Prevention of Infections Associated with Vascular Access Devices (VADs) Michigan Society of Infection Prevention & Control Fundamentals of Infection Prevention

Prevention of Infections Associated with Vascular Access Devices (VADs)

Michigan Society of Infection Prevention & ControlFundamentals of Infection Prevention & Control 2014Karen Hoover, RN

AGENDAEpidemiology -

• Costs; Risks/Benefits Definitions Microbiology Rates, Risk Factors and Pathogenesis Prevention and Patient Care PracticesRecommendations CDC guidelineReferences

2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html

http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html

Hand Hygiene and Aseptic Technique

Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application of skin antiseptics.

Maintain aseptic technique for the insertion and care of intravascular catheters

Sterile gloves should be worn for the insertion of arterial, central, and midline catheters .

Use new sterile gloves before handling the new catheter when guidewire exchanges are performed.

Wear either clean or sterile gloves when changing the dressing on intravascular catheters.

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Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR).

Guidelines for the Prevention of Intravascular Catheter-Related Infections

Prepare to clean skin with a greater than 0.5% chlorhexidine-based preparation before central venous catheter insertion and during dressing changes.

Avoid using the femoral vein for central venous access in adult patients, Category 1A.

And the second use a subclavian site rather than the jugular in adult

patients to minimize infection risk for non-tunneled CVC placement, Category 1B.

Minimize contamination risk by scrubbing the access port with an appropriate antiseptic chlorhexidine povidone-iodine IOTA 4 or 70% alcohol

Use either sterile gauze or sterile, transparent, sem-ipermeable dressing to cover the catheter site.

If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved .

Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.

Do not use topical antibiotic ointment or creams on insertion sites, except

for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance.

Do not submerge the catheter or catheter site in water.

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Catheter Site Dressing Regimens

Classification of Healthcare Associated Bloodstream Infection

Primary BSI: no apparent local site as cause of infection◦40% associated

with central lineSecondary BSI:

Another site of infection is source of BSI, e.g. UTI, SSI, Pneumonia

Primary40%

Secondary20%

Unknown40%

Comparison of Central Line Associated or Related BSI Definitions

Central Line Associated BSI* [CLA-BSI; surveillance]

◦LCBI-Laboratory- confirmed BSI

◦ Central line meeting NHSN definition was present prior to onset of BSI

Central Line-Related #[CR-BSI; clinical/research]

◦Positive semiquantitative (>15 CFU/catheter segment) or quantitative (>103 CFU/catheter segment catheter) culture

◦Same microorganism (species + antibiotic susceptibility profile) is isolated from the catheter segment AND peripheral blood; or simultaneous quantitative blood cultures with a >5:1 ratio CVC versus peripheral; or differential period of CVC culture versus peripheral blood culture positivity of >2 hours aka time to positivity

Pathogenesis of infection for percutaneous intravascular device; Clin Infect Dis 2002;34:1232-42

Central Line Definition

Definition

A vascular infusion device that terminates at or close to the heart or in one of the great vessels

The following are considered great vessels for the purpose of reporting central-line BSI and counting central-line days in the NHSN system:

July 2013 CDC/NHSN Protocol Clarifications

www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

◦ Great Vessels:

• Aorta • Pulmonary artery • Superior vena cava • Inferior vena cava • Brachiocephalic veins • Internal jugular veins • Subclavian veins • External iliac veins • Common iliac veins • Femoral veins • In neonates, the umbilical artery/vein.

Other types of central catheters

A tunneled catheter is surgically placed into a vein in the chest or neck and then passed under the skin. One end of the catheter comes out through the skin so medicines can be given right into the catheter

An implanted port is similar to a tunneled catheter, but an implanted port is placed entirely under the skin. Medicines are given by a needle placed through the skin into the catheter

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Not considered central lines:

Extracorporeal membrane oxygenation (ECMO)

• Femoral arterial catheters • Intraaortic balloon pump (IABP) devices. • Hemodialysis reliable outflow (HeRO)

dialysis catheters

Clinical Sepsis (CSEP)Neonate/Infants - ONLY

CSEP may be used only to report primary BSI in neonates and infants. It is not used to report BSI in adults and children.

Clinical sepsis must meet the following criterion:Patient < 1 year of age has at least 1 of the following

clinical signs or symptoms with no other recognized cause: fever (>38 C rectal), hypothermia (< 37 C rectal),apnea, or bradycardia

And:blood culture not done or no organisms detected in

blood +no apparent infection at another site + physician institutes treatment for sepsis.

CVS-CARDIOVASCULAR SYSTEM INFECTIONVASC-Arterial or venous infection

1. Organisms cultured from arteries or veins removed during a surgical operation and blood culture not done or no organisms.

2. Evidence of arterial or venous infection seen during a surgical operation or histopathologic examination.

3. At least 1 of the following signs or symptoms with no other recognized cause: fever; (>38 C), pain, erythema, or heat at involved vascular site and > than 15 colonies cultured from intravascular cannula tip using semiquant. method and blood culture not done or no organisms cultured from blood

4. Patient has purulent drainage at involved vascular site and blood culture not done or no organisms cultured from blood

V. Risk Factors

Risk depends on catheter type & use; 2 or more controlled studies identified following: prolonged hospitalization prior to catheter prolonged duration of catheterization heavy colonization of hub site heavy colonization at insertion site catheter insertion in internal jugular (IJ) vein antibiotic usage during catheterization

A closer look at CLABSI:Home sweet Biofilm

Donlon RM,Carr J. CDCPHIL #7488

Rates of BSI For Various Intravascular Devices (IVDs) [Maki DG, et al. Mayo Clin Proc 2006; 81:1159-71

Device No. of Studies Per 100 IVDs Per 1000 Device Days Comment

Peripheral catheter:

angiocatheter 13 0.1 0.6 Plastic cath.

arterial 6 0.8 1.7 Hemodyn.

midline 3 0.4 0.2

Central catheter:

Short term 79 4.4 2.7 Nontunneled

Short term, antim. 18 2.6 1.6 Chlor-Silver

Pulm Artery 12 1.5 3.7

Dialysis, long term 16 21.2 1.6 cuff, tunnel

PICC 9 3.5 1.0 Outpatient

Port 14 3.6 0.1

PICCs Are “Catching Up” [Safdar N. Chest 2005]

Prospective Study of 251 PICCs in 151 hospitalized patients; 40% spent part of their stay in ICU

6 CLABSIs from PICC = 2.4% or 2.1/1,000 central line days

Prior data from 13 studies: 0.2/100 PICCs; 0.4/1,000 central line days

Increased frequency of use likely contributing to increased rate of BSI that is comparable to standard, central line in jugular or subclavian site

PICCs HAVE Caught UP!!! ….2011

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PICC is threaded through the arm vein until it reaches a larger vein close to the heart. It is used to deliver medicine, nutrition, IV fluids, and chemotherapy

Risk factors for infection

•Having a catheter for a long time•Having a catheter that is not coated with a substance that kills bacteria•Having a catheter inserted into a vein in the thigh•Having a weakened immune system•Being in the intensive care unit•Having an infection elsewhere in the body or skin

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http://medicine.med.nyu.edu/conditions-we-treat/conditions/?ChunkIID=14789

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At Home •Follow all instructions concerning your PICC line.•Learn how to take care of your catheter. Follow these general guidelines:

• Follow specific instructions about showering and bathing• Before touching the catheter, wash your hands or use a

hand sanitizer. Wear gloves when touching the area.• Change bandages as directed• Wash the catheter caps with an antiseptic.• Do not allow anyone to touch the catheter or the tube.• Check the insertion site daily for signs of infection, such

as redness or pain.• Call your doctor if you think you have an infection.

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National Healthcare Safety Network (NHSN) Data Report on CLABSI

Edwards JR,et al. AJIC 2007;35:290-301.

Strategies for Prevention CLABSI QA and continuing education Site of & technique of catheter insertion Limit traffic in room during insertions Type of catheter material Hand hygiene and aseptic technique Skin antisepsis …CHG Catheter site dressing regimens ..Biopatch Catheter securement Antimicrobial/antiseptic impregnated caths&

cuffs Chlorhexidine/Silver sulfadiazine; Minocycline/Rifampin

Systemic antibiotic prophylaxis; antibiotic antiseptic ointments

Scrub the hub

Ways patients can protect themselves from CLABSI:Research the hospital, if possible, to learn about its

CLABSI rate.Speak up about any concerns so that healthcare

personnel are reminded to follow the best infection prevention practices.

Ask a healthcare provider if the central line is absolutely necessary. If so, ask them to help you understand the need for it and how long it will be in place.

Pay attention to the bandage and the area around it. If the bandage comes off or if the bandage or area around it is wet or dirty, tell a healthcare worker right away.

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http://www.cdc.gov/hai/pdfs/bsi/BSI_tagged.pdf

Don’t get the central line or the central line insertion site wet.

Tell a healthcare worker if the area around the catheter is sore or red or if the patient has a fever or chills.

Do not let any visitors touch the catheter or tubing.

The patient should avoid touching the tubing as much as possible.

In addition, everyone visiting the patient must wash their hands—before and after they visit.

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http://www.cdc.gov/hai/pdfs/bsi/BSI_tagged.pdf

Efficacy of Maximal Sterile Barrier Precautions

Minimal Maximum*

Local inf. 7.2% 2.3%

CLA-BSI 3.6% 0.6%

*cap, mask, sterile gloves, sterile gown, head/body of patient covered with large sterile drape

Vs. sterile gloves, small sterile drape

Other Aspects of BSI prevention

IV access devices:◦Temporal association:

newer needleless access devices & increased rate of CLABSI:◦Rupp ME, CID 2007◦Salgado CD, ICHE 2007◦Field K, ICHE 2007◦Maragakis LL, ICHE 2006

Flushing techniqueCatheter dressing, IV

system care & maintenance

Patient Safety Using Hygiene

1 yr. cross over study in two MICUs, Stroger hospital, Chicago IL◦ Intervention: daily cleansing of patients with disposable cloth

containing chlorhexidine gluconate (CHG)◦ Control group: daily cleansing with soap and water

Results:◦ Intervention group:

4.1 primary BSIs / 1,000 pt. days 6.4 / 1,000 central line days

◦ Control group: 10.4/ 1,000 pt. Days 16.8 / 1,000 central line days

Conclusion: Incidence of BSI in CHG-cloth group was 61% lower than control (soap and water) group. Reduction of concentration of bacteria on skin lessens risk of BSI.

Bleasdale SC,et al. Arch Intern Med 2007;167:2073-9

Using Surveillance to Prevent CVC-BSI, PHRI, 2001-05

Pittsburgh. Reg. Hth. Initiative- CDC ◦ 66 ICUs; 32

hospitals Evidence-based

care interventions

Education Equipment Process/outcome

◦ 68% drop in CVC-BSI [4.31 to 1.36/1000 CVC days

◦ MMWR 2005 (Oct.14);54:1013-16.

An estimated 41,000 central line-associated bloodstream infections (CLABSI) occur in U.S. hospitals each year.

* ↑ LOS * ↑ hospital cost * ↑ risk for mortality

NHSN Requirements: Surveillance for HAI CLABSI: 1/2011 Adult, Pediatric, and Neonatal ICUs

10/2012 Adult & Pediatric LTAC ICUs & Wards

1/2015 Adult & Pediatric Medical, Surgical, & Medical/Surgical Wards

http://www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements.pdf




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Present on Admission (POA): Infections that are POA, as defined in Chapter 2, are not considered HAIs and therefore are never reported to NHSN.

Healthcare-associated infections (HAI): All NHSN site specific infections must first meet the HAI definition as defined in Chapter 2 before a site specific infection (e.g., CLABSI) can be reported to NHSN.

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CMS Reporting Requirements

January 2011 – CLABSIs in adult, pediatric & neonatal ICUs

Outpatient Dialysis Facilities:January 2012 I.V. antimicrobial starts Positive blood cultures Signs of vascular access infection

Long Term Acute Care (LTAC)Facilities:October 2012CLABSIs in adult and pediatric ICUs and wards

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Recommendations for Placement of Intravascular Catheters in Adults & Children

I Education HCW ◦Educate on indications for use of IV catheters IA◦Assess competence for insertion and maintenance IA◦Ensure appropriate ICU nursing staff-to-patient ratios

II Surveillance for BSI◦Monitor sites visually and/or palpations◦Encourage patients to report changes◦Record operator, date and time of CR insertion in std manner◦Do not routinely culture catheter tips IA

III Hand Hygiene◦ Proper hand hygiene with soap/water; alcohol based gels

IA◦Use of gloves still requires hand hygiene IA

IV Aseptic technique during insertion and care IA◦Wear clean or sterile gloves; clean for insertion of PIV;

sterile for insertion of arterial lines or CVCs ◦Wear clean or sterile gloves when changing dressings


V Catheter Insertion◦Cutdown procedures should not be considered routine IA

VI Catheter Site care◦Cutaneous antisepsis: Preferred antiseptic = 2% CHG; also

tincture of iodine, iodophor or 70% alcohol IA◦Allow to dry (iodophor should dry 2 min)◦Do not apply organic solvent like acetone prior to insertion IA

VII Catheter site dressing regiments◦Sterile gauze or transparent semi-permeable dressings IA◦Well healed tunneled CVC site may not need dressing◦Replace dressing if damp, loose or soiled◦Change dressings regularly, at least weekly◦No topical antibiotic ointment on insertion sites IA (exception dialysis)


VIII Selection and replacement◦ Select catheter with lowest risk of complication IA◦ Remove catheter when no longer essential IA◦ Do not remove/replace routinely just to reduce infection risk◦ Adults -Replace PIV every72-96 hrs to prevent phlebitis; ◦ Peds-leave in place until therapy completed unless complication◦ Replace all catheter place under ER conditions within 48 hrs◦ Use clinical judgment to determine when to replace a catheter that could

be source of infection◦ Replace any short term CVC if purulence observed at site◦ Replace all CVCs is patient hemodynamically unstable and CR-BSI

suspected◦ Do not use guide wire technique to replace catheters when CR-BSI

suspected


IX Replacement of administration sets◦Replace sets no more frequently than 72 hours unless inf IA◦Replace tubing for blood, lipid emulsions within 24 hours.◦Replace tubing used for propofol every 6-12 hrs IA◦Needleless systems: change components as often as set;

change caps no more frequently than 72 hrs;wipe access port with appropriate antiseptic and access only with sterile devices

◦Parenteral fluids: Complete infusion of lipid-containing within 24 hrs of hanging; lipid emulsion: 12 hrs; blood within 4 hours; no recommendation for other parenteral fluids

X IV Injection ports◦Clean ports with 70% alcohol or iodophor IA◦Cap stopcocks when not in use.


XI Prep and QC of IV admixtures◦Admix in LAF hood using aseptic technique◦Do not use containers with cracks, leaks etc◦Use single dose vials whenever possible; do not

combine left over content for later use IA◦If multidose used, follow manufacturer recommendations

XII In line filters ◦Do not use routinely for IC purposes IA

XIII IV therapy personnel◦Designate trained personnel for insertion and

maintenance of IV catheters IAXIV Prophylactic antibiotics

◦Do not use prophylactic antibiotic routinely before insertion of IC catheters to prevent infection IA


PIV including Mid-line catheters:◦ Selection of catheter, site and catheter site care

CVC: Selected recommendations◦Surveillance: Determine CR-BSI rates & monitor; express as

BSI/1000 catheter-days; investigate unexpected events◦Use CVC with minimum # ports/lumens needed◦Use antimicrobial/antiseptic-impregnated CVC in adult if

expected in place for >5 days if after implementing strategy to reduce, rate remains.

◦KEY STRATEGY: Education; use of maximal sterile barrier precautions and 2% CHG prep during CVC insertion.


CVC Selected issues◦No recommendation: impregnated cath in children◦Designate competent personnel to supervise trainees for

catheter insertion 1A◦Maximal barriers for insertion means: cap, mask, sterile

gown, gloves, large sterile sheet for catheter, including PICCS and guidewire exchange 1A

◦Guidewire: exchange only for malfunction (not infection); use new set sterile gloves for new cath

◦Catheter care: Designate one port for hyperal◦Antibiotic locks: Do not use routinely to prevent CR-BSI◦Dressings: Replace when loose, wet, soiled. Short term

CVC every 2 days gauze; 7 days transparent (adults)◦Tunneled or implanted CVC: no more than 1/wk


Arterial and Pressure Monitoring Devices (Selected recommendations)

◦Use disposable transducer assemblies if possible; sterilize transducer domes if reusable required

◦Replace at 96 hr intervals◦Keep all solutions sterile◦Do not administer dextrose-container/TPN through

pressure monitoring circuit

New tubing/catheters planned to avoid attaching wrong solution.


Umbilical Catheters Selected recommendations◦Arterial or Venous: Remove and do not replace if any sign of

CR-BSI, vascular insufficiency or thrombosis◦Cleanse with antiseptic- avoid tincture of iodine◦Do not use topical antibiotic ointment/creams ◦Remove as soon as possible; venous catheters can be used

up to 14 days if managed aseptically

App. B Duration of Catheterization

CATHETER TYPE DURATION COMMENT

Peripheral IV 72-96hrs adults; None for children

Peripheral IV if ER change w/in 24 hr.

Arterial Catheter No routine replacement Transducer 72 hrs

Transducer 72 hrs

Pulmonary artery No routine replacement

Non-Tunneled CVC Tunneled; Total Implantable Device/port

Do not routinely replace No recommendations

(Do not rotate site or guidewires)

Umbilical No routine replacement

Hemodialysis cath No recommendations

Appendix B

CATHETER TYPE GAUZE DRESSING TRANSPARENT DRESSING

Peripheral At time of replacement wet ,loose soiled

Same

Arterial

At time of replacement, wet, loose, soiled

Same

Central Venous (include PICC)

q 48 hr; or if wet, loose, soiled

Every 7 days (short term caths)

Pulmonary

q 48- q 48 hr; or if wet, loose, soiled

q 48 hr; or if wet, loose, soiled

Umbilical Not applicable Not applicable

References

http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf July 2013

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs 2006; 29 (Jan./Feb): S1 – S92.

http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Definitions

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“one or more blood cultures” means that at least one bottle from a blood draw is reported by the laboratory as having grown at least one organism

“recognized pathogen”

A few of the recognized pathogens are S. aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., Candida spp.

“two or more blood cultures drawn on separate occasions” means 1) that blood from at least two blood draws were collected within two calendar days of each other

Comments on blood cults

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Blood cultures drawn from different sites (e.g., different venipunctures or different lumens of the same central line) should undergo separate decontaminations and are therefore considered drawn on “separate occasions”.

Blood culture may consist of a single bottle for a pediatric blood draw due to volume constraints. Each bottle from two or more draws would have to be culture-positive for the same commensal.

Blood cultures drawn through central lines can have a higher rate of contamination than blood cultures collected through peripheral venipuncture

Primary Bloodstream Infection

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Primary bloodstream infections (BSI) are laboratory-confirmed bloodstream infections (LCBI)that are not secondary to a community-acquired infection or an HAI meeting CDC/NHSN criteria at another body site .

Central line-associated BSI (CLABSI): A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1, and

a CL or UC was in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the LCBI criteria must be fully met on the day of discontinuation or the next day. If the patient is admitted or transferred into a facility with a central line in place (e.g., tunneled or implanted central line), day of first access is considered Day1.

Laboratory-Confirmed Bloodstream Infection Criteria

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Patient has a recognized pathogen cultured from one or more blood cultures, and

organism cultured from blood is not related to an infection at another site.

Patient has at least one of the following signs or symptoms: fever (>38 C), chills, or hypotension and

Signs and symptoms and positive laboratory results are not related to an infection at another site, and

Common commensal is cultured from two or more blood cultures drawn on separate occasions.

Laboratory-Confirmed Bloodstream Infection Criteria

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Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38oC core), hypothermia (<36oC core), apnea, or bradycardia and

positive laboratory results are not related to an infection at another site

And the same common commensal

http://www.cdc.gov/nhsn/XLS/master-organism-Com-Commensals-Lists.xlsx

http://www.cdc.gov/nhsn/XLS/master-organism-Com-Commensals-Lists.xlsx

Transfer Rule

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If all elements of a CLABSI are present within 2 calendar days of transfer from one inpatient location to another in the same facility or a new facility (i.e., on the day of transfer or the next day), the infection is attributed to the transferring location or facility. Receiving facilities should share information about such HAIs with the transferring facility to enable reporting.

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*Catheter tip cultures are not used to determine whether a patient has a primary BSI.

* When there is a positive blood culture and clinical signs or symptoms of localized infection at a vascular access site, but no other infection can be found, the infection is considered a primary BSI.

• Purulent phlebitis confirmed with a positive semiquantitative culture of a catheter tip, but with either negative or no blood culture is considered a CVS-VASC, not a BSI or a SST-SKIN or a ST infection.

• Occasionally a patient with both peripheral and central IV lines develops a primary bloodstream infection (LCBI) that can clearly be attributed to the peripheral line (e.g., pus at the insertion site and/or matching pathogen from pus and blood).

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Patient has a central line inserted on June 1. On June 3, the central line is removed and on June

4 the patient has a positive blood culture with S. aureus.

This is a CLABSI because the central line was in place for >2 calendar days (June 1, 2, and 3), and was in place the day before the date of event.

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Documents

Prevention of Infections Associated with Vascular Access Devices (VADs) Michigan Society of Infection Prevention & Control Fundamentals of Infection Prevention