Prevention of Central Line–Associated Bloodstream Infections (CLABSI) prevention.pptx

8-Conclusion
7-COVID-19 Pandemic and CLABSI
6-Non-Clinical Factors and CLABSI
5-Proven Preventive Strategies and
Devices
4-Risk Factors for CRBSI
3-Pathogenesis
2-Definition of CLABSI
1-Introduction

8-Conclusion
Devices
3-Pathogenesis
1-Introduction

8-Conclusion
Devices
1-Introduction
3-Pathogenesis

8-Conclusion
1-Introduction
3-Pathogenesis
Devices

1-Introduction
3-Pathogenesis
Devices
8-Conclusion

1-Introduction
In ICU, many medical and surgical conditions often involves long-
term infusion of:
• Intravenous fluids.
• Broad-spectrum antibiotics.
• Chemotherapeutic agents for cancer.
• Critical care therapies.
• Total parenteral nutrition, or hemodialysis.
For these interventions, central venous catheters.
“provide safe and reliable vascular access”.

1-Introduction
Central venous catheters carries the risk for infection with
subsequent Increase in:
• Antibiotic exposure.
• Hospital stay.
• Health care costs.
• The risk of death.

1-Introduction
Studies showed that CLABSIs are Often preventable.
• CLABSI is associated with
enormous morbidity and
mortality burden.
• Often preventable.

1-Introduction
For this, efforts have been made by several governmental,
public health, and professional organizations to sponsor and
promote evidence-based guidelines for strategies to prevent
CLABSI.

1-Introduction
These efforts have been recognized for successfully reducing
the occurrence of CLABSI in healthcare systems.
58%
2001 2009
AFTER APPLICATION OF PREVENTIVE STRATEGIES
After application of preventive strategies
2.5/1000
0.76/1000
2004 2013
AFTER APPLICATION OF PREVENTIVE STRATEGIES
After Application of preventive strategies

CLABSI vs CRBSI
CLABSI CRBSI

CLABSI vs CRBSI
CRBSI
CLABSI:
a laboratory-confirmed bloodstream
infection in a patient who has had a
central venous catheter in place for
more than 48 hours before the date on
which blood was drawn for culture, if
no other source of bacteremia or
fungemia is identified.

CLABSI vs CRBSI
CLABSI:
a laboratory-confirmed bloodstream
infection in a patient who has had a
central venous catheter in place for
more than 48 hours before the date on
which blood was drawn for culture, if
no other source of bacteremia or
fungemia is identified.
CRBSI:
CLABSI + clinical and
laboratory criteria

Is it adequate for diagnosis to solely take a culture from the
catheter tip instead of obtaining a blood culture?

Catheter tip cultures are no longer recommended for CRBSI
diagnosis, given low positive predictive value.
catheter tip cultures should not be used in place of blood
specimens
The blood culture bottles should be labeled to reflect the sites
from which the cultures were obtained. Ideally, at least two sets
of blood cultures should be obtained from peripheral veins via
separate venipuncture sites prior to initiation of antibiotic
therapy.
Is it adequate for diagnosis to solely take a culture from the
catheter tip instead of obtaining a blood culture?

3-Pathogenesis
Routes for catheter contamination:
“By Hospital Staff”
1. skin pathogens at the insertion site.
Most commonly happens within the
first 7 days after catheter placement.

3-Pathogenesis
 the number of times the catheter is manipulated or accessed.
“By Hospital Staff”
2. Intraluminal contamination when
the catheter hub is manipulated.
• typically happens more than 7
days after catheter insertion.
• Related to:
 the care and maintenance of the
catheter.
2. Intraluminal contamination when
the catheter hub is manipulated.
• typically happens more than 7
days after catheter insertion.
• Related to:

3-Pathogenesis
3. Hematogenous contamination
from a secondary bloodstream
infection. (Less common)

3-Pathogenesis
4. Contaminated infusate (i.e., in
outbreaks with contaminated
injectable flushes).

0
20
40
60
80
100
120
1 2 3 4 5 6
ICU vs Non-ICU CRBSIs
ICU CRBSI Non-ICU CRBSI

Risk factors are categorized to:
Patient factors.
Provider factors.
Device factors.

Patient factors:
• Immunocompromise
• Neutropenia
• Burns
• Malnutrition
• BMI >40
• Prolonged hospitalization before catheter insertion
• Prematurity in infants
• Limited venous access.

Provider factors:
• Emergency catheter insertion
• Incomplete adherence to aseptic technique
• Multiple manipulations of the catheter
• Low nurse-to-patient ratio
• Failure to remove unnecessary catheter

Device factors:
• Catheter material
• Catheter insertion site
• Indications for use (e.g., for hemodialysis)

Devices
Consist of specific step-by-step instructions on how to insert a
catheter with the use of standard infection-prevention practices
and aseptic technique.
Check-list:

Check-list:
 Improve adherence to infection-control practices.
 Reduce the incidence of infection.
Devices

Catheter-insertion Kit or Carts:
Ensuring that everything needing for successful catheter
insertion is in one place.
Devices

Devices
Essential part of an infection-prevention program
Involve washing with:
• Conventional soap and water.
• Or with an alcohol-based, waterless hand rub.
Hand Hygiene:

Devices
 CLEAN THEN DRY.
 Hand hygiene is essential before and after inserting, replacing,
accessing, repairing, or dressing an intravascular catheter.
Hand Hygiene:

Devices
“Using gloves does not preclude the need for
hand hygiene”
Hand Hygiene:

Devices
Defined as wearing a mask, cap, sterile gown, and sterile gloves
and placing a large sterile drape that fully covers the patient’s
entire body.
Maximal Sterile Barrier Precautions:

Devices
Is it necessary to employ maximal sterile barrier precautions
during the Central line insertion procedure, or is it sufficient to
wear sterile gloves and utilize a small drape?

The use of maximal sterile barrier precautions during catheter
placement has been associated with a reduced incidence of
CLABSI, as compared with the use of sterile gloves and a small
drape alone.
Devices

Antisepsis:
Devices
Which of the following antiseptics is considered the most effective option?
A) Povidone Iodine (Betadine).
B) Alcoholic Chlorhexidine.
C) Medical Alcohol 75%.

Antisepsis:
Devices
Alcoholic chlorhexidine preparation containing at least 2%
chlorhexidine gluconate at the time of catheter insertion has
become the standard of care.

Antisepsis:
Devices
Chlorhexidine has:
 More rapid action  Persistent activity despite exposure to blood and
body fluids
 Shorter drying  Longer residual effect at the site of catheter
insertion.

Site Selection:
Devices
Which of the following is the preferred catheter insertion site for reducing the risk of
Catheter-Related Bloodstream Infections (CRBSIs) in the ICU ?
A- Subclavian site.
B- Femoral site.
C- Deep Jugular site.

Site Selection:
Devices
The subclavian site is the preferred catheter-insertion site for
reducing the risk of CRBSI in the ICU.

Site Selection:
Devices
Subclavian Site carries the risk for:
• Pneumothorax.
• Subclavian-artery cannulization.
• Risk of subclavian stenosis in patients for whom catheter is used for
hemodialysis.

Chlorhexidine dressings:
Devices
Reduce the risk of CLABSI and should be routinely use in
patients older than 2 months.

Chlorhexidine dressings:
Devices
Available in 2 forms:
1. Gel-based chlorhexidine coating on a transparent
dressing.
2. Chlorhexidine-impregnated sponge dressing.

Daily Chlorhexidine Bathing:
1. One study, which involved patients on general medical and
surgical wards + Mupirocin>Significant ↓ in CLABSI
2. Studied in patients with cancer > ↓ in CLABSI.
Devices

Antibiotic- and Antiseptic-impregnated catheters:
• Very effective in reducing the risk of CLABSI.
• No additional benefit for patient care units with
a very low incidence of CLABSI.
Devices

Devices
“Scrub the hub” campaigns
Antiseptic-containing Hubs and Caps:
Contamination of catheter hubs and caps is a source of CLABSI.

Devices
“Scrub the hub” campaigns
Contamination of catheter hubs and caps is a source of CLABSI.

The use of these devices is supported by high-quality evidence
to reduce the risk of CLABSI.
Devices
But They have not been recommended for routine use because they
are not viewed as superior to manual disinfection.

Studies showed that CLABSIs are Often preventable.
• CLABSI is associated with
enormous morbidity and
mortality burden.
• Often preventable.

CMS

CMS
2. Tracking methods:
CLABSI rates depend not only on the definition used but also on
the methods of tracking. “Public reporting is Obligate”

2. Tracking methods:
CLABSI rates depend not only on the definition used but also on
the methods of tracking. “Public reporting is Obligate”
Current tracking strategies may underestimate the incidence of
CLABSI if bacteremia is attributed to alternative sources of
infection.
The current tracking strategies demonstrate a low level of
reliability.

Effects of Covid-19 pandemic on the U.S. health care system:
• Straining hospital resources.
• Exhausting hospital staff.
• Abrupt decrease in hospital admissions for patients with
common conditions (↑in the severity of illness among hospitalized patients)
• Alteration in the patient and provider risk factors for the
development of CLABSI.

A qualitative feedback from infection-prevention teams
regarding changes in practices after the beginning of the Covid-
19 pandemic:
• Less chlorhexidine bathing.
• Fewer bedside checks on catheters and.
• Disturbance of catheter dressings because of prone
positioning of patients.
• Increased number of traveling nurses and physicians in
response to increased patient volumes. (Not well trained)

325%
Before After
AFTER COVID-19 PANDEMIC
After COVID-19 Pandemic

• The Covid-19 pandemic revealed other vulnerabilities in the
CLABSI-prevention system.
• Collection of data is stopped from January through June
2020.
• This problem highlights the need for a new and simpler
definition that allows for computerized capture of CLABSI
rates with the use of AI.

• The remarkable success in reducing the incidence of CLABSI.
• Part of the reduction may have been artifactual.
• Despite this success, we should be circumspect, all of this success was
vanished during the first 3 months of the Covid-19 pandemic.
• Fragile CLABSI prevention system and vulnerable to stress.(provider)
• We need to engineer Flexible infection-prevention processes that can
withstand changing environmental conditions
• It is time to consider combining routine use of all available CLABSI
preventive strategies that do not depend on providers.
8-Conclusion

Prevention of Central Line–Associated Bloodstream Infections (CLABSI) prevention.pptx

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