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Introduction
Modern day medical practice cannot wish away the use of catheters in intensive care units. Despite the fact that catheters have undue access to vascular systems, patients are always under constant risk of developing local and systemic infections. Every year, health institutions use millions of money in buying of intravascular catheters. Types of infections differ depending on frequency of manipulation of catheter and acuteness of the patients illness (CDC 1998, 522). The frequently used devices are the peripheral venous catheters because of their access to the vascular system (CDC 1999, 520). Peripheral venous catheters have been associated with low incidences of bloodstream infections, however, current evidence strongly associate these catheters to the current high morbidity as a result of serious infections related to peripheral use of catheters. This research paper seeks to develop and refine a standardized guideline for use in clinical practice for catheter related bloodstream infections (Collignon 1994, p.301).
Main Body
Health professionals reckon that blood stream infections occasioned with use of catheters are so rampant and costly on individuals and health-care providers. Its use is also potentially lethal. For instance, about 28,000 patients in ICU die in United States as a result of catheter-related bloodstream infections each and every year. Costs related to care of such patients are estimated at $45 000. The costs can go up to $2.3 billion in a year. Reports by the CDCs National Nosocomial Infections Surveillance have recorded a median of 1.8 per every 1000 catheter days for catheter related bloodstream infections in patients undergoing treatment in the ICU.
Studies have shown that dedicated intravenous therapy team can effectively be used to mitigate catheter related contaminations. These include standardizing catheter insertion techniques and monitoring catheter sites on daily basis. Similarly, incidences of infections can be averted by limiting peripherally inserted central catheter. Other interventions include educating those who take part in insertion of catheters, use of chlorhexidine gluconate to create aseptic conditions on the skin surface, and being cautious when inserting catheters. Sterile barrier precautions should be observed, and finally use of catheter should be discontinued when it is not essential for medical management.
According the Guidelines for prevention of intravascular catheter report, guidelines have been devised for use by the health practitioners taking care of patients in the ICU and for those involved in the surveillance and control of infections programs in hospitals (OGrady, 1998, p.92). OGrady et al. (1998, p.92) states that, This report was made by a working group made up of members from professional organizations drawn from critical care medicine, infectious diseases, surgery, anesthesiology, health care infection control, nursing, pulmonary medicine, and pediatric medicine. The guidelines were intended to provide evidence based recommendations for preventing infections that arise from the use of catheter. Areas that were emphasized include; training and education of health-care providers who insert and maintain catheters, use of sterile barrier precautions when inserting central venous catheters. Emphasis was also put on the use of 2% chlorhexidine preparation for creating aseptic conditions on the skin surface, avoiding regular replacement of central venous catheters especially in situations where the rates of infections are considerably high while sticking to the previously mentioned strategies.
OGrady et al (1998, p.393) recount that terminologies used in identification of different catheters are confusing due to the fact that clinicians and researchers use informal terminologies when referring to catheters. Designation of catheters can be done on the basis of vessel they occupy; its internal lifespan; the site through which it is inserted; the pathway from the skin to the vessel; its length; and some other special features it may be having. Catheter related infection rates are difficult to determine (CDC 1998, p.521). There is need to recognize surveillance definitions and clinical definitions by health care professionals (CDC 1999, p.523). OGrady says that the surveillance definitions are biased as they overestimate the catheter-related blood stream infections incidences because it is not true that all blood stream infections do not occur as a result of use of catheters. Some bacteremias that have not been documented can also contribute to blood stream infections. The rate of catheter related blood stream infections should be expressed in terms of number of blood stream infections out of 1000 central venous catheter days.
OGrady et al (1998, p.393) asserts that many of Nosocomial blood stream infections are associated with central venous catheter use. The blood stream infection rates are projected to be higher among patients with central venous catheter in comparison to those without. This is said to vary depending on the size of the health facility, services, and central catheter size. A meta-analysis of 223 prospective studies of adults has been used to study the risks of blood stream infections that are occasioned by use of catheters. Risk of infection was ascertained by analysis of rates of infections by blood stream infections per 100 catheters and blood stream infection per 1000 catheters. Severity of illness was greatly influenced by severity of the patients illness and the type of illnesses, and the condition in which the catheter was placed. Organisms causing Nosocomial blood steam infections do change with time. Coagulase negative staphylococci used to be common. Then Staphylococcus aureus was then associated with hospital acquired infections. OGrady et al however reports that coagulase negative staphylococci and enterococci are presently associated with Nosocomial blood stream infections with coagulase negative staphylococci accounting for 37%, Staph 12.6 %. Staph is the most susceptible microbe with over 50% susceptibility. They are also resistant to oxacillin. The enterococcal ICU isolates that are resistant to Vancomycin has escalated from 0.5 % to 25.9 % in a span of 10 years between 1989 and 1999.
Miller-Hoover and Small (2009, p.192) assert that the evidence that has been provided within the period of 41 years representing varying levels of evidence, supports implementation of care bundle for central venous catheter on the basis of evidence based guidelines meant to reduce the number of CLABSI (Central line associated blood stream infections). The components of central venous catheter bundle should be hand hygiene; removal of central venous catheter should be removed early enough. The interventions are supported by evidence from systematic reviews, cohort groups and expert group reports. Use of 2% chlorhexidine also form a component of the care bundle for use as a skin antisepsis. Another care bundle should be the use of barrier precautions. The two precautions were supported by evidence from systematic reviews, cohort studies, and reports from expert committees. Successful implementation could only be realized by integration of education in regard to components of CVC care bundles. Reduction in central line associated blood stream infections could only be realized by organized protocol implementation, educating the staff, central line insertion, and surveillance of adherence to protocol.
Mermel (2000, p.301) attributes infection routes to catheter related intravascular related infection to contamination of catheter hub by extrinsic sources and the endogenous flora. Other contamination routes include contaminated infusate. These come from fluid or medication, extrinsic sources or manufacturer related contamination. The catheter can also be contaminated before it is inserted from extrinsic sources. Microbial flora of the skin also contributes to infection of catheters. Catheters can also be contaminated by hematogenous sources. Mermel attributes increase in risk of blood stream infections to use of non ICU trained nurses in ICU and decrease in the ratio of ICU nurse to patient ratio. Education to reduce risks of catheter related blood stream infections focuses on physician education on how to properly insert catheters and in the process of controlling infections. Mermel documents that catheter related infections in 1000 patients before education intervention was 4.5 and 3.2 after intervention. Other interventions include; catheter placement, barrier precautions during CVC insertion, use of antiseptics, antimicrobials and other novel devices, cutaneous antisepsis sponge that has been impregnated with chlorhexidine, catheters impregnated with chlorhexidine silver sulfadiazine, catheters that have been impregnated by Monocycline Rifampin.
OGrady et al 2002 states that there is need to change practice and that the decision to do so is undertaken by professional organizations such as those representing critical care medicine, infectious diseases and nursing among others. Decision for adoption of new guidelines was also made by university medical professors who belonged to infection control department of respective schools of medicine, and center for disease control and prevention (CDC).
Implementation of the guidelines squarely lie on the shoulders of practitioners like doctors, nurses and medical technologists who take part in insertion of catheters, individuals responsible for surveillance and mitigation of infections in the health-care facilities, and those who take part in home based cares (Pittet, Tarara and Wenzel 1994, p.1600). Catheters that are impregnated with antimicrobial agents decreases hospital costs that are associated with treating catheter related blood stream infections. However, some additional acquisition costs do come with the use of catheter that is coated with antimicrobial agents. Intervention like education has inherent costs that are attributed to it (Rello, Ochagavia and Sabanes 2000, p.1029).
This Guideline is known to have achieved its results only when aseptic techniques are used while inserting the catheters, when those handling the catheter observe proper hand hygiene, when proper surveillance is done to monitor the catheter sites, when catheter tips are not routinely cultured, and when patients are encouraged to report any changes in their catheter site to the health care provider (Pearson 1996, p.264). All this will help in reducing blood stream infections brought about by the use of the catheters (Kluger and Maki 1999, p.514). Trained health care workers should also ensure that proper hygienic conditions are observed when handling the catheter.
It is the work of hospital infection control practice advisory committee to collect outcome data, analyze it and make changes based on the results.
Technologies for prevention of central venous catheter related blood stream infections.
*Adapted from the Centers for Disease Control and Prevention guidelines for the prevention of intravascular catheter-related infections.
Conclusion
To ensure that blood stream infections do not result from the use of catheters, it is pertinent that the physicians, nurses, and medical technologists ensure that the hospital set-up is aseptic. The medical staff should also undergo intensive training on how to handle the catheters. Of the variety of the evidence based practices that have been proposed to help in reducing catheter related blood stream infections, the following interventions should be prioritized if blood stream infections are supposed to be curbed: use of chlorhexidine in ensuring the surfaces of skin is aseptic, education of the health expert on good practices during catheterization, ensuring maximal sterile barriers, use of antibiotics to counter the incidence of Nosocomial infections, and ensuring that hands of people handling the catheter are properly washed.
Recommendations
OGrady et al guidelines enjoy the support of well designed, experimental and epidemiological studies hence strongly recommended for implementation. The guidelines also have strong theoretical rationale. However, the guidelines represent unresolved issues with scanty evidence and no unanimity in their efficacy.
Mermel evidence from the meta-analysis is well designed and has stringent review criteria. The review criterion is at least met by evidence from one randomized controlled trial. The meta-analysis had evidence from at least a randomized controlled trial with criterion change. It had a well designed clinical trial without randomization. Evidence was also derived from expert committee report, descriptive studies, and opinions from with clinical experience.
Health care workers adherence to what is taught should periodically be assessed. Nursing staff in the ICU should be appropriate to avoid the risks of catheter related blood stream infections. Catheter tips should not be routinely cultured. Patients should report to their health care provider of any change in the catheter site or any discomfort they feel. Catheter tips should be monitored visually through the intact dressing regularly.
Reference List
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CDC. (1998). National Nosocomial Infections Surveillance (NNIS) System report. Am J Infect Control, 26:52233.
Kluger, D.M., Maki, D.G. (1999). The relative risk of intravascular device related bloodstream infections in adults [Abstract]. In: Abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco, CA: American Society for Microbiology, 514.
Mermel, L.A. (2000). Prevention of Intravascular Catheter-Related Infections. Annals of Internal Medicine 132(5): 391-402.
Miller- Hoover, S.R. and Small, L. (2009). Research Evidence Review and Appraisal: Pediatric Central Venous Catheter Care Bundling. Pediatric nursing, 35( 3):191-202.
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Pearson, M.L. (1996). Guideline for prevention of intravascular device-related infections. Part I. Intravascular device-related infections: an overview. The Hospital Infection Control Practices Advisory Committee. Am JInfect Control, 24:26277.
Pittet, D., Tarara, D., Wenzel, R.P. (1994). Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA, 271:1598601.
Rello, J., Ochagavia, A., Sabanes, E., et al.(2000). Evaluation of outcome of intravenous catheter-related infections in critically ill patients. Am J Respir Crit Care Med, 162:102730
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