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CSTS: The Cardiovascular Surgical Translational CSTS: The Cardiovascular Surgical Translational Study Study

The Role of Technology in CLABSI The Role of Technology in CLABSI PreventionPrevention

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Learning ObjectivesLearning Objectives

• To review considerations for picking new technology to reduce CLABSI

• To review currently available data regarding the efficacy of several technologies in reducing CLABSI– Chlorhexidine bathing– Chlorhexidine impregnated sponges– Antiseptic-coated catheters

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Considerations When Picking Considerations When Picking New TechnologyNew Technology

• Is technology needed to reduce CLABSI in your units?

– Has best practice been fully adopted?• CDC guidelines recommend consideration if rates

remain high after implementation of basic prevention strategies

• Risk of overreliance on technology

– Exercise caution in implementing new technology if rates rise after implementing best practice

• First go back and make sure they are doing what they are supposed to be doing

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Considerations When Picking Considerations When Picking New TechnologyNew Technology

• When are CLA-BSIs occurring?– < ~10 days often associated with extraluminal

contamination of the exit site– > ~10 days often associated with intraluminal

contamination via hub or connector– Best approach is prevention of both extraluminal and

intraluminal contamination

• What are central line use patterns in the unit?– Removed within 24-72 hours or in for long periods of

time?• May need patient-level protocol to direct technology to

those at higher risk for CLABSI

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Chlorhexidine BathingChlorhexidine Bathing

• Theory: decolonization of skin decreases organisms that might contaminate the insertion site at the time of placement and while the line is in situ

– May also reduce hub colonization if reduce overall microbial burden

– May offer the additional advantages of• Decreasing rate of blood culture contamination• Decreasing rates of other organisms (MRSA, VRE, etc.)

Moro ML et al. Infect Control Hosp Epidemiol. 1994;15:253-64.Vernon MO et al. Arch Intern Med. 2006;166:306-12.

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Chlorhexidine Bathing: Chlorhexidine Bathing: EvidenceEvidence

• 52 week crossover study in 2 MICUs in one center

• Chlorhexidine (CHG) washcloths vs. soap & water bath daily

• Primary BSI rate– CHG: 4.1 infections/1000

patient days– Soap & water: 10.4

infections/1000 patient days

– Incidence difference 6.3 (95% CI 1.2-11.0)

Bleasdale SC et al. Arch Intern Med. 2007;167:2073.

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CHG Impregnated Sponge CHG Impregnated Sponge (Biopatch)(Biopatch)

• Theory: decolonization of the catheter insertion site decreases chance of extraluminal catheter infection

• Considerations– Learning curve for optimal application—may initially have

extra manipulation of insertion site; incorrect application, etc.

– Insertion site not visible– No effect on hub

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CHG Impregnated SpongeCHG Impregnated Sponge

• RCT comparing Biopatch to standard dressings• Lines included: arterial catheters and central venous

catheters; none antiseptic or antimicrobial coated• Outcome: Catheter-related infection

– Catheter-related bloodstream infection• ≥ 1 positive peripheral blood culture, a quantitative

catheter tip culture growing the same organism or differential time to positivity of blood cultures ≥ 2 hours, and no other source

– Catheter-related clinical sepsis without bloodstream infection

• Fever, positive cath tip, pus at line site, and no other source

Timsit JF et al. JAMA. 2009;301:1231-41.

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CHG Impregnated Sponge CHG Impregnated Sponge

• 1636 catheters• Median duration of insertion:

6 days• Major catheter-related

infection rate– CHG sponge: 0.6

infections/1000 catheter days– Standard dressing: 1.4

infections/1000 catheter days– Hazard ratio 0.39 (95% CI

0.16-0.93)

• 8 episodes of contact dermatitis in sponge group

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Coated CathetersCoated Catheters

• Theory: decrease extraluminal catheter colonization and intraluminal colonization if interior surface of catheter also coated

• Types– Heparin + benzalkonium bonded

(activity on inner and outer surface)– Silver + platinum coating on inner & outer surface– Chlorhexidine and silver sulphadiazine

• Outer ± inner coating

– Antibiotic coating on outer & inner surface: minocycline and rifampin

Casey AL et al. Lancet Infect Dis. 2008;8:763-76Gilbert RE and Harden M. Curr Opin Infect Dis. 2008;21:235

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11stst Generation Chlorhexidine and Silver Generation Chlorhexidine and Silver Sulphadiazine vs. StandardSulphadiazine vs. Standard

RR 0.68 (0.47-0.98)

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22ndnd Generation Chlorhexidine and Generation Chlorhexidine and Silver Sulphadiazine vs. StandardSilver Sulphadiazine vs. Standard

• No additional benefit of outer and inner coating

OR 0.47 (0.20-1.10)

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Minocycline/Rifampin vs. StandardMinocycline/Rifampin vs. Standard

Minocycline/Rifampin vs. ChlorhexidineMinocycline/Rifampin vs. Chlorhexidine

RR 0.12 (0.02-0.67)

RR 0.29 (0.16-0.52)

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Coated Catheters: ConsiderationsCoated Catheters: Considerations

• Heparin and Minocycline/Rifampin coatings appear to be more effective than other coatings

• Limited data regarding:– Risk of development of minocycline or rifampin resistance– Risk of selection of fungal organisms

• In a different pooled analysis:– Treatment effect seen with catheters in place for 5-12

days but not 13-20 days– Treatment effect seen for femoral and internal jugular

insertion sites but not in studies using exclusively subclavian insertion sites

Hockenhull JC et al. Health Technol Assess. 2008;12(12).

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Coated Catheters: ConsiderationsCoated Catheters: Considerations

• Decision to use coated catheters depends on local factors– Extent of adoption of best practice– Duration of catheterization

• May need to make protocol based on expectations of duration of catheterization at individual patient level rather than unit level

– Usual sites of catheters – Concerns about rifampin resistance

• May choose not to use catheters with rifampin coating in patients with endovascular hardware

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Other TechnologiesOther Technologies

• Antiseptic hubs– No published clinical data supporting efficacy

• Dressings containing chlorhexidine (e.g. Tegaderm™ CHG dressing)– No published clinical data supporting efficacy

• Antimicrobial lock solutions– Not recommended for routine use– Could be considered in individual patients with limited

venous access & history of recurrent CLABSI or in patients at risk for severe sequelae of CLABSI (e.g. new prosthetic heart valve)

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Needleless Intravenous Needleless Intravenous Access DevicesAccess Devices

• “Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assessment of risk, benefits, and education regarding proper use (B-II)

– Routine use of the currently marketed devices that are associated with an increased risk of CLABSI is not recommended”

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

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Action ItemsAction Items

• Assess compliance with best practice for CLABSI prevention in your institution

• If new technologies are desired, evaluate which ones are most appropriate for your patients

• Monitor for any unexpected effects associated with adoption of new technologies