By Kelly M. Pyrek
The Centers for Disease Control and Prevention (CDC) and its Healthcare Infection Control Practices Advisory Committee (HICPAC) have updated a guideline, "Guidelines for the Prevention of Intravascular Catheter-Related Infections," designed to help practitioners eliminate bloodstream infections in patients with intravenous catheters, considered to be deadly and costly healthcare-associated infections (HAIs).
"The updated CDC guidelines are rich with new recommendations that are based on additional scientific research that has emerged since the prior version was published," says APIC 2011 president Russell N. Olmsted, MPH, CIC. "This is an important resource to support efforts toward the elimination of catheter-related bloodstream infections (CRBSIs)."
Another expert, William Jarvis, MD, president of Jason and Jarvis Associates, agrees that infection preventionists must be able to successfully translate science into practice. "I think all the data supporting recommendations in each CDC/HICPAC guideline should be in the room during discussions, everyone should be familiar with them and during discussions these data (the evidence) should be examined," Jarvis says.
As the guidelines note, "The goal of an effective prevention program should be the elimination of CRBSI from all patient-care areas. Although this is challenging, programs have demonstrated success, but sustained elimination requires continued effort. The goal of the measures discussed in this document is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and the limitations of current strategies and technologies."
In recent years, a reinvigorated patient safety movement has spawned new study results demonstrating significant success in reducing and eliminating HAIs like CRBSIs. Specifically, the Keystone ICU Project, a federally funded program led by patient safety expert Peter Pronovost, MD, PhD, FCCM, involving intensive care units in Michigan hospitals, demonstrated the potential for the elimination of CRBSIs. The Michigan collaborative reduced the incidence of CRBSIs by two-thirds, saving more than 1,500 lives and $200 million in the first 18 months. Similarly organized initiatives in other states and countries have also reported similar degrees of success. The critical underlying foundation for these successes has been use of five key prevention strategies from the 2002 version of CDC's guidelines that were based on published, scientific evidence.
The combination of national and local focus on preventing CRBSIs, and specifically central line-associated bloodstream infections (CLABSIs), has proven to be effective in improving patient safety. A recent CDC report showed a 58 percent decrease in CLABSIs among hospital ICU patients in 2009, compared to 2001. In 2009 alone, reducing these infections saved about 3,000 to 6,000 lives and about $414 million in extra medical costs, compared with 2001. However, infections still occur in healthcare settings, and diligent prevention efforts must continue.
Jarvis says its time for any hospitals still not implementing evidence-based practices such as those in the updated guideline to understand the importance of compliance with proven methods. "The data for use of an insertion and a maintenance bundle (similar to SHEA's basic and special approaches in the SHEA Compendium) should be mandated for all ICUs today," Jarvis emphasizes. "We have at least six to 10 studies showing that when such bundles are used that the majority of CLABSIs in ICU patients are preventable. Unfortunately, many hospitals are not fully implementing these recommendations, but rather pick and chose on the basis of cost. We need the goal to be zero, not our rate is low."
The many drivers of compliance, including public reporting, CMS pay-for-performance mandates and a call for HAI elimination in the Department of Health and Human Services (HHS) Healthcare-Associated Infection (HAI) Action Plan, are applying added pressure to doing whats right for improved patient outcomes.
"The timing for this updated guideline is perfect because starting this year hospitals that accept Medicare patients are required to report their central line-associated bloodstream infections to the Centers for Medicare & Medicaid Services, or risk losing 2 percent of their Medicare payments," Olmsted says.
"More and more pressure will be put on hospitals to fully implement these bundles, as public reporting of their rates occurs," Jarvis says. "There was a major article in The Tennessean a couple of weeks ago criticizing a couple of hospitals in Nashville (including a major teaching hospital) about their high CLABSI rates in their ICU patients. This type of activity will force hospital administrators to implement insertion and maintenance bundles and to enforce clinician accountability."
The guidelines suggest that healthcare institutions can reduce infection rates to as low as feasible given the specific patient population being served, and Jarvis says the data show this is possible. "The surgical ICU at Johns Hopkins reduced their CLABSI rate from 11.4 to zero and others can do this as well," Jarvis says. "The Keystone ICU Project showed we can markedly reduce our CLABSI rates and sustain this after the funding and personnel go away. It is a change in culture from it is inevitable to it is preventable and should not happen."
The guidelines also examine the significance of the universal presence of microorganisms in the human environment related to catheter placement, maintenance, and Jarvis notes that "The insertion and maintenance bundles reduce the risk of CLABSI associated with these organisms."
The guidelines also explore the limitations of current strategies and technologies.
"We need to document the efficacy of the insertion and maintenance bundles outside of ICUs, although a hospital in ca has zero CLABs for four years now," Jarvis says. "Some populations (oncology, hemodialysis, etc.) may need additional interventions. When we move these interventions outside of ICUs, we will need IV teams (one cannot control hundreds or thousands of nurses and physicians)."
As director of the Hospital Infections Program at the CDC for more than 20 years, Jarvis is qualified to provide some unique insights relating to the guidelines process and makes several observations: "First, all those in infection control should read and comment on these CDC guidelines (only about 350 people submitted comments for this guideline and one-third were industry members commenting on their product and of the remainder, less than 10 read all the document, the references, and commented on the entire document). The infection control community must become more actively involved in this process," Jarvis says. "Second, we should all require that the data for each recommendation be specified (so we can review the papers and decide if we agree. Third, if all the studies documenting the efficacy of a product are all on one product (see CHG-impregnated sponge dressing), CDC and HICPAC should not be afraid to name the product. Data should be the determinant of the recommendation and the more specific the better. Following this example, CDC recommended use of the CHG-impregnated sponge disk instead of the Biopatch. Now, another company, Guardiva, has come out with a CHG-impregnated dressing with a hemostatic agent in it. It meets the CDC recommendation criteria, yet the package insert says not for prevention of CLABSIs (required by the FDA). This leads to confusion."
Jarvis continues, "A fourth observation is that all CDC and HICPAC personnel should be required to read the entire guideline and the references and then to sign that they agree with the final result. Fifth, the criteria for the level of recommendation should be stated and consistently applied from guideline to guideline and from recommendation to recommendation. For example, the Biopatch has 12 to 14 randomized controlled trials and is rated a category 1B. The CHG/silver-impregnated catheter (second generation) and minocycine-rifampin impregnated catheter together have fewer than 10 randomized controlled trials -- all either in ICU or cancer patients -- yet it is a category 1A recommendation. Science should be politically blind and totally based on the data."
The guidance document, "Guidelines for the Prevention of Intravascular Catheter-Related Infections" replaces guidelines published in 2002, and was developed by a working group led by the Society of Critical Care Medicine, in collaboration with the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Surgical Infection Society, American College of Chest Physicians, American Thoracic Society, American Society of Critical Care Anesthesiologists, Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society, Oncology Nursing Society, American Society for Parenteral and Enteral Nutrition, Society of Interventional Radiology, American Academy of Pediatrics, Pediatric Infectious Diseases Society, the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee.
The document will be published in its entirety in a special supplement to the American Journal of Infection Control. The journal will also present a video roundtable that features perspectives of healthcare professionals on the impact of this new guideline on infection prevention practices. To access the complete guidelines, visit: www.cdc.gov/hicpac. The guidelines also appear in the journal Clinical Infectious Diseases, http://cid.oxfordjournals.org/.
Summary of Recommendations
Education, Training and Staffing
1. Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Category IA
2. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Category IA
3. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. Category IA
4. Ensure appropriate nursing staff levels in ICUs. Observational studies suggest that a higher proportion of "pool nurses" or an elevated patientto-nurse ratio is associated with CRBSI in ICUs where nurses are managing patients with CVCs. Category IB
Selection of Catheters and Sites
Peripheral Catheters and Midline Catheters
1. In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. Category II
2. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site. Category II
3. Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators. Category IB
4. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs. Category IA
5. Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. Category II
6. Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection. If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually. Category II
7. Remove peripheral venous catheters if the patients develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter. Category IB
Central Venous Catheters
1. Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement). Category IA
2. Avoid using the femoral vein for central venous access in adult patients. Category 1A
3. Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement. Category IB
4. No recommendation can be made for a preferred site of insertion to minimize infection risk for a tunneled CVC. Unresolved issue
5. Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis. Category IA
6. Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis. Category 1A
7. Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique. Category 1B
8. Use a CVC with the minimum number of ports or lumens essential for the management of the patient. Category IB
9. No recommendation can be made regarding the use of a designated lumen for parenteral nutrition. Unresolved issue
10. Promptly remove any intravascular catheter that is no longer essential. Category IA
11. When adherence to aseptic technique cannot be ensured (i.e catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e, within 48 hours. Category IB
Hand Hygiene and Aseptic Technique
1. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. Category IB
2. Maintain aseptic technique for the insertion and care of intravascular catheters. Category IB
3. 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. Category IC
4. Sterile gloves should be worn for the insertion of arterial, central, and midline catheters. Category IA
5. Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
6. Wear either clean or sterile gloves when changing the dressing on intravascular catheters. Category IC
Maximal Sterile Barrier Precautions
1. Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange. Category IB
2. Use a sterile sleeve to protect pulmonary artery catheters during insertion. Category IB
1. Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion. Category IB
2. Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. Category IA
3. No comparison has been made between using chlorhexidine preparations with alcohol and povidone-iodine in alcohol to prepare clean skin. Unresolved issue.
4. No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Unresolved issue
5. Antiseptics should be allowed to dry according to the manufacturers recommendation prior to placing the catheter. Category IB
Catheter Site Dressing Regimens
1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. Category IA
2. If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved. Category II
3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. Category IB
4. 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. Category IB
5. Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower). Category IB
6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. Category II
7. Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. Category IB
8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. Category II
9. No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. Unresolved issue
10. Ensure that catheter site care is compatible with the catheter material. Category IB
11. Use a sterile sleeve for all pulmonary artery catheters. Category IB
12. Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, and MSB. Category 1B
13. No recommendation is made for other types of chlorhexidine dressings. Unresolved issue
14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. Category IB
15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category II
Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI. Category II
Catheter Securement Devices
Use a sutureless securement device to reduce the risk of infection for intravascular catheters. Category II
Antimicrobial/Antiseptic Impregnated Catheters and Cuffs
Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin -impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion. Category IA
Systemic Antibiotic Prophylaxis
Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI . Category IB
Use povidone iodine antiseptic ointment or bacitracin/gramicidin/ polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturers recommendation. Category IB
Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis
Use prophylactic antimicrobial lock solution in patients with long term catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique. Category II
Replacement of Peripheral and Midline Catheters
1. There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults. Category 1B
2. No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated. Unresolved issue
3. Replace peripheral catheters in children only when clinically indicated. Category 1B
4. Replace midline catheters only when there is a specific indication. Category II
Replacement of CVCs, Including PICCs and Hemodialysis Catheters
1. Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. Category IB
2. Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Category II
3. Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection. Category IB
4. Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. Category IB
5. Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. Category IB
6. Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
Needleless Intravascular Catheter Systems
1. Change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently than every 72 hours.. Category II
2. Change needleless connectors no more frequently than every 72 hours or according to manufacturers recommendations for the purpose of reducing infection rates. Category II
3. Ensure that all components of the system are compatible to minimize leaks and breaks in the system. Category II
4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. Category IA
5. Use a needleless system to access IV tubing. Category IC
6. When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves. Category II
Use hospital-specific or collaborative-based performance improvement initiatives in which multifaceted strategies are "bundled" together to improve compliance with evidence-based recommended practices. Category IB