ICT invited experts in infection prevention and control to share their perspectives on device-related infections. Our participants for this roundtable are:
Lisa Maragakis, MD, MPH, associate professor of medicine and senior director of infection prevention, Johns Hopkins Health System
John D. Goldman, MD, vice president of hospital-based medicine, PinnacleHealth System
Paul Chittick, MD, Beaumont Hospital, Royal Oak infectious disease physician
ICT: In general, do you believe U.S. hospitals have made progress in curbing or eliminating CLABSIs/CRBIs and CAUTIs?
Maragakis: I believe that U.S. hospitals have made tremendous progress in preventing and reducing the incidence of CLABIs and CAUTIs, though we still have opportunities for further improvement. In particular, the Centers for Disease Control and Prevention’s National Healthcare Safety Network data show an impressive decrease in CLABSI rates nationally, which is very encouraging. Now our efforts need to be focused on achieving further reductions in these health care-associated infections and, importantly, on how to best sustain the results that we have achieved to date.
Goldman: Hospitals in the U.S. have made tremendous progress in decreasing healthcare associated infections. According to the Center for Diseases Control (CDC), between 2008 and 2014, there has been a decrease in almost every category of common hospital acquired infections. For example, there has been a 50 percent decrease in central line associated blood stream infections, there has been a 17 percent decrease in surgical site infections, and there has also been an 8 percent reduction in Clostridium difficile infections; an infection that results in severe form of diarrhea typically after the patient has been given antibiotics. The only major category that did not show a decrease during this time frame was catheter associated urinary tract infections. Across the country, we have actually seen a remarkable decrease in the number of hospital-acquired infections in the last several years.
Chittick: We have absolutely made progress. The most recent CDC data shows a 50 percent decrease in CLABSIs nationally from 2008 to 2014. CAUTI drops have not been as dramatic but national data from 2013-2014 suggests improvement. I think stakeholders at all levels, from nurses to physicians, patients, infection control practitioners, hospital administrators and government administrators, have realized the importance of preventing infections, and have, in turn increased the amount of time, energy and money spent trying to do reduce rates.”
ICT: What are the practices you believe to be most effective in preventing infection related to venous catheters? Urinary catheters?
Maragakis: The evidence-based best practices for preventing infection due to venous catheters and urinary catheters are compiled and presented very nicely in the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, which was written and updated in 2014 by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America, with partner organizations the American Hospital Association, Association for Professionals in Infection Control and Epidemiology, and the Joint Commission. These practices fall into several broad categories, including prevention at the time of device insertion, proper maintenance of the devices, removing devices as soon as possible, and ensuring adequate training and competency of all staff members involved with the insertion and care of the devices.
Goldman: The most effective practice for preventing central line associated are insertion checklists that are observed by someone other than the team putting in the line. These checklists include a sterile gown, gloves, and mask for the physician inserting the line, a full sterile drape for the patient, and that the patient has been prepped in a proper manner. These checklists also include standards for properly maintain the lines including assessing the line, proper dressings, and regularly changing these dressings. The best way to prevent catheter associated urinary tract infections is also check lists to ensure they are inserted in a sterile manner, maintained in a sterile manner, and that they are taken out as soon as possible. The biggest risk factor for a catheter associated urinary tract infection is the duration of catheterization. Therefore, routine reassessment of whether a urinary tract catheter is still needed; (preferably on a daily basis) is one of the most effective ways to reduce the frequency of these infections.
Chittick: The most important aspect is to identify patients who do not need a central venous catheter or urinary catheter. No device, no device related infection. If a patient truly needs a catheter, it should be removed just as soon as it is no longer necessary, thereby reducing the risk of infection.
ICT: Is the insertion/removal of the catheter or maintenance of the catheter more problematic in terms of opportunity to cause infections?
Maragakis: Insertion, maintenance and removal of venous and urinary catheters are all important aspects to address when implementing a comprehensive program to prevent device-associated infections. Insertion practices must be pristine so that the devices are not contaminated at the time they are placed. Maintenance practices are extremely important and often overlooked or not optimal given the many demands and competing priorities in busy clinical settings. Data suggest that approximately 80 percent of CLABSIs occur when the associated catheter has been in place for five or more days, suggesting that we need to continue to work to improve catheter maintenance. Of course, removing catheters as soon as possible is one of the most important things we can do to prevent infections.
Goldman: Both are problematic. Early infections of a catheter (within the first week) are often caused by improper insertion techniques) and later infections (after the first week) are often caused by improper maintenance techniques. It should be noted that in hospitals that pay meticulous attention to both sterile insertion of central line catheters and proper maintenance of these catheters the infections rates of these catheters can be reduced to essentially zero. However, the longer a catheter is kept in place, the more likely that it will become infected, and if catheters are left in long enough, most will become infected. Therefore, in terms of preventing these infections, it is critical to make sure than are used only as long as they are needed.
Chittick: Catheter insertion, removal and maintenance can all contribute to infection. I think our insertion techniques have improved dramatically in the last 15 years, with better use of aseptic technique, insertion bundles, catheter checklists. We have also empowered health care providers to abort procedures when there’s a problem. This is the area in which we’ve recently made the greatest progress. To further decrease infection rates, hospitals should focus on length of use. Another area of promise for decreasing infection: the use of prevention devices, including passive disinfection connector caps, CHG-impregnated dressings and antimicrobial catheters.
ICT: Do you believe that biofilms are still a major threat, and do you think newer technology is helping address this?
Maragakis: Biofilms are undoubtedly an important factor in device related infections. Newer technologies strive to help reduce biofilm formation. Since biofilm is only one factor and catheters can become contaminated in a variety of ways, I believe that our main emphasis should always be on ensuring that evidence-based best practices occur and that our staff members have the knowledge, skills and tools they need to provide the safest use of these devices at all times.
Goldman: Biofilms are one of the microbiologic reasons that catheters are at higher risk of infection. However, it has been shown that central line infections can be reduced to essentially zero with proper insertion and maintenance of these catheters despite the presence of biofilms.
Chittick: Biofilms will always be a problem. They are the reason bacteria exists in nature and make treatment of infections, particularly if the goal is curative or eradication, more difficult. I tend to think about them more as they relate to permanent device-related infections. For example, prosthetic joints, pacemakers, etc. But they certainly play a role in the use of short term devices as well. I don't think anti-biofilm technology has progressed to the point that it's making a huge difference thus far, but it certainly has that potential, either as a preventive or as a treatment.
ICT: Are catheters being removed more timely these days or is this still a significant issue in hospitals?
Maragakis: Hospital staff members are much more aware of the need to remove invasive devices as soon as possible to prevent infections. Most hospital units have implemented strategies to review each patient’s need for these devices each day so that they can be promptly removed.
Goldman: There has been an increased emphasis on the timely removal of central venous catheters and urinary tract catheters. In most hospitals, the need for the continued use of these catheters is reviewed on a daily basis, and as a result, they are removed more quickly. The more timely removal of these catheters is one of the major reasons that the incidence of these infections are decreasing.
Chittick: Hospitals are making progress in this area, but there is still plenty of room for improvement.
ICT: In your own institution, what have been the challenges related to devices and infections, and how have you addressed them?
Maragakis: One of the main challenges we face in infection prevention is how to sustain the very best prevention practices over a long period of time. This is especially true in academic centers or other settings where there is a high turnover rate of new trainees or staff members. For all health care settings, this means that issues including orientation, training, competency assessment, and staff recruitment and retention are vital aspects of the infection prevention approach.
Goldman: At PinnacleHealth, we have been very successful in reducing both the number of central line associated catheter infection and catheter associated UTIs by the use of checklists, observed insertions, and early removal of the catheters. The challenge is to continue the keep the levels of these infections low as we take care of patients in the hospital that are increasing ill, have more medical problems, and often have a greater need for the type of interventions that put them at risk of infection.
Chittick: We face the same challenges here as in all hospitals. We are seeing increasingly complex cases, including patients who require high levels of care, as well as invasive procedures and devices. We have and continue to address all aspects of patient care as it relates to device usage, from prevention, to insertion to maintenance and removal.