According the U.S. Centers for Disease Control and Prevention, hand hygiene remains the single most important intervention in the quest for targeting zero healthcare-associated infections; however, experts recognize the growing role the patient's own skin flora plays in the potential development of an HAI, specifically bloodstream infections[1]. Bloodstream Infections are a major cause of healthcare-associated mortality and morbidity. Recent statistics from the CDC have demonstrated an up to 35 percent attributable mortality, and an excess length of stay of 24 days. Annually, there are more than 72,000 primary bloodstream infections estimated in the United States[2].
Epidemiology and microbiology of central line-associated bloodstream infections
The most commonly reported causative pathogens remain coagulase-negative staphylococci, Staphylococcus aureus, enterococci, and Candida spp. Gram negative bacilli accounted for 19 percent and 21 percent of CLABSIs reported to CDC and the Surveillance and Control of Pathogens of Epidemiological Importance database, respectively[3].
For all common pathogens causing CLABSIs, antimicrobial resistance is a problem, particularly in intensive care units. Although Methicillin-resistant Staphylococcus aureus now accounts for more than 50 percent of all Staphylococcus aureus isolates obtained in ICUs, the incidence of MRSA CLABSIs has decreased in recent years, perhaps as a result of prevention efforts. For gram negative rods, antimicrobial resistance to third generation cephalosporins among Klebsiella pneumoniae and E. coli has increased significantly as has imipenem and ceftazidine resistance among Pseudomonas aeruginosa. Candida spp. are increasingly noted to be fluconazole resistant. As you can see from the latest estimates from the CDC, many of these organisms have the potential to develop resistance mechanisms, which can dramatically increase the patient mortality and morbidity.
Evidence-based practices to prevent CLABSIs
The CDC guidelines were developed to provide evidence-based practices for preventing CLABSI and have five major areas of emphasis. First, those with responsibility for inserting and/or maintaining catheters must receive ongoing formal education and training on proper technique. Next, clinicians should utilize maximal sterile barrier precautions during the insertion process of the central venous catheter. Third, prior to inserting the device, clinicians should perform thorough skin antisepsis using a greater than 0.5 percent Chlorhexidine preparation with alcohol. Fourth, clinicians should avoid the routine replacement of central venous catheters as a strategy to prevent infection. Lastly, healthcare providers should consider the use of an alcohol/Chlorhexidine antiseptic for disinfection of needleless access sites prior to use as stated in the CDC evidence-based guidelines[4].
Checklist for the prevention of CLABSIs
The following checklist is based on the 2011 CDC Guideline for the Prevention of Intravascular Catheter-Associated Bloodstream Infections:
- Promptly remove unnecessary central lines. Perform daily audits to assess whether each central line is still needed
- Follow proper insertion practices:
- Perform hand hygiene before insertion of the line
- Adhere to aseptic technique
- Use maximal sterile barrier precautions (i.e. mask, cap, gown, sterile gloves, and sterile full-body drape)
- Perform skin antisepsis with >0.5 Chlorhexidine with isopropyl alcohol antiseptic
- Choose the best site to minimize infections and mechanical complications (avoid the femoral site in adult patients)
- Cover the site with sterile gauze or sterile, transparent, semipermeable dressings
- Handle and maintain central lines appropriately:
- Comply with hand hygiene requirements
- Scrub the access port or hub immediately prior to use with an appropriate antiseptic (e.g. Chlorhexidine, povidone iodine, an iodophor, or 70 percent alcohol). Some studies have shown that disinfection of the devices with chlorhexidine/alcohol solutions appears to be most effective in reducing colonization
- Access catheters only with sterile devices
- Replace dressings that are wet, soiled or dislodged
- Perform dressing changes under aseptic technique using clean or sterile gloves
- Empower staff to stop non-emergent insertion if proper procedures are not followed
- Bundle supplies to ensure items are readily available for us
- Provide the checklist above to clinicians to ensure all insertion practices are followed
- Ensure efficient access to hand hygiene products
Recently, emerging clinical evidence has demonstrated the efficacy of a 3.15 percent chlorhexidine gluconate/70 percent isopropyl alcohol antiseptic compared to traditional techniques using alcohol only. In a recent clinical study, disinfection of needleless access sites for 5 seconds followed by a 5 second dry time with the 3.15 percent chlorhexidine gluconate/70 percent isopropyl alcohol antiseptic demonstrated a statistically significant reduction in contamination of the devices compared to alcohol-only antiseptic[5].
Conclusion
In order to reduce the morbidity and mortality associated with HAI's, and to comply with stringent infection prevention and control standards of accreditation agencies, patient/skin hygiene and a holistic approach to infection prevention which includes the patient and their families must become an integral part of daily routines in healthcare facilities. The last line of defense in infection prevention is the patient and their families. Healthcare providers must now more actively engage these resources in properly accessing needleless access sites and disinfecting them appropriately prior to use. The use of a chlorhexidine gluconate/isopropyl alcohol antiseptic for disinfection of needleless access sites prior to use can assist healthcare professionals in reducing the risk for Healthcare Associated Infections.
For more information, contact Dr. Hudson Garrett at hudson.garrett@pdihc.com.
[1] Centers for Disease Control and Prevention, www.cdc.gov/hai, 2012.
[2] National Healthcare Safety Network, Centers for Disease Control and Prevention, 2012.
[3] Gaynes R, Edwards JR. Overview of Nosocomial Infections caused by gram-negative bacilli. Clin Infec Dis 2005: 41: 848-54.
[4] Guidelines for the Prevention of Intravascular Catheter-Related Infections, Centers for Disease Control and Prevention, 2011.
[5] Hayden, M. K., et al. A Randomized Cross-Over Clinical Trial to Compare 3.15% Chlorhexidine/70% Isopropyl Alcohol (CHG) vs 70%
Isopropyl Alcohol Alone (Alcohol) and 5s vs 15s Scrub for Routine Disinfection of Needleless Connectors (NCs) on Central Venous
Catheters (CVCs) in an Adult Medical Intensive Care Unit (ICU), Oral Abstract Presented at 2014 ID Week Conference, October 11, 2014, Philadelphia, PA.