How to Prevent Central Line- Associated Sepsis in the NICU

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1 How to Prevent Central Line- Associated Sepsis in the NICU Professor of Pediatrics, Molecular Virology and Microbiology International Symposium on Neonatology Texas Children s Hospital Sao Paulo, Brazil April 11, 2013

2 Financial Disclosure I am a consultant for Novartis Vaccines & Diagnostics. I have no relevant financial relationship with the manufacturer(s) of any commercial product(s) or provider(s) of services discussed in this lecture.

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4 Definition Central line-associated bloodstream infection (CLABSI): hospitalized >48 hours with a CL in place and positive blood cultures (requires CL and peripheral blood cultures to meet the definition if CONS is isolated)

5 Definition of CLABSI in Neonates National Healthcare Safety Network (NHSN) of the CDC definition changed in 2008 A single positive blood culture for a skin flora organism (eg, CONS) is not a CLABSI Is the reduction in all CLABSI rates in the U.S. a result of the change in the definition?

6 Risk Factors and Etiologic Agents

7 Why Is CL-Associated Sepsis in the NICU a Problem? Biologic factors (poor immune function) Skin integrity Prolonged parenteral support for nutrition or therapies is a necessity Exposure to biofilm-producing organisms

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9 The Host Intrinsic: Immune function immaturity (all components impaired) Abnormal flora Extrinsic: Iatrogenic factors Exposures in the hospital

10 Intrinsic Factors: Poor Innate and Adaptive Immunity Incompletely developed cutaneous and mucosal barriers maternal IgG (26 weeks GA = ~300 mg/dl) C 3, factor B, etc. ( opsonins) that take weeks to months to fully develop PMN mobility, receptors, killing of organisms T-cell and cytokine function down regulated

11 Extrinsic Factors (Iatrogenic) Cutaneous barriers violated Mucosal devices (ET, OG, etc.) Indwelling intravascular devices (e.g., umbilical, peripherally-inserted catheter, surgically implanted catheter) Exposure to hospital and community pathogens via hands of personnel and visitors

12 How To Improve the Host? Prevent Preterm Delivery Other benefits: no need for CL s, TPN, lipids, exposure to NICU personnel or NICU pathogen transmission

13 Etiologic Agents Coagulase negative staphylococci (CoNS) Staphylococcus aureus (MRSA, MSSA) Enterococcus Candida species (parapsilosis, albicans) E. coli, Klebsiella, Enterobacter, Pseudomonas, etc.

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16 ( Schulman J et al. Pediatrics 2011;127: NY Regional Perinatal Centers

17 Prevention is Easy: Key Strategies Surveillance: prompt recognition (PICC and peripheral blood cultures before therapy) and standard definitions Validated PICC insertion and maintenance guidelines: bundles

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19 Bundles : CLABSI Prevention Bundle : a limited number of specific practices essential and effective for safe patient care that when implemented together result in improved patient outcomes (SYNERGY) Evidence-based insertion and maintenance protocols for NICU patients

20 PICC Insertion Bundle: Components Equipment availability (cart or kit) Hand hygiene Aseptic technique Maximal barrier precautions (gown, gloves, surgical hat and mask, drapes) Appropriate PICC site selection Skin disinfection (2% chlorhexidine, 70% alcohol) Sterile transparent dressing or gauze Surveillance of procedure and insertion technique

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22 M.D. collaboration and PICC team ownership of all central lines Upper arm site selection by ultrasound Septum disinfection Saline only flushes

23 Extraluminal and Intraluminal Strategies Effective surface disinfection / skin antisepsis Prevent active / passive organism migration Minimize fibrin adhesion INTRALUMINAL PATHWAY EXTRALUMINAL PATHWAY Skin Hub Insertion Site IV CONNECTOR Catheter

24 Extraluminal Fluid Pathway Protection Contamination Skin Antisepsis Minimize Moisture Migration Prevent microorganism entry with dressing management

25 Intraluminal Pathway Contamination /Migration Swabbing IV CONNECTOR Adhesion Prevent fibrin build-up by flushing success Colonization Minimize habitat availability by Minimizing their Food Source by eliminating Heparin

26 Septum Disinfection Septum: Protects the intraluminal pathway

27 Septum Surface Intraluminal Protection Device (IPD)

28 Maintenance Bundle: Components Hand hygiene before and after accessing the catheter or changing the dressing Evaluate catheter insertion site daily for signs of infection and dressing integrity If dressing wet, soiled or loose, disinfect skin around site and replace dressing Develop/use standard IV tubing setup/changes Maintain aseptic technique when changing IV tubing and entering the catheter (scrub the hub) Daily review of catheter necessity (removal?)

29 Checklists Using the insertion and maintenance bundles, create checklist templates or use one from another established source Decide whether these should be included in the medical record or just for a qualityimprovement tool

30 Sample insertion surveillance checklist

31 Is It Worth The Effort? Schulman J et al. Pediatrics 2011;127:

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33 Pre-Intervention 2007 Post-Intervention 2009 Schulman J et al. Pediatrics 2011;127:

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36 You Should Be Willing To Know the number of blood cultures performed to calculate rates/patient or rates/cl day Identify the number of true pathogen positive blood cultures and proportion called CLABSI Perform selective periodic or random auditing with consequences for good or poor performances

37 Take Home Points Maintenance bundles may be more effective in preventing CLABSI s in NICU s Intellectually prevention is easy but change in practice is hard It s worth the effort

38 Thank You

39 QUESTIONS?

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