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8/14/2019 Reducing Catheter-related Bloodstream Infections in the NICU
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Reducing catheter-relatedbloodstream infections in the
NICU
Martin Skidmore
University of Toronto
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The scope of the problem
15 million CVC days per year in USA
Average rate of CRBSI 5.3/1000 catheterdays
80,000 CRBSI per year in NICUs and ICUs
250,000 per year in total Mortality is 12-25%
Cost estimated $25,000 per episode CDC, 2002
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Strategies for prevention of CRBSI
Site of catheter insertion Type of intravascular catheters used The use of a closed medication system
Differing techniques of insertion and securement The use of inline filters Procedures for tubing changes Procedures for dressing changes
Routine replacement of central catheters The use of systemic antibiotic prophylaxis The use of anticoagulants.
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Site of catheter insertion
Subclavian better than jugular?
Avoid femorals? (?in neonates)
u/s confirmation of placement preferred
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Type of intravascular cathetersused
Teflon, polyurethane catheters preferred overPVC or polyethylene
Antimicrobial/antiseptic impregnated cathetersseem cost effective
(None approved/available for infants
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Hand hygiene, aseptic technique,skin antisepsis
No touch technique (+gloves)
Maximal sterile barrier precautions
Povidone-iodine v. 2% aqueouschlorhexidine gluconate
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Site dressing regimens/securement
Transparent, semipermeable polyurethane
dressings (?gauze if bleeding)
Chlorhexidineimpregnated sponge
(Biopatch) over site
Sutureless securement advantageous
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Inline filters
Reduce incidence of infusion relatedphlebitis
Infusate-related BSI is rare especially ifdone in pharmacy
May become blocked by infusion of somesolutions
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Systemic antibiotic prophylaxis
No studies show oral/parental antibacterialor antifungal drugs reduce CRBSI in
adults
2 studies in LBW have shown vancomycinprophylaxis decreases CRBSI risk of acquiring VRE
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Anticoagulants
Prophylactic heparin 3 units/ml in TPN
5000 units q6 or q12 hour flush
2,500 units LMW heparin S/C
Catheters are available with heparinbonded coating (benzalkonium chloride)
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Replacement of Catheters
Replacement schedules have not loweredrates of CRBSI
Scheduled guidewire exchanges alsohave not lowered rates of CRBSI
high vs. low UVC placement
Remove uac before 5 days
Remove uvc before 14 days
OR when no longer needed
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Practical Approach To CRBSI
Remove promptly if s.aureus or gramnegative rod infection
CoNS infections - remove after 3 positiveblood cultures
Benjamin, 2001
Application of closed medication system showed immediate results in one study
Aly, 2006
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Suspected or proven CRBSI
Remove catheter if:
Catheter is no longer required
Child is haemodynamically unstable
Metastatic foci of infection (septicemboli/infective endocarditis) are present
Candidaemia/mycobacterial infection Catheter tunnel is inflamed
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Suspected or proven CRBSI
Unrepaired congenital heart disease
Suspected pathogen is a gram-negativeorganism
Remove catheter unless replacement will bevery difficult or bacteraemia appears to beresolving
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Suspected or proven CRBSI
Suspected pathogen is Staphylococcusaureus:
Retain catheter only if bacteraemia resolveswithin 24 h and there is no clinical orechocardiographic evidence of infectiveendocarditis
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Suspected or proven CRBSI
In all other situations:
Retain catheter unless bacteraemia persistsafter four days of appropriate intravenousantibiotics or child becomes unstable.