady NP et al, Am J Infec Ctrl (2011) 39:S1-S34. CHG currently available in the UK [0.5% (w/v)
aqueous CHG, 2% (w/v) aqueous CHG and 0.5% (w/v)
CHG in 70% (v/v) IPA] when challenged with S.
epidermidis RP62A in a biofilm in the presence of
8
10% human serum (P<0.0001).
8
 Supplemental strategies for infection reduction rely on technology

Based on 2011 CDC guideline for prevention of intravascular catheter associated bloodstream infections:
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
9
 Daily bathing of Intensive Care Unit patients with chlorhexidine does
NOT reduce the incidence of healthcare acquired infection

 Noto MJ, Domenico HJ, Byrne DW, Talbot T, Rice TW, Bernard GR, Wheeler AP
Chlorhexidine bathing and health care associated infections: a randomized clinical trial. J Amer
Med Assn (2015) 313: 369-378.

 “…daily bathing did not reduce the incidence of healthcare-associated infections

including central line associated bloodstream infections, catheter associated
urinary tract infections, ventilator associated pneumonias or Clostridium difficile.
These findings do not support daily bathing of critically ill patients with
chlorhexidine.”
10
10
 Coated catheters have unclear value for long term infection protection.
-The magnitude of benefits in catheter
colonization varied according to the
setting, with significant benefits only
in studies conducted in ICUs.
-Limited evidence suggests that
antimicrobial CVCs do not appear to
significantly reduce clinically
diagnosed sepsis or mortality.
Antimicrobial catheters did not provide
any significant benefit over standard
catheters.
Standard catheters can safely be left in
place for up to14 days with appropriate
infection control measures.

Cochrane Databse of Systematic Reviews 2013 Issue 6 Art No CD007878

11
11
 Chlorhexidine gluconate containing dressings reduce infection risk by ~50%
Safdar N, O’Horo JC, Ghufran A., Bearden, A. Didier MA, Chateau D, Maki DG. Chlorhexidine-impregnated dressing for prevention
of catheter-related bloodstream infection: A meta-analysis. Critical Care Medicine (2014) 42: 1703-1713.

Prevalence of CRBSI:
64 of 5,639 patients (1.1%) in the CHG group
120 of 5,608 (2.1%) in the comparator group.

The CHG-impregnated dressing: RR of 0.52 (95% CI, 0.43–0.64; p < 0.001)

12
 In vitro analysis:
CHG pad

GEL PAD GEL PAD

13
13
 CHG gel pad kills bacteria for up to 10 days
Zone of inhibition (mm)
as a function of time
(against Staph. Epidermidis)

Zone of Inhibition 10
9

Mean +/- Std Dev

GEL PAD
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10
Days

14
In vitro analysis: CHG pad zones of inhibition similar for all Gram positive
and all Gram negative organisms. C albicans 10231
S epi 12228
C albicans 58716 60 S epi 13518
S epi 49461
Pr mirabilis 7002 S epi 49134
Pr mirabilis 12453 50 S epi 14990
E coli 25922 40 S epi MRSE 51625

K pneumoniae 23357 S epi MRSE nasal

30
K pneumoniae 13883 S aureus 25923
20
E cloacae 35549 S aureus MRSA/GRSA 33592
10

Zone of Inhibition Ps aeruginosa 27853

0
S aureus MRSA.USA100

Ps aeruginosa 9027
Zone of Inhibition S aureus MRSA.USA300

GEL PAD Ps aeruginosa 35032 S aureus MRSA.USA600

Ps aeruginosa 10622 S aureus MRSA.USA500

Ps aeruginosa 10145 S aureus MRSA.USA800

A baumanii Wound S aureus Nasal isolate
A baumanii BAA-747 Ent faecium VRE 700221
A baumanii 19606 Ent faecium MDR 51559
C diphtheriae 13612wound
Ent faecalis Ent faecalis
Ent faecalis 19433 7080

15
15
Catheter related bloodstream infection reduction is 65% (CHG gel pad dressing)

16
16
 Randomised trial: CHG gel pad reduces infection rate

11 CRBSI in controls (1.78/1000 catheter days)

4 CRBSI in CHG gel pad (0.65/1000 catheter days)
p = 0.11

17 17
 CHG gel pad reduces central line associated infection rate in
18 interventional study.
Central line associated bloodstream infection rate
Interventional study
Gram positive organisms: infections per 1000 catheter days
6

In our study, the reduction in CLABSI rates was 1

mainly a result of fewer infections due to Gram-
positive bacterial infection. 0
CHG gel pad Flat film

18 3M Confidential. 27 March
© 3M 2015. All Rights Reserved.
 CHG gel pad reduces infectious risk by ~60%

CR-BSI Study Name Lower limit Mean Upper limit Probability

Timsit/Scoppettuolo 0.2422 0.4664 0.8980 0.018

+ Blood Culture

CLABSI
+ Blood Culture Study Name Lower limit Mean Upper limit Probability
Timsit/Schiethauer 0.2025 0.3149 0.4898 0.000

19 19
 20
20
 Problem convergence: securement and infection are related

21
21
 Phlebitis predisposes to peripheral vascular catheter associated CRBSI.
 We estimate that there may be as many as
10,028 PVC-related S. aureus bacteremias
yearly in US adult hospitalized inpatients.
 Peripheral vascular catheter related S.
aureus bacteremia is an underrecognized
complication.
 Peripheral catheters cause ~19% of all
CRBSIs.
TT Trinh et al., Peripheral venous catheter related
Staphylococcus aureus bacteremia. Infect Control
Hosp Epidemiol. 2011 Jun;32(6):579-83.
22
• Peripheral vein phlebitis is related to the
incidence of peripheral catheter bloodstream
infection
1 catheter related bloodstream infection/
320 episodes of peripheral vein phlebitis
• Peripheral catheters are the most used
(CVC:PVC::1:90)
Maestre G, Berbel C, Tortajada P et al., Successful
multifaceted intervention aimed to reduced short peripheral
venous catheter related adverse events: A quasi experimental
study. Am J Infect Control (2013) 41:520-526.
22
 Dressing failure raises infection risk for central venous catheters.
 Risk of central venous catheter infection
rises as the number of unintentional dressing
changes rises.
Hazard ratio
100

10

1
1st 2nd final

0.1
Timsit JF, Bouadma L, Ruckly S, et al. Dressing
disruption is a major risk factor for catheter related
infections. Crit Care Med (2012) 40:1707-1714.
23
23
 Future: Antisepsis may develop new molecules

OCTENIDINE CHLORHEXIDINE

24 24
25
O'Sullivan,DD et al, Am.Soc.Microbiol. 18-22, May 2003
 Summary:

Technology solutions for infection reduction require antimicrobial effect

and improved catheter securement.

Peripheral catheters represent under-recognised risk of infection

Chlorhexidine will be antiseptic of choice for technologies.

26
 THANK YOU..

27