SYMPOSIUM
tensive care unit setting. The most common organisms associated with catheter-associated bloodstream in- fection include Staphylococcus aureus, coagulase negative Staphylococci, En- terococcus, and enteric gram-negative bacilli such as Escherichia coli, Pseu- domonas aeruginosa, Klebsiella pneu- moniae, and Candida species.21
There
are two major mechanisms for the occurrence of a CLABSI: coloniza- tion at the insertion site with migra- tion of organism(s) along the external surface of the catheter within the first few weeks of catheterization and di- rect contamination of connectors or hubs resulting in internal colonization and subsequent CLABSI. Rarely can a catheter be seeded hematogenously from another site of infection or rarely from a contaminated infusion fluid.22 Further, similar to CAUTI, the clinical definition of CLABSI may vary from an NHSN-based surveillance definition to identify a bloodstream infection that occurred in patients with a central ve- nous line.23,24
Many prevention strategies that
involve insertion, maintenance, and other special approaches have been proposed to be extremely beneficial. (See Table 2.) Appropriate implemen- tation of these strategies may reduce the overall incidence of CLABSIs. 24
VENTILATOR-ASSOCIATED PNEUMONIA
In 2013, VAP surveillance transitioned to ventilator-associated events (VAEs) monitoring as an alternative approach for surveillance of events related to the patient being on a ventilator. VAE is associated with increased mortal- ity and increased length of stay.25
The
purpose of the transition was to more accurately define what can be reli- ably determined using surveillance definitions and to reduce ambiguity, improve reproducibility, and enable electronic collection of all variables.26 The transition to VAE empha-
sizes the importance of preventing all mechanical ventilator-associated complications, not just pneumonia. These include fluid overload, acute
respiratory distress syndrome, and atelectasis.27
institution approximately $36,286 to $44,220.16
Many tools are available on
the CDC’s NHSN website (
www.cdc .gov/nhsn), including calculators to help assess whether the patient has VAE.28 About 37 percent of VAEs are pre-
ventable with proper implementation of prevention strategies called VAP/ VAE bundle. It has been suggested that a typical VAP bundle should be implemented in its entirety for maxi- mal benefits.29
The components of a
typical VAP bundle are daily sedation vacations, daily spontaneous breath- ing trials (SBTs), daily assessment of readiness to wean, peptic ulcer dis- ease prophylaxis, daily oral care with chlorhexidine, venous thromboembo- lism prophylaxis (VTE), and elevation of the head of the bed (HOB).30 Studies have shown bundle compo-
nents vary in their associations with patient-centered outcomes. HOB el- evation, sedative infusion interrup-
A VAP may cost a health
TABLE 2. CATHETER LINE-ASSOCIATED BLOODSTREAM INFECTION PREVENTION STRATEGIES
Insertion 1. Rigorous performance and compliance of hand hygiene 2. Chlorhexidine (CHG)-alcohol based Skin-Prep 3. Usage of maximum sterile barrier precautions 4. Appropriate site selection such as avoidance of femoral insertion site in nonemergent settings 5. Use of ultrasound guidance for insertion of catheters in areas such as internal jugular vein
Maintenance 1. Disinfection of catheter hubs and connectors before accessing the catheter 2. Removing catheters promptly when no longer indicated 3. CHG bathing on a daily basis 4. Changing transparent dressing with CHG-based product every 5-7 days 5. Usage of antimicrobial or antiseptic impregnated catheters and/or caps to cover connectors
Special approaches 1. Usage of chlorhexidine/silver sulfadiazine- or minocycline/rifampin-impregnated central line 2. Usage of antimicrobial lock solutions in certain populations
Source: Table adapted and modified from Septimus EJ, Moody J. Prevention of Device-Related Healthcare-Associated Infections [version 1; referees: 2 approved]. F1000Research 2016 Jan 14;5. (doi:#10.12688/f1000research.7493.1)
44 TEXAS MEDICINE February 2017
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