Hygiene and education key to reducing catheter-related infections

Medical Tribune August 2008 P7
David Brill

Some 250,000 catheter-related bloodstream infections (BSIs) occur each year in the US, with mortality as high as 35 percent and avoidable costs totaling around US$6.25 billion.
Pic: hospital patient with a catheter line

However the number of infections can be dramatically reduced by following a range of simple steps, according to Trish Perl who is Professor of medicine, pathology and epidemiology at Johns Hopkins Hospital (JHH) in Baltimore.

Since introducing measures to reduce the rates of catheter-related BSIs, JHH has seen a 75 percent decrease across all of their adult intensive care units in the past 6 years, she said. The hospital published a report in 2004 in which they estimate that 43 BSIs, 8 deaths and nearly US$2 million dollars in costs have been prevented each year by the intervention strategy. [Crit Care Med 2004 Oct;32(10):2014-20]

Perl outlined three major contamination sites that can cause BSIs: the skin and insertion site, the catheter hub and the infusate. Each of these points provides a focal target for prevention strategies, she said, noting that the former two are of the greatest concern in developed countries whereas the latter is more of a problem in the developing world.

“It remains important to cleanse your hands … that recommendation actually has the strongest evidence,” said Perl, adding that employing maximal barrier precautions and educating health care workers who place catheters can also help to avoid skin-derived infections.

“These three recommendations are highly, highly supported by the evidence and should be in place in all settings. Knowledge and adherence to guidelines for all persons placing lines has also been shown to decrease your BSI rates,” she said.

Suggested maximal barrier precautions include wearing sterile gloves and gowns and tight-fitting non-sterile masks and hats, and covering the patient’s body with a sterile drape. Consideration should also be given to the site of catheter insertion, as the subclavian vein is associated with lower infection rates than the internal jugular and femoral veins she said.

Beyond the insertion site, catheter hubs and infusates are also an important source of infections said Perl, citing a study of four pediatric hospitals in Mexico City which found that 70 percent of injection ports and 7 percent of infusates were contaminated. [Infect Control Hosp Epidemiol 2004 Mar;25(3):226-30]

“Coated catheters have been shown to decrease BSI rates but given the cost we need to determine the high-risk patients and ensure that other prevention strategies are in place,” she said, adding that the use of antiseptic ports and caps and new stopcock models seem to cut infection rates.

BSI rates also seem to increase when nursing staff levels are low, and ensuring adequate levels of care at all times may also be an important prevention strategy.

Perl noted, however, that certain newer models of needleless connectors have actually led to increased infection rates.

“I think we have to really start considering whether or not the technology can actually contribute to BSIs,” she said.

Perl concluded by adding that future infection control programs should use standard definitions, so that feedback can be easily provided to the healthcare workers who are responsible for the placement of catheters.