Reducing Catheter-related Bloodstream Infections in the NICU

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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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 pathogen is Staphylococcusaureus:

Retain catheter only if bacteraemia resolveswithin 24 h and there is no clinical orechocardiographic evidence of infectiveendocarditis


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In all other situations:

Retain catheter unless bacteraemia persistsafter four days of appropriate intravenousantibiotics or child becomes unstable.

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Reducing Catheter-related Bloodstream Infections in the NICU