Strategies for prevention of catheter-related bloodstream infections

 Prevention of catheter-related bloodstream infections is critically dependent on an accurate knowledge of the two main routes by which intravascular devices become contaminated: the extraluminal (skin-related) and the intraluminal (hub-related) routes. Extraluminal catheter seeding results from infection of the catheter entry site by microorganisms and leads to bacteremia most often during the week following catheter placement. The main ways of preventing it are appropriate skin disinfection and the adoption of maximal antiseptic barriers at the time of catheter insertion. Avoiding the internal jugular and the femoral veins, whenever possible, will reduce the likelihood of bacteremia. Intraluminal contamination is the consequence of improper handling of the catheter hub at the time of connection and disconnection of the administration set. It is the most common origin of catheter infections after the first week of catheter placement. Multiple-lumen catheters, side-ports and multipurpose catheters particularly increase the risk of endoluminal contamination. To prevent it, strict asepsis should be observed in hub handling and hubs should be protected against environmental soiling with an antiseptic impregnated gauze at all times. New technology is available for prevention of catheter infections: antibiotic and antiseptic-coated catheters, antiseptic hubs, disinfecting caps and flushing solutions are currently undergoing scientific assessment. Published online: 22 July 1999     

集束化策略在防止中心静脉导管相关性血流感染中的应用

中心静脉置管在临床运用日渐广泛,然而,由其带来的中心静脉导管相关性血流感染(central venous catheter-related blood stream infection,CRBSI)也成为临床最主要和最常见的并发症之一,其发病率已达到5%～30%[1],感染病人中病死率为12%～25%[2],且感染最常见的病原微生物是金黄色葡萄球菌和白色念珠菌[3].因此,实施严格的感染控制规范来防止CRBSI的发生是临床亟待解决的问题.     

Eliminating catheter-related bloodstream infections in the intensive care unit

OBJECTIVE: To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). DESIGN: Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. SETTING: The Johns Hopkins Hospital. PATIENTS: All patients with a central venous catheter in the ICU. INTERVENTION: To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. MEASUREMENT: The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. MAIN RESULTS: Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU. CONCLUSIONS: Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.     

Antimicrobial-impregnated catheters for the prevention of catheter-related bloodstream infections

Central venous catheters are commonly used in critically ill patients. Such catheterization may entail mechanical and infectious complications. The interest in catheter-related infection lies in the morbidity, mortality and costs that it involved. Numerous contributions have been made in the prevention of catheter-related infection and the current review focuses on the possible current role of antimicrobial impregnated catheters to reduce catheter-related bloodstream infections (CRBSI). There is evidence that the use of chlorhexidine-silver sulfadiazine (CHSS), rifampicin-minocycline, or rifampicin-miconazol impregnated catheters reduce the incidence of CRBSI and costs. In addition, there are some clinical circumstances associated with higher risk of CRBSI, such as the venous catheter access and the presence of tracheostomy. Current guidelines for the prevention of CRBSI recommended the use of a CHSS or rifampicin-minocycline impregnated catheter in patients whose catheter is expected to remain in place > 5 d and if the CRBSI rate has not decreased after implementation of a comprehensive strategy to reduce it.     

ICU病人中心静脉置管相关血流感染的临床特点分析

[目的]分析重症监护病房(ICU)中心静脉置管相关血流感染(CVC-RBI)临床特点及病原菌分布,为防治CVC-RBI提供参考。[方法]回顾性分析2006年7月—2010年6月ICU CVC-RBI 53例病人的临床资料,分析病原菌分布及易感因素分布情况等。[结果]CVC-RBI易感因素有中心静脉置管≥14d、低蛋白血症≥10d、开关中心静脉导管接头每日≥3次或连接多个三通管、留置体腔引流管≥4根、应用2种以上抗生素≥7d、合并其他部位(腹腔、肺、尿路)感染、胃肠外营养(PN)≥10d、外科大手术后;共分离出53种病原菌,革兰阳性球菌占58.49%,真菌占33.96%,革兰阴性杆菌占7.55%。[结论]重视ICU内CVC-RBI病原菌分布情况,针对易感因素进行综合防治。     

"Targeting to zero" in pediatric oncology: a review of central venous catheter-related bloodstream infections

Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12,400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.     

Preventing intravascular catheter-related bloodstream infections in the critical care setting

Although intravascular catheters are indispensable for managing the care of critically ill patients, they can be associated with serious infection. Catheter-related bloodstream infections (CR-BSI) are a major cause of morbidity and mortality in the critical care setting. These infections are largely preventable. This article reviews the epidemiology and pathogenesis of these infections, the role of the critical care nurse in the diagnostic evaluation of CR-BSI, and strategies for their prevention.     

中心静脉导管溶栓相关性血流感染的原因分析及预防

目的分析中心静脉导管溶栓相关性血流感染的原因并探讨预防措施。方法选择中心静脉导管血栓患者750例,采用尿激酶和华法林进行溶栓治疗。分析患者溶栓后血流感染病原菌分布情况及各类病原菌的耐药率,探讨溶栓相关性血流感染的预防措施。结果 750例中心静脉导管血栓患者中有60例发生血流感染,感染率为8%。60例感染者中,存在60株3大类病原菌(革兰阴性杆菌、革兰阳性球菌、真菌),其中以革兰氏阳性菌为主(占68.33%),革兰氏阳性菌中主要致病菌为金黄色葡萄球菌(占58.34%)。3大类病原菌感染患者主要就诊科室为普外科和内分泌科。股静脉置管发生感染的比率(8.07%)较高,不同置管部位感染率差异不显著(P0.05)。置管时间越长感染率越高,置管时间21 d的患者感染率为21.43%,显著高于置管时间7 d患者的感染率3.14%。金黄色葡萄球菌对万古霉素、氯霉素的耐药率达100%,完全不耐庆大霉素;9株表皮葡萄球菌完全耐万古霉素(100%),完全不耐氯霉素和庆大霉素;大肠埃希菌对哌拉西林/他唑巴坦、亚胺培南的耐药率高达100%,几乎不耐氨苄西林,对其他药物如头孢唑林、头孢他啶、庆大霉素等具有一定耐药性。结论临床应依据患者感染病原菌种类和药敏试验结果选择合适的抗菌药物,以降低中心静脉导管溶栓相关性血流感染的发病率。     

Prevention of catheter-related bloodstream infections in the neonatal intensive care setting

Nosocomial infection causes substantial morbidity and mortality among neonates treated in the neonatal intensive care setting. Colonization and subsequent infection of central venous catheters leading to catheter-related bloodstream infection is among the most common causes of nosocomial sepsis in this patient population. Prevention of catheter-related bloodstream infection is a major challenge and numerous strategies have been attempted in this context with varying success. Given the dynamic epidemiology of nosocomial infection among neonates and the emergence of antimicrobial resistance, novel prevention strategies are urgently required.     

Prevention of catheter-related bloodstream infections in the neonatal intensive care setting

Nosocomial infection causes substantial morbidity and mortality among neonates treated in the neonatal intensive care setting. Colonization and subsequent infection of central venous catheters leading to catheter-related bloodstream infection is among the most common causes of nosocomial sepsis in this patient population. Prevention of catheter-related bloodstream infection is a major challenge and numerous strategies have been attempted in this context with varying success. Given the dynamic epidemiology of nosocomial infection among neonates and the emergence of antimicrobial resistance, novel prevention strategies are urgently required.     

The cost of catheter-related bloodstream infections: implications for the value of prevention

Catheter-related bloodstream infections (CRBSIs) are frequently observed in the intensive care unit (ICU) and are a serious cause of morbidity and mortality in the United States. This article summarizes what is currently known about the cost of CRBSIs in the ICU setting. The cost of CRBSIs is between $33,000 and $44,000 in the general adult ICU, between $54,000 and $75,000 in the adult surgical ICU, and approximately $49,000 in the pediatric ICU. Finally, CRBSIs are associated with reimbursement that is more than $26,000 less than costs. Hospital and clinical decision makers should be aware of the high cost of CRBSIs in the ICU, the relatively poor reimbursement, and the implied high value of prevention efforts.     

ICU患者发生导管相关性血流感染的原因分析及对策

目的 探讨ICU患者发生导管相关性血流感染(catheter related bloodstream infection,CRBSI)的原因,并制订相应的对策.方法 回顾性分析2010年5月～2011年5月本院实施中心静脉置管治疗的患者751例,其中发生CRBSI 21例,分析发生的原因并制订相应的对策.结果 21例患者发生CRBSI的原因与操作流程不当、患者个体因素、导管的类型和材料、置管部位和时间等有关;其中2例患者进行了导管更换,4例拔除了导管,其余15例感染得到控制,病情稳定转出ICU,1例患者死亡.结论 ICU应制订完善的预防机制,对医护人员进行正规的置管培训,同时加强无菌观念,落实血管内导管的管理与监测,以保证患者的置管安全,预防CRBSI的发生.     

国内集束化护理预防深静脉导管相关性血流感染效果的Meta分析

目的 系统评价集束化护理干预对预防深静脉导管相关性血流感染的效果.方法 应用计算机检索国内相关文献,采用RevMan5.2软件进行统计处理.结果 共纳入13篇符合条件的文献.其合并OR值为0.33,95％CI为(0.26,0.43),说明集束化护理干预可以显著降低深静脉导管相关性血流感染的发生率.结论 集束化护理是一种切实可行的干预措施,值得在临床上推广.     

The role of nurses working in emergency and critical care environments in the prevention of intravascular catheter-related bloodstream infections

Intravascular catheter-related infections are a major problem in healthcare. This review provides up-to-date guidance of evidence-based recommendations for the prevention of intravascular catheter-related infections with special focus on strategies relevant for nurses working in emergency and critical care environments or practitioners responsible for surveillance and control of infections. The review concludes by providing a range of approaches advocated for: (i) translating guidelines to the needs and expectations of emergency and critical care nurses, and (ii) increasing the chance of successful implementation and compliance with these recommendations.     

浅谈介入导管相关性血流感染的预防与控制

由于介入放射疗法具有微创、简便、安全、有效的特点,并为一些传统疗法难以治疗或疗效不佳的疾病提供了一种新的治疗途径,在近20年里获得了突飞猛进的发展,应用范围不断拓宽,被广大患者所接受。但作为一种侵入性操作,增加了医院感染的可能。为了预防和控制介入导管相关血流感染的发生,我们在实际工作中采取了一系列措施,至今没有1例相关事件发生。现将我们的经验介绍如下。     

中心静脉导管相关血流感染的流行病学变迁:革兰阴性病原菌发生率增加

革兰阳性菌是中心静脉导管相关血流感染(CRBSIs)的主要病原菌。近期指南所推荐的经验治疗方案也主要针对革兰阳性菌,仅在特殊情况覆盖革兰阴性菌。本研究分析1991—2008年期间CRBSIs的流行病学变迁,并探讨革兰阴性菌CRBSIs的易感因素。本研究前瞻性收集确诊CRBSIs病例进行分析。收集     

Intervention to reduce catheter-related bloodstream infections in a pediatric intensive care unit

Objective  

Identification of catheter-related bloodstream infection (CR-BSI) risk factors and determination of whether intervention related to identified risk factors would reduce CR-BSI rates.     

Use of central venous catheter-related bloodstream infection prevention practices by US hospitals

OBJECTIVE: To examine the extent to which US acute care hospitals have adopted recommended practices to prevent central venous catheter-related bloodstream infections (CR-BSIs). PARTICIPANTS AND METHODS: Between March 16, 2005, and August 1, 2005, a survey of infection control coordinators was conducted at a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n=600) and at all Department of Veterans Affairs (VA) medical centers (n=119). Primary outcomes were regular use of 5 specific practices and a composite approach for preventing CR-BSIs. RESULTS: The overall survey response rate was 72% (n=516). A higher percentage of VA compared to non-VA hospitals reported using maximal sterile barrier precautions (84% vs 71%; P=.01); chlorhexidine gluconate for insertion site antisepsis (91% vs 69%; P<.001); and a composite approach (62% vs 44%; P=.003) combining concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Those hospitals having a higher safety culture score, having a certified infection control professional, and participating in an infection prevention collaborative were more likely to use CR-BSI prevention practices. CONCLUSION: Most US hospitals are using maximal sterile barrier precautions and chlorhexidine gluconate, 2 of the most strongly recommended practices to prevent CR-BSIs. However, fewer than half of non-VA US hospitals reported concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Wider use of CR-BSI prevention practices by hospitals could be encouraged by fostering a culture of safety, participating in infection prevention collaboratives, and promoting infection control professional certification.     

抗感染中心静脉导管预防导管相关性血流感染的效果

目的评价抗感染中心静脉导管在预防导管相关性血流感染（CRBSI）中的临床价值。方法采用随机数字法,将850例肿瘤患者随机分为实验组420例（采用抗感染中心静脉导管）和对照组430例（采用普通中心静脉导管）,比较两组CRBSI发生率,分析导管相关性血流感染病原菌的种类与特点。结果发生CRBS166例,其中实验组25例,对照组41例,两组导管留置7d前CRBSI感染牢差异无统计学意义（χ2=0．06,P〉0．05）,7d后实验组CRBSI感染率较对照组低,差异有统计学意义（χ2分别为3．91,4．30,P〈0．05）。实验组减少导管相关性血流感染的病原体主要为革兰阳性菌。结论抗感染中心静脉导管可明显减少导管相关性血流感染的发生,有很大的临床价值。