Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Central Line-Associated Bloodstream Infections (CLABSI)
12 Plays2 years ago
In this episode, we will discuss Central Line-Associated Bloodstream Infections (CLABSI). My guest is Dr. Naomi O’Grady, a critical care and infectious disease physician at the National Institutes of Health. She is Chief of the Internal Medicine Service and an attending physician in the Clinical Center's Critical Care Medicine Department (CCMD). Her research focuses on strategies to reduce the incidence of antimicrobial-resistant pathogens in the ICU and catheter-related bloodstream infections.
Additional Resources:
Prevention of Central Line-Associated Bloodstream Infections. N. O’Grady. New Engl J Med 2023: https://pubmed.ncbi.nlm.nih.gov/37733310/
Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-year analysis. P Pronovost, et al. Am J Med Qual 2016: https://pubmed.ncbi.nlm.nih.gov/25609646/
Bloodstream infection event (central line-associated bloodstream infection and non central-line associated bloodstream infection.) National Healthcare Safety Network: https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
Books Mentioned in this Episode:
Nancy Drew Book Series. By Carolyn Keene. Nancy Drew Books: https://tinyurl.com/4rjx6st8
The Checklist Manifesto. By Atul Gawande The Checklist Manifesto- Atul Gawande: https://tinyurl.com/5pccn98p
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now, your host, Dr. Sergio Zanotti.
Role of Central Venous Catheters in ICU
00:00:33
Speaker
Central venous catheters are commonly utilized in the care of critically ill patients.
00:00:38
Speaker
Central venous catheters provide safe and reliable vascular access for delivering a wide range of therapeutics.
00:00:43
Speaker
However, central line-associated bloodstream infection is a significant problem contributing to increased morbidity, mortality, and
Expert Introduction: Dr. Naomi O'Grady
00:00:51
Speaker
cost in the ICU.
00:00:51
Speaker
In today's episode of the podcast, we will discuss central line-associated bloodstream infections, CLABSI.
00:00:58
Speaker
Our guest is Dr. Naomi O'Grady, a critical care and infectious disease physician at the National Institutes of Health.
00:01:04
Speaker
She is chief of the Internal Medicine Service and an attending physician in the Clinical Center's Critical Care Medicine Department.
00:01:10
Speaker
Her research focuses on strategies to reduce the incidence of antimicrobial-resistant pathogens in the ICU,
00:01:16
Speaker
and catheter-related bloodstream infections.
00:01:18
Speaker
She's a prolific author and researcher, has served as chair for numerous clinical guidelines, and recently published an excellent review on prevention of central and associated bloodstream infections in the New England Journal of Medicine.
Impact of CLABSI on Patient Outcomes and Hospital Perception
00:01:30
Speaker
Naomi, welcome to Critical Matters.
00:01:33
Speaker
Thank you.
00:01:34
Speaker
Thank you so much for having me.
00:01:36
Speaker
I think a good place to start would be the why.
00:01:38
Speaker
Why should critical care clinicians care about this topic?
00:01:43
Speaker
Well, that's a good question, and I think the answer is because it impacts our patients so dramatically in the ICU.
00:01:53
Speaker
For decades, the ICU has been the focus of measuring central venous catheter-related bloodstream infections, although it's
00:02:02
Speaker
In the last few years, the infection rates for patients outside of the ICU have also been measured routinely in certain areas of the hospital.
00:02:15
Speaker
But traditionally, it's been the ICU where we've had a focus on this infection because it does cause so much morbidity and some mortality associated with the infections.
00:02:26
Speaker
And in the last couple of decades,
00:02:30
Speaker
CLABSI rates have become proxies for measurement of patient safety and clinical quality.
00:02:37
Speaker
So hospital administrators care a lot about this topic.
00:02:41
Speaker
And when their hospitals are being measured by rates of CLABSI, if they have high rates of CLABSI, the assumption is poor hospital quality or poor clinical quality.
00:02:53
Speaker
care, administrators get agitated about that, and they come to the ICU director to find out what can be done about the infection rates.
00:03:05
Speaker
Perfect.
00:03:05
Speaker
And you did mention morbidity and mortality.
00:03:07
Speaker
Could you tell us a little bit more in detail what the literature shows on the impact of a CLABSI on a patient's risk of dying or having complications and also on the cost of care for that patient?
00:03:20
Speaker
Well, sure.
00:03:22
Speaker
You know, the studies, they don't really measure individual costs, but certainly studies have shown that CLABSI causes a lot of
00:03:35
Speaker
Morbidity, morbidity in terms of excessive length of hospital stay, excessive use of antibiotics.
00:03:43
Speaker
And we know antibiotics have their own downside.
00:03:48
Speaker
There was one study that reported...
00:03:51
Speaker
a significant increase in the unadjusted ICU length of stay, which was 24 days compared to five days for patients without CLABSI.
00:04:00
Speaker
The hospital length of stay was increased.
00:04:03
Speaker
The median was 45 days versus 11 days in patients without CLABSI.
00:04:08
Speaker
And then there's always a debate about mortality.
00:04:12
Speaker
One study did measure mortality at 51% versus 28%.
00:04:17
Speaker
in patients without CLABSI.
00:04:18
Speaker
And then hospital costs are enormously increased just based on the excessive length of stay.
00:04:26
Speaker
So in this one study that I mentioned, the hospital cost was $83,544 compared to $23,800.
00:04:30
Speaker
So CLABSI is something that causes, I think,
00:04:42
Speaker
much more morbidity and possibly mortality than we generally think of.
00:04:51
Speaker
And I think it's a great example of how something can be important to patients, important to clinicians, and important to hospital administrators, right?
00:05:00
Speaker
I mean, for multiple reasons, but I do believe that at the end of the day, as clinicians, we need to recognize that
00:05:07
Speaker
The danger it poses for a patient individually is one that we obviously would not want to expose them to.
00:05:15
Speaker
And I think that alone should be a great reason for us to focus on decreasing or preventing them as much as possible.
COVID-19's Effect on CLABSI Rates
00:05:23
Speaker
Absolutely.
00:05:24
Speaker
I wanted to ask you a little bit more about epidemiology of CLABSIs.
00:05:29
Speaker
It seems that obviously this became a hot topic after Peter Pronovost's checklist, and a lot of it was discussed outside of medical journals as well.
00:05:39
Speaker
But like you mentioned, it became a focus of attention for high-value care proxy.
00:05:45
Speaker
And it seems that at least per reports it had improved significantly.
00:05:50
Speaker
But then COVID came.
00:05:52
Speaker
What has happened with the rates and where do we stand today?
00:05:56
Speaker
Well, COVID obviously had a very disruptive effect on our health care systems because it strained hospital resources and exhausted our hospital staff.
00:06:11
Speaker
The interesting thing about the pandemic is that it resulted in an abrupt decrease in hospital admissions for patients who had very common conditions and led to a disproportionate increase in the admission of patients with severe illness.
00:06:29
Speaker
So in addition, the healthcare provider component of the healthcare system was stressed.
00:06:37
Speaker
So what we saw during the pandemic was that essentially 20 years of improvement in CLABSI rates disappeared in about 10 minutes with all of the stress that the health care system was exposed to.
00:06:54
Speaker
So we had things like, when I say providers were stressed, well, they were not only stressed by the numbers of patients they were caring for, but they were stressed by the potential for exposure to infection.
00:07:12
Speaker
So what happened was there were fewer healthcare provider to patient contacts or interactions leading to reduced patients
00:07:24
Speaker
care and maintenance of these catheters.
00:07:28
Speaker
Lines were disrupted by long IV poles and tubing hanging out in the hallway and maybe 20 feet away from the patient's bedside.
00:07:40
Speaker
We had patients that did not receive chlorhexidine baths the way that they have been recommended.
00:07:49
Speaker
And some of that is not related to healthcare
00:07:52
Speaker
providers, but is related to the fact that chlorhexidine wipes were in short supply.
00:07:59
Speaker
And sometimes we were unable to even get any.
00:08:04
Speaker
There were fewer bedside checks on catheters.
00:08:08
Speaker
You know, protocols for, for example, scrubbing the hub for 15 seconds.
00:08:13
Speaker
Well, when health care providers are stressed and their time is at a premium, they don't spend 15 seconds scrubbing the hub of a catheter before accessing it.
00:08:26
Speaker
So lots of little details like that crept in during the pandemic and our rates skyrocketed.
00:08:34
Speaker
Where do we stand today?
00:08:35
Speaker
Today, I think we are getting back to our baseline numbers, but the healthcare system is still stressed.
00:08:45
Speaker
And we learned a lot of things during the pandemic that exposed the fragility and the vulnerabilities in our infection prevention systems.
00:08:56
Speaker
And I think today we can still do better.
00:09:01
Speaker
And I think that in terms of timing, also very important for us to talk about this topic today, because like you said, after the stress, some systems probably have a little bit more resilience than others.
00:09:11
Speaker
But as a whole, I think that that fragility was exposed and there's still a lot of opportunity for us to improve care.
00:09:19
Speaker
A ton, a ton of a lot of a lot of opportunity.
00:09:24
Speaker
And I think it's an important point for our listeners, because this is one of those topics that we've all talked about.
00:09:31
Speaker
We all know about, right?
00:09:33
Speaker
Yet, there's still a lot to do.
00:09:36
Speaker
And the fact that we still have a lot of room for improvement, I think should be enough motivator for all of us to try to move the needle in the right direction.
00:09:46
Speaker
Yeah, I would agree with
Infection Prevention Strategies in Critical Care
00:09:48
Speaker
that.
00:09:48
Speaker
And, you know, I think one thing that the pandemic did teach us was that when we rely on
00:09:59
Speaker
The human element, in other words, health care providers and people as resources, let's say, there's a lot of opportunity for mistakes to happen compared to relying on an engineered system, for example.
00:10:15
Speaker
And I'll talk a little bit more about these prevention systems, but we know we have antibiotic impregnated catheters or antiseptic impregnated catheters.
00:10:24
Speaker
We have...
00:10:26
Speaker
chlorhexidine impregnated dressings, we have alcohol, alcoholic caps that we can put on the hubs of catheters, and little technological improvements like that.
00:10:39
Speaker
When we rely on those things a little more repeatedly, we are able to build some redundancy into the system and some resilience into a system that is currently highly fragile.
00:10:55
Speaker
Excellent.
00:10:57
Speaker
So can we move on to some definitions in pathophysiology?
00:11:01
Speaker
And I think that these are terms that are commonly utilized interchangeably, but they, I don't think, mean the same thing.
00:11:09
Speaker
And I just wanted you to clarify for us.
00:11:12
Speaker
So CLABSI is central line associated bloodstream infection, and CRBSI is central line related bloodstream infection.
00:11:20
Speaker
I hear people talk about both of them as they're the same.
00:11:24
Speaker
Is it the same or is there a difference?
00:11:28
Speaker
Well, there is a difference and the difference is nuanced, but these terms are somewhat, they are used interchangeably, I would say.
00:11:37
Speaker
And when you look at studies that examine the problem, sometimes studies use the definition of CLABSI and sometimes they use the definition of catheter-related bloodstream infection.
00:11:53
Speaker
And that may, it may compromise some of the validity of the evidence because they are used interchangeably.
00:12:02
Speaker
But to get to what CLABSI is, it is a surveillance definition.
00:12:07
Speaker
So the CDC defines CLABSI as a laboratory-confirmed bloodstream infection in a patient who has had a central line in place for more than 48 hours before the date on which the blood culture was drawn.
00:12:22
Speaker
if no other source of bacteremia is identified.
00:12:26
Speaker
So this, again, is a surveillance definition and not a clinical definition because there is no requirement for a patient to have signs or symptoms of infection.
00:12:37
Speaker
Now, because it's often difficult to determine whether the bloodstream infection is related to the central line or whether it's a secondary source such as an abdominal abscess or pneumonia, the NHSN definition may actually overestimate the true incidence of central line-associated infections.
00:12:59
Speaker
But this is a definition used by the NHSN network because it's easy to apply to areas of the hospital where tracking the rates of CLABSI is important.
00:13:09
Speaker
So if it's applied consistently, it will provide very useful information on an institution's trends towards reduced or increased CLABSI.
Defining CLABSI vs. CRBSI
00:13:24
Speaker
Now, the catheter-related bloodstream infection definition is
00:13:28
Speaker
It's a clinical definition used for the diagnosis and treatment of a patient at the bedside, basically.
00:13:36
Speaker
It requires the specific laboratory testing that...
00:13:41
Speaker
identifies a bloodstream infection.
00:13:43
Speaker
It meets the criteria of the surveillance definition.
00:13:47
Speaker
In other words, it's all of those components of the surveillance definition plus a patient with signs and symptoms of infection.
00:13:55
Speaker
That could be either fever, elevated white count, or erythema at the catheter exit site.
00:14:01
Speaker
It can be influenced by a variety of other factors such as catheter removal, laboratory resources such as quantitative blood cultures or time to positivity,
00:14:11
Speaker
But catheter-related bloodstream rates are not used for surveillance because the definition is complex, and the process of establishing the catheter as the source of the infection would make the broad application for epidemiologic purposes very challenging.
00:14:31
Speaker
So in other words...
00:14:32
Speaker
It sometimes takes a day or two to sort this out.
00:14:36
Speaker
Whereas if you are using the CLABSI definition, you can look at all your bloodstream infections in a particular unit, say the ICU, and you would just have somebody count the number of bloodstream infections and count the number of patients with catheters, and you would come up with a CLABSI rate.
00:14:57
Speaker
Again, that might overestimate the actual true rate of infection.
00:15:02
Speaker
I think it's important, even though it's nuanced, because as physicians and APPs in the ICU care for these patients, understanding what we're talking about is important, and what we're measuring, I think, is also important.
00:15:17
Speaker
How do these catheters get infected?
00:15:19
Speaker
How do we develop a catheter-related bloodstream infection?
00:15:22
Speaker
What's the pathophysiology in terms of roots of contamination?
00:15:27
Speaker
Sure.
00:15:27
Speaker
Well, there are essentially four routes for contamination.
00:15:32
Speaker
The most common are the first two.
00:15:36
Speaker
First, skin pathogens at the insertion site enter the cutaneous catheter tract and then migrate down the external surface of the catheter toward the catheter tip.
00:15:47
Speaker
This most commonly happens within the first seven days after catheter placement, and it's thought to occur at the time of insertion.
00:15:56
Speaker
So insertion site contamination can also happen when the skin microorganism density increases underneath the catheter dressing over time.
00:16:05
Speaker
And if this area is not decontaminated frequently, microorganisms can migrate down that external surface of the catheter.
00:16:17
Speaker
Second, the intraluminal contamination happens when the catheter hub is manipulated.
00:16:23
Speaker
This happens when blood is drawn through the catheter or medications are infused through the catheter.
00:16:30
Speaker
Pathogens gain access to the intraluminal surface of the device where they adhere and become incorporated into the biofilm.
00:16:39
Speaker
This allows for sustained infection and hematogenous dissemination.
00:16:44
Speaker
This type of contamination typically happens more than seven days after the catheter has been inserted, and it's related to care and maintenance of the catheter, as well as the number of times the catheter is accessed or manipulated.
00:16:59
Speaker
Less commonly, catheters become contaminated hematogenously from a secondary bloodstream infection that develop from another focus of infection, for example, a pneumonia or urinary tract infection.
00:17:13
Speaker
Bacteria stick to the biofilm that is formed and adhere to the internal lumen of the catheter.
00:17:19
Speaker
And then lastly, in rare cases, contaminated infusate taints the catheter.
00:17:27
Speaker
In other words, there have been reports of outbreaks with contaminated injectable flushes and such things.
00:17:34
Speaker
So those are the four basic ways that catheters become contaminated.
00:17:41
Speaker
Is there one in particular that is overwhelmingly more commonly seen?
00:17:45
Speaker
Yes.
00:17:48
Speaker
Well, I think it depends on your institution, but in general, the most common way is the intraluminal contamination that happens when the catheter is manipulated is probably the most common way.
00:18:03
Speaker
We've gotten very good at inserting catheters using aseptic technique, using chlorhexidine as skin antisepsis and large sterile drapes as barrier precautions.
00:18:17
Speaker
So catheters rarely are infected at the time of insertion, unless, of course, they've been put in under duress or in an emergency situation or in an obvious situation where there's contamination.
00:18:35
Speaker
But in general, we've gotten quite good at inserting these aseptically.
00:18:40
Speaker
So catheters,
00:18:41
Speaker
The most common way of catheters becoming contaminated is really with the manipulation of the catheter after seven days from insertion.
00:18:54
Speaker
Perfect.
00:18:55
Speaker
And I think it's important just to highlight that to our listeners.
00:18:58
Speaker
Our audience, obviously, is mostly composed of physicians and APPs.
00:19:02
Speaker
And our role in these catheters is usually heavily focused on the insertion because that's what we do.
00:19:10
Speaker
Right.
00:19:11
Speaker
And and I think a lot of times a lot of focus in trying to analyze collapse cases on the insertion.
00:19:17
Speaker
But the most common cause, like you said, in most ICUs would be, I mean, the manipulation.
00:19:23
Speaker
And we need to be very well aware of that.
00:19:27
Speaker
Yes.
00:19:29
Speaker
But, you know, we are pretty good at maintaining catheters for long, long periods of time without any consequence of infection.
Factors Influencing CLABSI Risk
00:19:39
Speaker
So it can be done if we pay attention to the details.
00:19:43
Speaker
Perfect.
00:19:45
Speaker
What about risk factors for CLABSI?
00:19:47
Speaker
Obviously, we think of it as a preventable disease or a problem, and that in many cases is true, but there are also risk factors at different levels that are important to understand.
00:20:01
Speaker
Yes, for sure.
00:20:04
Speaker
I like to think of risk factors divided into sort of three different categories.
00:20:09
Speaker
First are patient factors, which are certain risk factors.
00:20:13
Speaker
So
00:20:14
Speaker
Patients who are immunocompromised, such as patients who are receiving cancer treatments, patients who are neutropenic, patients who have burns.
00:20:25
Speaker
Malnutrition is a big risk factor.
00:20:30
Speaker
Patients who have a BMI greater than 40 are at risk.
00:20:34
Speaker
So patient factors are one category of risk factors.
00:20:41
Speaker
Provider factors are another category of risk factors.
00:20:45
Speaker
So when I think of provider factors, I think about catheters being inserted under emergency conditions.
00:20:54
Speaker
I think about incomplete adherence to aseptic technique.
00:20:59
Speaker
Low patient, I'm sorry, low nurse to patient ratio is another risk factor.
00:21:05
Speaker
And
00:21:06
Speaker
That just reflects the demand on nursing time to, you know, if there's a low nurse-to-patient ratio, nurses have lots of patients, and they just don't have the time to spend carrying and maintaining that catheter in the best possible condition.
00:21:24
Speaker
And then lastly, failure to remove unnecessary catheters.
00:21:28
Speaker
I would consider a provider risk factor.
00:21:31
Speaker
And then lastly, there are device factors.
00:21:34
Speaker
So the catheter material, the catheter insertion site, for example, the
00:21:41
Speaker
The femoral site has a higher risk for infection than the subclavian site.
00:21:47
Speaker
The subclavian site is the site for the lowest risk for infection.
00:21:54
Speaker
Of course, there are other risks associated with putting a catheter into the subclavian site, but that is a device factor.
00:22:04
Speaker
And then the
00:22:06
Speaker
The last device factor that I would consider is the indications for its use.
00:22:11
Speaker
So if you need a catheter for hemodialysis or you need a catheter for pulmonary artery measurements, those types of catheters have a slightly higher risk than a standard catheter for access.
00:22:30
Speaker
Perfect.
00:22:30
Speaker
So I guess we can talk about really the prime topic here, which is prevention of clapsies, right?
00:22:38
Speaker
I mean, ultimately, what we want to do is prevent these as much as possible.
00:22:44
Speaker
And I think there is...
00:22:46
Speaker
Evidence-based prevention, and then there seems to be game-ship-based prevention in many institutions, and we can talk about those later, but I would like to start with sticking to the evidence.
00:22:57
Speaker
What have been evidence-based approaches that can help us reduce that number of CLABSIs?
00:23:05
Speaker
Well, I'll start with checklists.
00:23:08
Speaker
Checklists are basically one prevention strategy that has been shown to reduce rates of infection by using step-by-step instructions on how to insert the catheter with the use of standard infection prevention practices and aseptic technique.
Preventing CLABSI: Best Practices
00:23:27
Speaker
Usually the list begins with hand hygiene and works through all the steps related to infection control, including gowning, gloving, masking, draping the patient, and applying the antiseptic agents to the patient's skin.
00:23:41
Speaker
They've been shown to improve adherence to infection control practices at the time of insertion and to reduce the incidence of infection.
00:23:48
Speaker
It's usually completed by someone who is directly observing the procedure, and the thought is that this approach helps the members of the procedure team focus their attention on the details in the list and makes them less prone to skipping any of the small but very important steps.
00:24:07
Speaker
The second approach
00:24:09
Speaker
area of prevention would be catheter insertion kits.
00:24:14
Speaker
This is the use of an all-inclusive catheter insertion kit or a bundle, which has been shown to reduce the risk of CLABSI by ensuring that everything that's needed for the successful insertion of that central line is in one place, thus making it easy to do the right thing and more difficult to make a mistake.
00:24:35
Speaker
So for example, choosing the correct antiseptic agent, CLABSI.
00:24:41
Speaker
for the skin is no longer a decision that the proceduralist needs to make if the agent comes bundled in the kit or in the catheter insertion cart.
00:24:51
Speaker
So these kits usually contain all the necessary components for completion of the sterile procedure, including the gowns, the gloves, the masks, the drapes, the antiseptic agent, the local anesthetic, and of course the catheter itself.
00:25:08
Speaker
Maximal sterile barrier precautions.
00:25:11
Speaker
That's another one that's defined as wearing a mask, a cap, a sterile gown, and sterile gloves and placing a large sterile drape that fully covers the patient's entire body.
00:25:22
Speaker
The use of the maximal sterile barrier precaution during catheter placement has been associated with reduced incidence of CLABSI as compared with the use of just sterile gloves and a small drape alone.
00:25:34
Speaker
Of course, I don't have to mention hand hygiene because hand hygiene has become so ingrained to all of us, I hope.
00:25:43
Speaker
Well, I would push back there.
00:25:44
Speaker
I think we do have to mention it.
00:25:49
Speaker
I do find it interesting that for probably the single most impactful intervention in medicine and saving lives, we're still not perfect at it.
00:26:01
Speaker
Well, it's a good point.
00:26:03
Speaker
Hand hygiene before the insertion is, let me put it this way.
00:26:12
Speaker
Sterile gloves are not a substitute for hand hygiene.
00:26:16
Speaker
We always want to do hand hygiene prior to the donning of the sterile gloves.
00:26:22
Speaker
Hopefully the checklist is,
00:26:24
Speaker
uh, ensures that everybody's doing hand hygiene before embarking on the procedure.
00:26:29
Speaker
But, uh, hand hygiene, you know, it, it requires, it's an essential, uh, part of the, uh, part of the procedure.
00:26:39
Speaker
It, uh, involves washing with either conventional soap and water or with an alcohol-based waterless hand scrub.
00:26:47
Speaker
Uh, the alcohol-based sanitizer is preferred for hands that are not visibly soiled.
00:26:52
Speaker
Um,
00:26:53
Speaker
Alcohol-based products should be applied according to the manufacturer's guidelines on the dispensing product.
00:26:59
Speaker
Typically, it's 3 to 5 cc's applied to the palm of the hands, and the fingers are rubbed vigorously for usually about 20 seconds and allowed to dry before donning your sterile gloves.
00:27:13
Speaker
Perfect.
00:27:14
Speaker
And you did mention chlorhexidine.
00:27:15
Speaker
So there's definitely a lot of literature that has emerged on chlorhexidine, antisepsis, dressings, and bath bathing of patients.
00:27:24
Speaker
Can you tell us a little bit more about that, Naima?
00:27:27
Speaker
Sure.
00:27:29
Speaker
Well, I'll start with chlorhexidine as skin antisepsis.
00:27:34
Speaker
There has been a lot of literature that has come out in the last decade or two that a preparation containing at least 2% chlorhexidine gluconate at the time of insertion has become the standard of care based on multiple randomized trials showing a reduced incidence of CLABSI using the chlorhexidine compared to the povidone iodine.
00:27:55
Speaker
Now, although both antiseptic preparations have broad-spectrum antimicrobial activity, the superior clinical protection provided by the chlorhexidine is probably related to a more rapid onset of action and a shorter drying time,
00:28:11
Speaker
owing to the combination of alcohol and the residual effect at the site of the catheter insertion by the chlorhexidine thought to last maybe a few days.
00:28:28
Speaker
Chlorhexidine has been added to dressings, and they've been available for more than a handful of years, I think even more than a decade.
00:28:37
Speaker
So,
00:28:40
Speaker
There is a chlorhexidine impregnated sponge dressing that is used to cover the catheter insertion site.
00:28:48
Speaker
There is also an available chlorhexidine impregnated translucent dressing.
00:28:54
Speaker
It's basically a chlorhexidine coated tape, if you will, that goes over the catheter exit site.
00:29:03
Speaker
There are advantages and disadvantages to both of these.
00:29:06
Speaker
The sponge dressing is an opaque dressing, so you can't actually visualize the catheter insertion site properly.
00:29:15
Speaker
while that dressing is in place and that dressing is designed to stay in place for up to seven days.
00:29:20
Speaker
So you put that dressing on and it should not be disrupted for seven days, but you have to acknowledge that you're not going to be looking at the insertion site for those seven days.
00:29:33
Speaker
The chlorhexidine coated tape is a translucent tape coated with that chlorhexidine preparation.
00:29:43
Speaker
You are able to visualize the catheter exit site, but that dressing is extremely sticky, and patients complain about it from time to time because it is quite sticky.
00:29:58
Speaker
And then lastly, chlorhexidine bathing.
00:30:00
Speaker
So chlorhexidine baths basically consist of wiping the patient down like a sponge bath using a chlorhexidine sponge or a chlorhexidine wash or wipe daily.
00:30:18
Speaker
And that has been shown to reduce catheter-related bloodstream infection as well.
00:30:24
Speaker
So chlorhexidine has really revolutionized our ability to keep these catheters in place safely.
00:30:31
Speaker
Now, you mentioned the chlorhexidine dressings, right, with evidence to support its use, yet I don't think it's commonly utilized or maybe not utilized as much as it could be due to cost concerns, I presume.
00:30:46
Speaker
Any thoughts on that?
00:30:51
Speaker
Well, I...
00:30:55
Speaker
I think that some of it, I think, depends on how well these products are marketed in terms of whether or not you're using them.
00:31:04
Speaker
But the data is clearly in favor of reduced CLABSI rates when these dressings are utilized.
00:31:15
Speaker
I'm not sure if it's a cost issue because I don't think they're terribly expensive.
00:31:21
Speaker
It's possibly a...
00:31:25
Speaker
a familiarity issue, and there may be some... There may be some...
00:31:34
Speaker
issues about wondering which patients would really benefit.
00:31:38
Speaker
In other words, if you're going to have a central line in place for only two or three days, there sometimes is that thought in the back of people's head that, well, it's not going to be in place for that long.
00:31:49
Speaker
We don't need to use all of these technologically advanced ways of preventing infection because we're going to pull the catheter out in two or three days.
00:32:00
Speaker
I would say that that's sort of a false line of reasoning.
00:32:06
Speaker
Okay, perfect.
00:32:08
Speaker
And another area that you did mention a little bit, but I just wanted to reemphasize because it's also a source of discussion among clinicians is site selection.
00:32:23
Speaker
Well, there have been lots of studies looking at site selection in terms of the best
00:32:31
Speaker
place for a catheter for reduced infection.
00:32:34
Speaker
And the subclavian site is the preferred site for reducing risk of CLABSI.
00:32:41
Speaker
In the non-ICU setting, the difference in infection risk among insertion sites is less clear, but the influence of the site on the risk of CLABSI is related in part to the density of the skin flora at the site.
00:32:55
Speaker
So the femoral catheter has the highest colonization rate, and in some studies, it
00:33:01
Speaker
are associated with higher incidence of CLABSI than catheters inserted at the subclavian or the internal jugular site.
00:33:10
Speaker
All three sites have some pluses and minuses associated with them, but in terms of the lower risk for CLABSI, the subclavian site is the preferred site.
00:33:26
Speaker
Perfect.
00:33:27
Speaker
And the last thing I wanted to ask you about in terms of prevention is the use of antibiotic and antiseptic impregnated catheters or antibiotic antiseptic impregnated hubs and caps.
00:33:41
Speaker
Well, sure.
00:33:42
Speaker
Catheters impregnated with chlorhexidine, silver sulfadiazine, or minocyclin and fampain have been studied for more than 20 years and have been shown to be very effective in reducing the risk of CLABSI.
00:33:55
Speaker
When these catheters were first introduced, they were expensive.
00:34:00
Speaker
They were certainly more expensive than standard catheters, and that higher cost prevented widespread adoption since the cost-benefit ratio was not perceived to be very favorable.
00:34:11
Speaker
But over the years, the costs have decreased, and these catheters have been recommended for use in hospital units or special patient populations that have
00:34:21
Speaker
high incidence of CLABSI despite compliance with the essential prevention practices of gowns and gloves, hand washing, large barrier precautions, etc.
00:34:35
Speaker
So I think that antibiotic and antiseptic impregnated catheters certainly have a role.
00:34:44
Speaker
Many studies investigating the effectiveness of these catheters were performed before chlorhexidine-based skin antisepsis became the standard of care.
00:34:53
Speaker
Now, some data suggests that for patient care units with a very low incidence of CLABSI, the use of these antimicrobial impregnated catheters may not provide additional benefit.
00:35:07
Speaker
But what I would posit is that the
00:35:10
Speaker
COVID-19 pandemic showed how fragile our healthcare system is.
00:35:16
Speaker
And if we can rely on things like antimicrobial impregnated catheters more firmly, I think we would have a better chance of not having such dramatic spikes in catheter-related bloodstream infection during times of crisis.
00:35:35
Speaker
I would liken it to the use of seatbelts in automobiles, actually.
00:35:43
Speaker
Years ago, we didn't have any seatbelts.
00:35:46
Speaker
Your parents threw you in the back of the car on a bench seat, and nobody had a seatbelt.
00:35:51
Speaker
Then we had a lap belt, which we complained about, and then they added a shoulder strap, which we also complained about.
00:35:59
Speaker
Now we have...
00:36:01
Speaker
shoulder straps and airbags and side airbags.
00:36:04
Speaker
And no one has shown, you know, the incremental contribution to each.
00:36:09
Speaker
And we also acknowledge that you don't benefit from these things unless you get into a wreck.
00:36:15
Speaker
So I would liken the whole CLABSI situation and the idea that we shouldn't be using, you know, antimicrobial impregnated catheters or antimicrobial impregnated dressings, that we shouldn't be using them on everyone,
00:36:30
Speaker
to sort of the automobile analogy.
00:36:33
Speaker
I mean, we should be using them.
00:36:36
Speaker
And I think it's a great analogy.
00:36:37
Speaker
And also, I think, speaks to the fact that this is not a zero sum game.
00:36:43
Speaker
It's additive and synergistic, right?
00:36:46
Speaker
We have these evidence based interventions, the idea is to add layers of resiliency, that we can decrease the number at a large scale.
00:36:54
Speaker
And
00:36:55
Speaker
And I do believe that the fact that you haven't had a clapsy at your ICU for X amount of months or years is great, but it doesn't mean that something like COVID can happen and that goes just out the window very, very quickly.
00:37:08
Speaker
Exactly.
00:37:10
Speaker
Perfect.
00:37:12
Speaker
So...
00:37:13
Speaker
Just a comment maybe on the gamemanship part of it, right?
00:37:17
Speaker
I do believe that a lot of times people are just fudging with definitions as opposed to really working on improving processes with a lot of healthcare-related quality measures.
00:37:28
Speaker
And ultimately, as clinicians, I think our goal is always or should be always to improve care.
00:37:33
Speaker
Any comments on that real quickly, Naomi?
Financial Impact on CLABSI Rates
00:37:38
Speaker
Well, you know, certainly...
00:37:42
Speaker
In 2008, I'll talk a little bit about the public policy aspect of it.
00:37:47
Speaker
In 2008, as part of an effort to encourage hospitals to strengthen their CLABSI prevention measures, Medicare and Medicaid stopped reimbursement for the treatment of hospital-acquired infections that were not present on admission.
00:38:03
Speaker
So this change in policy shifted the cost of CLABSI acquired in the health care system to the hospital or the nursing home or the rehab facility where the CLABSI was acquired.
00:38:18
Speaker
Now, several studies have reviewed the effects of these financial penalties on CLABSI.
00:38:23
Speaker
hospital CLABSI rates.
00:38:25
Speaker
And while one study showed no effect and another showed a decline in infection rates, and a third one showed no change in infection rates, one of those studies did report a change in the provider's coding patterns with an increase in codes that categorized the infections as present on admission.
00:38:45
Speaker
So the findings suggest that the financial penalties may change practice patterns and
00:38:52
Speaker
But one concern is that these policies provide an incentive to stop ordering blood cultures for patients with catheters.
00:38:59
Speaker
If you do less testing, you would lower your detection rates and improve hospital performance without actually changing clinical care at the bedside.
00:39:10
Speaker
So, you know, in addition to that, financial penalties put forward back in 2008.
00:39:17
Speaker
At about the same time, several states were passing laws requiring public reporting of hospital-acquired infections.
00:39:25
Speaker
So in my mind, it's difficult to determine how those policies affect clinical care, but they put pressure by design on hospital administrators to reduce CLABSI rates within their institution,
00:39:40
Speaker
So these pressures lead to unintended consequences, such as how changes in CLABSI definitions are applied or how CLABSI is detected.
00:39:52
Speaker
And I think that also, like you mentioned, it leads to people coming up with strategies like, let's put more PICC lines, or now they're using midline catheters.
00:40:05
Speaker
Any comments on that?
00:40:08
Speaker
Yeah, they are.
00:40:10
Speaker
People are finding all kinds of ways to avoid using central lines because because they want to reduce their central line.
00:40:20
Speaker
bloodstream infection rate.
00:40:23
Speaker
Substituting one catheter for another just so that you don't have to count it as part of your rate doesn't really change care at the bedside or the care we provide to the patient.
00:40:38
Speaker
One thing that I've always been in favor of is simplifying the definition so that we collect all hospital-acquired bloodstream infections.
00:40:50
Speaker
not just central lines.
00:40:53
Speaker
We know that PICC lines are central lines, so let's be clear about that.
00:40:59
Speaker
We know that midline catheters, we know that peripheral IVs, we know that arterial catheters also have bacteremia associated with them.
00:41:08
Speaker
And so simplifying the definition of
00:41:14
Speaker
of how we collect, simplifying the definition and collecting all hospital-acquired bacterimia would do everybody a favor because it would,
00:41:26
Speaker
It would allow us to grapple with the extent of the problem.
00:41:33
Speaker
Right now, we don't know how extensive the problem is because we are not counting the peripheral, the arterial, or the midline catheters.
00:41:44
Speaker
So I think...
00:41:47
Speaker
I think in the next few years, we will see a push towards simplifying this definition such that we could use the electronic medical record to help us acquire all the data rather than relying on people with clipboards to run around in the ICU and count the number of catheters and count the number of bloodstream infections manually.
00:42:14
Speaker
Absolutely.
00:42:14
Speaker
Absolutely.
00:42:17
Speaker
We talked a lot about prevention, but sometimes catheter-related bloodstream infections do occur.
Diagnosing and Treating Catheter-Related Infections
00:42:23
Speaker
And you did mention also that we have changed our behavior towards cultures, and people have all sorts of rules for blood cultures in these catheters.
00:42:32
Speaker
Could we just talk as we close a little bit about how do you diagnose and treat a true catheter-related bloodstream infection?
00:42:41
Speaker
Well, sure.
00:42:45
Speaker
The first thing you need is a positive blood culture.
00:42:50
Speaker
So we tend to use a lot of time to positivity.
00:42:56
Speaker
So these are blood cultures taken, ideally, one from the catheter and one peripherally.
00:43:05
Speaker
That doesn't always happen, but in patients who have, say, two different catheters, you could draw blood cultures from both catheters.
00:43:15
Speaker
And in a situation where one culture turns positive...
00:43:23
Speaker
two hours more than the other blood culture, that time to positivity is sort of a poor man's quantitative culture and gives you an indication that that catheter is the source of the bacteremia.
00:43:42
Speaker
The antibiotic selection for a
00:43:47
Speaker
A bloodstream infection is obviously based on the organism and the sensitivity pattern, but we have to be clear about pulling the catheter, and the duration of antibiotic treatment is usually about seven days for a typical organism.
00:44:07
Speaker
With Staph epi,
00:44:11
Speaker
That's typically, it's typically a contaminant, although it is listed as the CDC's, one of the CDC's most common organisms that infect catheters.
00:44:24
Speaker
There is some literature that indicates you can pull those catheters and not use antibiotics to treat the bacteremia, although I would not particularly recommend that.
00:44:36
Speaker
I think a five to seven day course treating the Staph epi is appropriate.
00:44:42
Speaker
There are some studies that indicate you could treat through an infection, meaning leaving the catheter in place, giving antibiotics to which the organism is sensitive, and treating that for 7 to 10 days.
00:44:58
Speaker
That is typically used in a patient who has a very short-term need for the catheter, knowing that we're going to pull the catheter out in two or three days and there won't be a need for that catheter, or that the patient is going to be getting a more permanent catheter in a few days' time.
00:45:18
Speaker
I don't think that treating catheters in place often
00:45:23
Speaker
usually has a good long-term resolution.
00:45:28
Speaker
These typically relapse after several days of no antibiotics.
00:45:36
Speaker
So pulling the catheter is the ideal practice.
00:45:42
Speaker
Perfect.
00:45:43
Speaker
Any other things you want to add as we close?
Future Innovations in Infection Control
00:45:51
Speaker
Well, I think, you know, again, I would emphasize what I've talked about earlier, which is relying more firmly on new and novel technologies such as antimicrobial impregnated catheters, impregnated dressings, alcoholic caps, and things that don't depend on people themselves.
00:46:16
Speaker
spending lots of time at the patient's bedside, you know, scrubbing the hub for 15 seconds and attending to aseptic technique and cleaning the exit site of the catheter daily.
00:46:30
Speaker
It's not that these practices shouldn't be done.
00:46:32
Speaker
They absolutely should be done in addition to the new technologies that we have.
00:46:40
Speaker
Again, I think that...
00:46:43
Speaker
making the argument that we don't know what the impact of each component of these strategies are, what value each technology adds, I think using them all together adds redundancy and resilience to a very fragile system.
00:47:06
Speaker
And the more we can rely on that, I think the less risk we are at risk
00:47:13
Speaker
the less risk we have in facing our next health care crisis with spiking infection rates all over the place.
00:47:23
Speaker
Absolutely.
00:47:23
Speaker
And I think that we don't put enough emphasize on improving the system.
00:47:27
Speaker
And I think over and over again, outside of medicine, it's been demonstrated and also in medicine that a bad system will beat good people every single time.
00:47:37
Speaker
Right.
00:47:38
Speaker
So it's not about having not having good intentions, but I think it's just making the system more robust.
00:47:44
Speaker
Mm hmm.
00:47:45
Speaker
Perfect.
00:47:46
Speaker
Well, Naomi, I really appreciate you sharing your expertise with us.
00:47:51
Speaker
On the podcast, we like to close with a couple of questions that are unrelated to the clinical topic, just to tap into the knowledge of our guest.
00:47:59
Speaker
Would that be okay?
00:48:01
Speaker
Sure.
00:48:02
Speaker
So the first question relates to books.
00:48:04
Speaker
Are there any books that have influenced you significantly or books that you have gifted often to other people?
00:48:14
Speaker
Oh, that's a tough one.
00:48:17
Speaker
There have been so many important books.
00:48:20
Speaker
I think one of the most influential was long ago when I read the Nancy Drew Mystery Series.
00:48:26
Speaker
Those books ignited my general interest in reading and specifically in solving mysteries.
00:48:32
Speaker
I think that's kind of how important teamwork is in seeing the whole picture and considering alternatives.
00:48:41
Speaker
I love the Nancy Drew mysteries, and I've given them to lots of kids.
00:48:46
Speaker
Perfect.
00:48:47
Speaker
And I think it's a great way for people to start reading, right?
00:48:51
Speaker
Give them something that is interesting at an early age and capture that interest, which I think, unfortunately, is an interest that might be going in the wrong direction.
00:49:03
Speaker
The second question is, what do you believe to be true in medicine or in life that most other people do not believe or at least don't behave like they believe?
00:49:14
Speaker
I think luck favors the prepared.
00:49:18
Speaker
I think that is true in life.
00:49:19
Speaker
I think that is true in medicine for health care conditions, for illnesses.
00:49:24
Speaker
I think a lot of people don't believe that, but luck does favor the prepared.
00:49:31
Speaker
Perfect.
00:49:32
Speaker
And the last would be just anything you want our listeners to know.
00:49:36
Speaker
Could be a thought, a quote, a fact, just to close.
00:49:42
Speaker
Sure.
00:49:43
Speaker
Put your own oxygen mask on before helping others.
00:49:46
Speaker
How's that?
00:49:48
Speaker
I think this quote, we hear it on airplanes all the time, right?
00:49:52
Speaker
But this really emphasizes the importance of self-care and maintaining strong interpersonal relationships outside of work in order to be your best self and be the best doctor you can be.
00:50:05
Speaker
Absolutely.
00:50:05
Speaker
And I think it's a perfect place to stop.
00:50:08
Speaker
Again, thank you for sharing your time and expertise with us.
00:50:12
Speaker
I hope that we will have you back as a guest to talk about other important topics in critical care and look forward to talking with you soon.
00:50:21
Speaker
Thank you for having me.
00:50:25
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:50:28
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:50:34
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:50:39
Speaker
To learn more, visit www.soundphysicians.com.