1
|
Boulet N, Bobbia X, Gavoille A, Louart B, Lefrant JY, Roger C, Muller L. Axillary vein catheterization using ultrasound guidance: A prospective randomized cross-over controlled simulation comparing standard ultrasound and new needle-pilot device. J Vasc Access 2023; 24:1042-1050. [PMID: 34965763 DOI: 10.1177/11297298211063705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Real-time ultrasound (US) guidance facilitates central venous catheterization in intensive care unit (ICU). New magnetic needle-pilot devices could improve efficiency and safety of central venous catheterization. This simulation trial was aimed at comparing venipuncture with a new needle-pilot device to conventional US technique. METHODS In a prospective, randomized, simulation trial, 51 ICU physicians and residents cannulated the right axillary vein of a human torso mannequin with standard US guidance and with a needle-pilot system, in a randomized order. The primary outcome was the time from skin puncture to successful venous cannulation. The secondary outcomes were the number of skin punctures, the number of posterior wall puncture of the axillary vein, the number of arterial punctures, the number of needle redirections, the failure rate, and the operator comfort. RESULTS Time to successful cannulation was shorter with needle-pilot US-guided technique (22 s (interquartile range (IQR) = 16-42) vs 25 s (IQR = 19-128); median of difference (MOD) = -9 s (95%-confidence interval (CI) -5, -22), p < 0.001). The rates of skin punctures, posterior wall puncture of axillary vein, and needle redirections were also lower (p < 0.01). Comfort was higher in needle-pilot US-guided group on a 11-points numeric scale (8 (IQR = 8-9) vs 6 (IQR = 6-8), p < 0.001). CONCLUSIONS In a simulation model, US-guided axillary vein catheterization with a needle-pilot device was associated with a shorter time of successful cannulation and a decrease in numbers of skin punctures and complications. The results plea for investigating clinical performance of this new device.
Collapse
Affiliation(s)
- Nicolas Boulet
- Intensive Care Unit, Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Xavier Bobbia
- EA 2992 IMAGINE, Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Antoine Gavoille
- Department of Biostatistics-Bioinformatic, Hospices Civils de Lyon, Lyon, France
| | - Benjamin Louart
- Intensive Care Unit, Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Jean Yves Lefrant
- Intensive Care Unit, Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Claire Roger
- Intensive Care Unit, Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Laurent Muller
- Intensive Care Unit, Department of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| |
Collapse
|
2
|
Morse R, Childers C, Nowak E, Rao J, Vlaisavljevich E. Catheter-Based Medical Device Biofilm Ablation Using Histotripsy: A Parameter Study. ULTRASOUND IN MEDICINE & BIOLOGY 2023:S0301-5629(23)00203-X. [PMID: 37394375 DOI: 10.1016/j.ultrasmedbio.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Biofilm formation in medical catheters is a major source of hospital-acquired infections which can produce increased morbidity and mortality for patients. Histotripsy is a non-invasive, non-thermal focused ultrasound therapy and recently has been found to be effective at removal of biofilm from medical catheters. Previously established histotripsy methods for biofilm removal, however, would require several hours of use to effectively treat a full-length medical catheter. Here, we investigate the potential to increase the speed and efficiency with which biofilms can be ablated from catheters using histotripsy. METHODS Pseudomonas aeruginosa (PA14) biofilms were cultured in in vitro Tygon catheter mimics and treated with histotripsy using a 1 MHz histotripsy transducer and a variety of histotripsy pulsing rates and scanning methods. The improved parameters identified in these studies were then used to explore the bactericidal effect of histotripsy on planktonic PA14 suspended in a catheter mimic. RESULTS Histotripsy can be used to remove biofilm and kill bacteria at substantially increased speeds compared with previously established methods. Near-complete biofilm removal was achieved at treatment speeds up to 1 cm/s, while a 4.241 log reduction in planktonic bacteria was achieved with 2.4 cm/min treatment. CONCLUSION These results represent a 500-fold increase in biofilm removal speeds and a 6.2-fold increase in bacterial killing speeds compared with previously published methods. These findings indicate that histotripsy shows promise for the treatment of catheter-associated biofilms and planktonic bacteria in a clinically relevant time frame.
Collapse
Affiliation(s)
- Ryan Morse
- Virginia Tech Carilion School of Medicine, Virginia Tech, Roanoke, VA, USA.
| | | | - Elizabeth Nowak
- Internal Medicine, Division of Infectious Disease, Carilion Medical Center, Roanoke, VA, USA
| | - Jayasimha Rao
- Virginia Tech Carilion School of Medicine, Virginia Tech, Roanoke, VA, USA; Internal Medicine, Division of Infectious Disease, Carilion Medical Center, Roanoke, VA, USA
| | - Eli Vlaisavljevich
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Roanoke, VA, USA
| |
Collapse
|
3
|
Iachkine J, Buetti N, de Grooth HJ, Briant AR, Mimoz O, Mégarbane B, Mira JP, Valette X, Daubin C, du Cheyron D, Mermel LA, Timsit JF, Parienti JJ. Development and validation of a multivariable model predicting the required catheter dwell time among mechanically ventilated critically ill patients in three randomized trials. Ann Intensive Care 2023; 13:5. [PMID: 36645531 PMCID: PMC9842826 DOI: 10.1186/s13613-023-01099-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The anatomic site for central venous catheter insertion influences the risk of central venous catheter-related intravascular complications. We developed and validated a predictive score of required catheter dwell time to identify critically ill patients at higher risk of intravascular complications. METHODS We retrospectively conducted a cohort study from three multicenter randomized controlled trials enrolling consecutive patients requiring central venous catheterization. The primary outcome was the required catheter dwell time, defined as the period between the first catheter insertion and removal of the last catheter for absence of utility. Predictors were identified in the training cohort (3SITES trial; 2336 patients) through multivariable analyses based on the subdistribution hazard function accounting for death as a competing event. Internal validation was performed in the training cohort by 500 bootstraps to derive the CVC-IN score from robust risk factors. External validation of the CVC-IN score were performed in the testing cohort (CLEAN, and DRESSING2; 2371 patients). RESULTS The analysis was restricted to patients requiring mechanical ventilation to comply with model assumptions. Immunosuppression (2 points), high creatinine > 100 micromol/L (2 points), use of vasopressor (1 point), obesity (1 point) and older age (40-59, 1 point; ≥ 60, 2 points) were independently associated with the required catheter dwell time. At day 28, area under the ROC curve for the CVC-IN score was 0.69, 95% confidence interval (CI) [0.66-0.72] in the training cohort and 0.64, 95% CI [0.61-0.66] in the testing cohort. Patients with a CVC-IN score ≥ 4 in the overall cohort had a median required catheter dwell time of 24 days (versus 11 days for CVC-IN score < 4 points). The positive predictive value of a CVC-IN score ≥ 4 was 76.9% for > 7 days required catheter dwell time in the testing cohort. CONCLUSION The CVC-IN score, which can be used for the first catheter, had a modest ability to discriminate required catheter dwell time. Nevertheless, preference of the subclavian site may contribute to limit the risk of intravascular complications, in particular among ventilated patients with high CVC-IN score. Trials Registration NCT01479153, NCT01629550, NCT01189682.
Collapse
Affiliation(s)
- Jeanne Iachkine
- grid.411149.80000 0004 0472 0160Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France ,grid.460771.30000 0004 1785 9671INSERM U1311 DYNAMICURE, Caen Normandy University, Caen, France
| | - Niccolò Buetti
- grid.8591.50000 0001 2322 4988Infection Control Program and World Health Organization Collaborating Center on Patient Safety, Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Harm-Jan de Grooth
- grid.12380.380000 0004 1754 9227Department of Intensive Care, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Anaïs R. Briant
- grid.411149.80000 0004 0472 0160Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France
| | - Olivier Mimoz
- grid.11166.310000 0001 2160 6368Inserm U1070, Poitiers University, Poitiers, France ,grid.411162.10000 0000 9336 4276Poitiers University Hospital, 86021 Poitiers, France
| | - Bruno Mégarbane
- Medical and Toxicological Intensive Care Unit, Lariboisière Hospital, AP-HP, INSERM, UMRS-1144, Paris University, Paris, France
| | - Jean-Paul Mira
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Xavier Valette
- grid.411149.80000 0004 0472 0160Department of Medical Intensive Care, Caen University Hospital, 14000 Caen, France
| | - Cédric Daubin
- grid.411149.80000 0004 0472 0160Department of Medical Intensive Care, Caen University Hospital, 14000 Caen, France
| | - Damien du Cheyron
- grid.411149.80000 0004 0472 0160Department of Medical Intensive Care, Caen University Hospital, 14000 Caen, France
| | - Leonard A. Mermel
- grid.411024.20000 0001 2175 4264Department of Epidemiology and Infection Prevention, Lifespan Hospital System, Providence, RI USA ,grid.40263.330000 0004 1936 9094Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Jean-François Timsit
- grid.411119.d0000 0000 8588 831XMedical and Infectious Diseases ICU (MI2), Bichat Hospital, AP-HP, University of Paris, IAME, INSERM U1137, Paris, France
| | - Jean-Jacques Parienti
- grid.411149.80000 0004 0472 0160Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France ,grid.460771.30000 0004 1785 9671INSERM U1311 DYNAMICURE, Caen Normandy University, Caen, France
| |
Collapse
|
4
|
Malheiro R, Peleteiro B, Silva G, Lebre A, Paiva JA, Correia S. Hospital context in surgical site infection following colorectal surgery: a multi-level logistic regression analysis. J Hosp Infect 2023; 131:221-227. [PMID: 36414166 DOI: 10.1016/j.jhin.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/08/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are associated with poor health outcomes. Their incidence is highest after colorectal surgery, with little improvement in recent years. The role of hospital characteristics is undetermined. AIM To investigate whether SSI incidence after colorectal surgery varies between hospitals, and whether such variance may be explained by hospital characteristics. METHODS Data were retrieved from the electronic platform of the Directorate General of Health, from 2015 to 2019. Hospital characteristics were retrieved from publicly available data on the Portuguese public administration. Analysis considered a two-level hierarchical data structure, with individuals clustered in hospitals. To avoid overfitting, no models were built with more than one hospital characteristic. Cluster-level associations are presented through median odds ratio (MOR) and intraclass cluster coefficient (ICC). Beta coefficients were used to assess the contextual effects. FINDINGS A total of 11,219 procedures from 18 hospitals were included. The incidence of SSI was 16.8%. The ICC for the null model was 0.09. Procedural variables explained 25% of the variance, and hospital dimension explained another 17%. More than 50% of SSI variance remains unaccounted for. After adjustment, heterogeneity between hospitals (MOR: 1.51; ICC: 0.05) was still found. No hospital characteristic was significantly associated with SSI. CONCLUSION Procedural variables and hospital dimension explain almost half of SSI variance and should be taken into account when implementing prevention strategies. Future research should focus on compliance with preventive bundles and other process indicators in hospitals with significantly less SSI in colorectal surgery.
Collapse
Affiliation(s)
- R Malheiro
- EPI Unit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal.
| | - B Peleteiro
- EPI Unit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal; Department of Public Health and Forensic Sciences and Medical Education, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| | - G Silva
- Programa de Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (PPCIRA), Direção-Geral de Saúde (Directorate General of Health), Lisboa, Portugal
| | - A Lebre
- Programa de Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (PPCIRA), Direção-Geral de Saúde (Directorate General of Health), Lisboa, Portugal; Instituto Português de Oncologia do Porto Francisco Gentil, E. P. E., Porto, Portugal
| | - J A Paiva
- Instituto Português de Oncologia do Porto Francisco Gentil, E. P. E., Porto, Portugal; Intensive Care Medicine Department, Centro Hospitalar Universitário São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| | - S Correia
- Department of Public Health and Forensic Sciences and Medical Education, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| |
Collapse
|
5
|
Fournil C, Boulet N, Bastide S, Louart B, Ambert A, Boutin C, Lefrant JY, Muller L, Roger C. High success rates of ultrasound-guided distal internal jugular vein and axillary vein approaches for central venous catheterization: A randomized controlled open-label pilot trial. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:158-166. [PMID: 36385459 DOI: 10.1002/jcu.23383] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/27/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Ultrasound (US)-guided axillary vein (AV) catheterization has been considered as the preferred site of insertion to minimize catheter-related infections. Given its difficulty of realization, internal jugular vein (IJV) access remains, thus, the first choice of catheter insertion site. This descriptive study was aimed to assess the success and complication rates of in-plane short axis approach of IJV in the lower neck and the AV approach under US-guidance. METHODS In a prospective randomized controlled open-label pilot trial, all patients requiring central venous catheterization (CVC) in intensive care unit or operating room were randomly assigned to low IJV or AV groups. The primary objective was to estimate the overall success rate of both approaches. The secondary objectives were immediate complication rates, procedure durations, success rate after the first puncture, late complication rates (i.e., thrombosis, catheter colonization, and catheter-related infections), and nurse satisfaction regarding insertion site dressings. RESULTS One hundred and seventy-three out of two hundred and ten included patients were fully analyzed (90 and 83 in the IJV and AV approach groups, respectively). Overall success rates for IJV and AV sites were 96% (95% confidence interval (CI) [90-99]) and 89% (95% CI [81-94]) respectively. First puncture success rates were 90% and 80% respectively. The median overall procedure duration from US pre-procedural screening to guidewire insertion was 8 and 10 min in IJV and AV groups. Overall immediate complications rates for IJV and AV sites were 11.6% and 14.6%, respectively. Incidence of catheter colonization were 7.9% and 6.8% and catheter-related infection rate were 2.6% and 0%, respectively. CONCLUSION In this pilot study, US-guided low IJV and AV approaches are safe and efficient techniques for CVC insertion associated with high success and low complications rates. Duration for guidewire insertion seemed to be shorter in the short axis in-plane IJV approach. It provides the basis for a future randomized trial comparing these two approaches.
Collapse
Affiliation(s)
- Céline Fournil
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Nicolas Boulet
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Sophie Bastide
- Laboratoire de Biostatistique, Epidémiologie Clinique, Santé Publique Innovation et Méthodologie (BESPIM), Pôle Pharmacie, Santé Publique, Nîmes University Hospital, University of Montpellier, France
| | - Benjamin Louart
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Audrey Ambert
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Caroline Boutin
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Jean-Yves Lefrant
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Laurent Muller
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Claire Roger
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| |
Collapse
|
6
|
Gouel-Cheron A, Swihart BJ, Warner S, Mathew L, Strich JR, Mancera A, Follmann D, Kadri SS. Epidemiology of ICU-Onset Bloodstream Infection: Prevalence, Pathogens, and Risk Factors Among 150,948 ICU Patients at 85 U.S. Hospitals. Crit Care Med 2022; 50:1725-1736. [PMID: 36190259 PMCID: PMC10829879 DOI: 10.1097/ccm.0000000000005662] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Bloodstream infections (BSIs) acquired in the ICU represent a detrimental yet potentially preventable condition. We determined the prevalence of BSI acquired in the ICU (ICU-onset BSI), pathogen profile, and associated risk factors. DESIGN Retrospective cohort study. DATA SOURCES Eighty-five U.S. hospitals in the Cerner Healthfacts Database. PATIENT SELECTION Adult hospitalizations between January 2009 and December 2015 including a (≥ 3 d) ICU stay. DATA EXTRACTION AND DATA SYNTHESIS Prevalence of ICU-onset BSI (between ICU Day 3 and ICU discharge) and associated pathogen and antibiotic resistance distributions were compared with BSI present on (ICU) admission (ICU-BSI POA ); and BSI present on ICU admission day or Day 2. Cox models identified risk factors for ICU-onset BSI among host, care setting, and treatment-related factors. Among 150,948 ICU patients, 5,600 (3.7%) had ICU-BSI POA and 1,306 (0.9%) had ICU-onset BSI. Of those with ICU-BSI POA , 4,359 (77.8%) were admitted to ICU at hospital admission day. Patients with ICU-onset BSI (vs ICU-BSI POA ) displayed higher crude mortality of 37.9% (vs 20.4%) ( p < 0.001) and longer median (interquartile range) length of stay of 13 days (8-23 d) (vs 5 d [3-8 d]) ( p < 0.001) (considering all ICU stay). Compared with ICU-BSI POA , ICU-onset BSI displayed more Pseudomonas , Acinetobacter , Enterococcus, Candida , and Coagulase-negative Staphylococcus species, and more methicillin-resistant staphylococci, vancomycin-resistant enterococci, ceftriaxone-resistant Enterobacter , and carbapenem-resistant Enterobacterales and Acinetobacter species, respectively. Being younger, male, Black, Hispanic, having greater comorbidity burden, sepsis, trauma, acute pulmonary or gastrointestinal presentations, and pre-ICU exposure to antibacterial and antifungal agents was associated with greater ICU-onset BSI risk after adjusted analysis. Mixed ICUs (vs medical or surgical ICUs) and urban and small/medium rural hospitals were also associated with greater ICU-onset BSI risk. The associated risk of acquiring ICU-onset BSI manifested with any duration of mechanical ventilation and 7 days after insertion of central venous or arterial catheters. CONCLUSIONS ICU-onset BSI is a serious condition that displays a unique pathogen and resistance profile compared with ICU-BSI POA . Further scrutiny of modifiable risk factors for ICU-onset BSI may inform control strategies.
Collapse
Affiliation(s)
- Aurelie Gouel-Cheron
- Clinical Epidemiology Section, Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
- Biostatistics Research Branch, NIAID, NIH, Bethesda, MD
- Department of Anesthesiology and Intensive Care, Bichat Hospital, AP-HP, Paris Cité University, Paris, France
- Unit of Antibodies in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, 75015 Paris, France
| | | | - Sarah Warner
- Clinical Epidemiology Section, Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| | - Lauren Mathew
- Clinical Epidemiology Section, Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai West and Morningside, New York, NY
| | - Jeffrey R Strich
- Clinical Epidemiology Section, Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
- United States Public Health Service Commissioned Corps, Rockville, MD
| | - Alex Mancera
- Clinical Epidemiology Section, Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| | - Dean Follmann
- Biostatistics Research Branch, NIAID, NIH, Bethesda, MD
| | - Sameer S Kadri
- Clinical Epidemiology Section, Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| |
Collapse
|
7
|
Iachkine J, Buetti N, de Grooth HJ, Briant AR, Mimoz O, Mégarbane B, Mira JP, Ruckly S, Souweine B, du Cheyron D, Mermel LA, Timsit JF, Parienti JJ. Development and validation of a multivariable prediction model of central venous catheter-tip colonization in a cohort of five randomized trials. Crit Care 2022; 26:205. [PMID: 35799302 PMCID: PMC9261073 DOI: 10.1186/s13054-022-04078-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The majority of central venous catheters (CVC) removed in the ICU are not colonized, including when a catheter-related infection (CRI) is suspected. We developed and validated a predictive score to reduce unnecessary CVC removal.
Methods
We conducted a retrospective cohort study from five multicenter randomized controlled trials with systematic catheter-tip culture of consecutive CVCs. Colonization was defined as growth of ≥103 colony-forming units per mL. Risk factors for colonization were identified in the training cohort (CATHEDIA and 3SITES trials; 3899 CVCs of which 575 (15%) were colonized) through multivariable analyses. After internal validation in 500 bootstrapped samples, the CVC-OUT score was computed by attaching points to the robust (> 50% of the bootstraps) risk factors. External validation was performed in the testing cohort (CLEAN, DRESSING2 and ELVIS trials; 6848 CVCs, of which 588 (9%) were colonized).
Results
In the training cohort, obesity (1 point), diabetes (1 point), type of CVC (dialysis catheter, 1 point), anatomical insertion site (jugular, 4 points; femoral 5 points), rank of the catheter (second or subsequent, 1 point) and catheterization duration (≥ 5 days, 2 points) were significantly and independently associated with colonization . Area under the ROC curve (AUC) for the CVC-OUT score was 0.69, 95% confidence interval (CI) [0.67–0.72]. In the testing cohort, AUC for the CVC-OUT score was 0.60, 95% CI [0.58–0.62]. Among 1,469 CVCs removed for suspected CRI in the overall population, 1200 (82%) were not colonized. The negative predictive value (NPV) of a CVC-OUT score < 6 points was 94%, 95% CI [93%–95%].
Conclusion
The CVC-OUT score had a moderate ability to discriminate catheter-tip colonization, but the high NPV may contribute to reduce unnecessary CVCs removal. Preference of the subclavian site is the strongest and only modifiable risk factor that reduces the likelihood of catheter-tip colonization and consequently the risk of CRI.
Clinical Trials Registration: NCT00277888, NCT01479153, NCT01629550, NCT01189682, NCT00875069.
Collapse
|
8
|
Pusparajah P, Letchumanan V, Law JWF, Ab Mutalib NS, Ong YS, Goh BH, Tan LTH, Lee LH. Streptomyces sp.-A Treasure Trove of Weapons to Combat Methicillin-Resistant Staphylococcus aureus Biofilm Associated with Biomedical Devices. Int J Mol Sci 2021; 22:ijms22179360. [PMID: 34502269 PMCID: PMC8431294 DOI: 10.3390/ijms22179360] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022] Open
Abstract
Biofilms formed by methicillin-resistant S. aureus (MRSA) are among the most frequent causes of biomedical device-related infection, which are difficult to treat and are often persistent and recurrent. Thus, new and effective antibiofilm agents are urgently needed. In this article, we review the most relevant literature of the recent years reporting on promising anti-MRSA biofilm agents derived from the genus Streptomyces bacteria, and discuss the potential contribution of these newly reported antibiofilm compounds to the current strategies in preventing biofilm formation and eradicating pre-existing biofilms of the clinically important pathogen MRSA. Many efforts are evidenced to address biofilm-related infections, and some novel strategies have been developed and demonstrated encouraging results in preclinical studies. Nevertheless, more in vivo studies with appropriate biofilm models and well-designed multicenter clinical trials are needed to assess the prospects of these strategies.
Collapse
Affiliation(s)
- Priyia Pusparajah
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (P.P.); (V.L.); (J.W.-F.L.); (N.-S.A.M.)
| | - Vengadesh Letchumanan
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (P.P.); (V.L.); (J.W.-F.L.); (N.-S.A.M.)
| | - Jodi Woan-Fei Law
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (P.P.); (V.L.); (J.W.-F.L.); (N.-S.A.M.)
| | - Nurul-Syakima Ab Mutalib
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (P.P.); (V.L.); (J.W.-F.L.); (N.-S.A.M.)
- UKM Medical Molecular Biology Institute (UMBI), UKM Medical Centre, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Yong Sze Ong
- Biofunctional Molecule Exploratory Research Group (BMEX), School of Pharmacy, Monash University Malaysia, Bandar Sunway 47500, Malaysia;
| | - Bey-Hing Goh
- Biofunctional Molecule Exploratory Research Group (BMEX), School of Pharmacy, Monash University Malaysia, Bandar Sunway 47500, Malaysia;
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
- Correspondence: (B.-H.G.); (L.T.-H.T.); (L.-H.L.)
| | - Loh Teng-Hern Tan
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (P.P.); (V.L.); (J.W.-F.L.); (N.-S.A.M.)
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Johor Bahru 80100, Malaysia
- Correspondence: (B.-H.G.); (L.T.-H.T.); (L.-H.L.)
| | - Learn-Han Lee
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (P.P.); (V.L.); (J.W.-F.L.); (N.-S.A.M.)
- Correspondence: (B.-H.G.); (L.T.-H.T.); (L.-H.L.)
| |
Collapse
|
9
|
Singh T, Hook AL, Luckett J, Maitz MF, Sperling C, Werner C, Davies MC, Irvine DJ, Williams P, Alexander MR. Discovery of hemocompatible bacterial biofilm-resistant copolymers. Biomaterials 2020; 260:120312. [PMID: 32866726 PMCID: PMC7534038 DOI: 10.1016/j.biomaterials.2020.120312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 12/24/2022]
Abstract
Blood-contacting medical devices play an important role within healthcare and are required to be biocompatible, hemocompatible and resistant to microbial colonization. Here we describe a high throughput screen for copolymers with these specific properties. A series of weakly amphiphilic monomers are combinatorially polymerized with acrylate glycol monomers of varying chain lengths to create a library of 645 multi-functional candidate materials containing multiple chemical moieties that impart anti-biofilm, hemo- and immuno-compatible properties. These materials are screened in over 15,000 individual biological assays, targeting two bacterial species, one Gram negative (Pseudomonas aeruginosa) and one Gram positive (Staphylococcus aureus) commonly associated with central venous catheter infections, using 5 different measures of hemocompatibility and 6 measures of immunocompatibililty. Selected copolymers reduce platelet activation, platelet loss and leukocyte activation compared with the standard comparator PTFE as well as reducing bacterial biofilm formation in vitro by more than 82% compared with silicone. Poly(isobornyl acrylate-co-triethylene glycol methacrylate) (75:25) is identified as the optimal material across all these measures reducing P. aeruginosa biofilm formation by up to 86% in vivo in a murine foreign body infection model compared with uncoated silicone.
Collapse
Affiliation(s)
- Taranjit Singh
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK; Biodiscovery Institute and School of Life Sciences, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Andrew L Hook
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Jeni Luckett
- Biodiscovery Institute and School of Life Sciences, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Manfred F Maitz
- Leibniz Institute of Polymer Research Dresden, Max Bergmann Centre for Biomaterials Dresden, Hohe Str. 6, D-01069, Dresden, Germany
| | - Claudia Sperling
- Leibniz Institute of Polymer Research Dresden, Max Bergmann Centre for Biomaterials Dresden, Hohe Str. 6, D-01069, Dresden, Germany
| | - Carsten Werner
- Leibniz Institute of Polymer Research Dresden, Max Bergmann Centre for Biomaterials Dresden, Hohe Str. 6, D-01069, Dresden, Germany
| | - Martyn C Davies
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Derek J Irvine
- Department of Chemical and Environmental Engineering, Faculty of Engineering, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Paul Williams
- Biodiscovery Institute and School of Life Sciences, University of Nottingham, Nottingham, NG7 2RD, UK
| | | |
Collapse
|
10
|
Cattaneo D, Corona A, De Rosa FG, Gervasoni C, Kocic D, Marriott DJ. The management of anti-infective agents in intensive care units: the potential role of a 'fast' pharmacology. Expert Rev Clin Pharmacol 2020; 13:355-366. [PMID: 32320302 DOI: 10.1080/17512433.2020.1759413] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients in intensive care units (ICU) are often developing severe infections in which are associated with significant mortality rates. A number of novel technologies for the rapid microbiological diagnosis of these infections have been developed, introducing the era of 'fast microbiology.' Treatment of bacterial and fungal infections in ICU is however complicated by alterations in the pharmacokinetics of antimicrobial agents. AREAS COVERED We review novel pharmacologic tools that can be used to optimize anti-infective therapies and patient management in ICU. A MEDLINE Pubmed search for articles published from January 1995 to 2019 was completed matching the terms pharmacokinetics and pharmacology with antimicrobial agents and ICU or critically ill patients. Moreover, additional studies were identified from the reference list of retrieved articles. EXPERT OPINION Several tools are in development for the full automation of the analytical methods used for the quantification of antimicrobial concentrations within a few hours after sample collection. Ad hoc software with adaptive feedback is also available for appropriate dose adjustments based on both individual patient covariate data and therapeutic drug monitoring (TDM) data when available. The application of these technological improvements in the clinical practice should open the way to a 'fast pharmacology' at the bedside.
Collapse
Affiliation(s)
- Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Alberto Corona
- Intensive Care Unit, ASST Fatebenefratelli Sacco, University Hospital , Milan, Italy
| | | | - Cristina Gervasoni
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Danijela Kocic
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney , Sydney, Australia
| | - Deborah Je Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital , Sydney, Australia
| |
Collapse
|
11
|
Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med 2020; 46:266-284. [PMID: 32047941 PMCID: PMC7223992 DOI: 10.1007/s00134-020-05950-6] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Abstract
Bloodstream infection (BSI) is defined by positive blood cultures in a patient with systemic signs of infection and may be either secondary to a documented source or primary—that is, without identified origin. Community-acquired BSIs in immunocompetent adults usually involve drug-susceptible bacteria, while healthcare-associated BSIs are frequently due to multidrug-resistant (MDR) strains. Early adequate antimicrobial therapy is a key to improve patient outcomes, especially in those with criteria for sepsis or septic shock, and should be based on guidelines and direct examination of available samples. Local epidemiology, suspected source, immune status, previous antimicrobial exposure, and documented colonization with MDR bacteria must be considered for the choice of first-line antimicrobials in healthcare-associated and hospital-acquired BSIs. Early genotypic or phenotypic tests are now available for bacterial identification and early detection of resistance mechanisms and may help, though their clinical impact warrants further investigations. Initial antimicrobial dosing should take into account the pharmacokinetic alterations commonly observed in ICU patients, with a loading dose in case of sepsis or septic shock. Initial antimicrobial combination attempting to increase the antimicrobial spectrum should be discussed when MDR bacteria are suspected and/or in the most severely ill patients. Source identification and control should be performed as soon as the hemodynamic status is stabilized. De-escalation from a broad-spectrum to a narrow-spectrum antimicrobial may reduce antibiotic selection pressure without negative impact on mortality. The duration of therapy is usually 5–8 days though longer durations may be discussed depending on the underlying illness and the source of infection. This narrative review covers the epidemiology, diagnostic workflow and therapeutic aspects of BSI in ICU patients and proposed up-to-date expert statements.
Collapse
Affiliation(s)
- Jean-François Timsit
- AP-HP, Hôpital Bichat, Medical and Infectious Diseases ICU, 75018, Paris, France. .,Université de Paris, IAME, INSERM, 75018, Paris, France.
| | - Etienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.,AP-HP, Hôpital Bichat, Bacteriology Laboratory, 75018, Paris, France
| | | | - Alexis Tabah
- ICU, Redcliffe Hospital, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino-IRCCS, Genoa, Italy
| |
Collapse
|
12
|
Thorarinsdottir HR, Rockholt M, Klarin B, Broman M, Fraenkel C, Kander T. Catheter-related infections: A Scandinavian observational study on the impact of a simple hygiene insertion bundle. Acta Anaesthesiol Scand 2020; 64:224-231. [PMID: 31523802 DOI: 10.1111/aas.13477] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Catheter-related infections (CRIs) and catheter-related bloodstream infections (CRBSIs) are among the most frequent hospital acquired infections. CRI/CRBSI studies in Scandinavian cohorts are scarce. The primary aim of this study was to investigate the CRI/CRBSI incidence and the association between potential risk factors, including the introduction of a simple hygiene insertion bundle and CRIs at a large university hospital in Sweden. METHODS We retrospectively included all patients aged 12 and above who received a central venous catheter (CVC) or a central dialysis catheter during a 2-year period, 1 year before and 1 year after the implementation of a simple hygiene insertion bundle. Microbiological data, including catheter tip cultures and blood cultures, were merged with CVC insertion data. RESULTS A total of 1722 catheter insertions in 1428 patients were included. CRI and CRBSI incidence were 1.86/1000 and 0.62/1000 catheter days, respectively. In a multivariable regression model, the implementation of a simple hygiene insertion bundle was the independent factor most strongly associated with significantly lower CRI-incidence (95% confidence interval [CI] of odds ratio [OR] 0.23-0.92, P = .029). Choosing multiple lumen catheters was associated with increasing CRI-incidence (95% CI of OR 1.11-2.39, P = .013). CONCLUSION The incidence of catheter-related infections and catheter-related bloodstream infections in this Scandinavian cohort was low. The implementation of a simple hygiene insertion bundle seems to be an effective intervention for reducing catheter-related infections. The use of multiple-lumen catheters is associated with increased risk of catheter-related infections.
Collapse
Affiliation(s)
- Hulda Rosa Thorarinsdottir
- Department of Intensive and Perioperative Care Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Mika Rockholt
- Department of Intensive and Perioperative Care Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Bengt Klarin
- Department of Intensive and Perioperative Care Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Marcus Broman
- Department of Intensive and Perioperative Care Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Carl‐Johan Fraenkel
- Department of Clinical Sciences Lund University Lund Sweden
- Department of Infection Control Region Skåne Lund Sweden
| | - Thomas Kander
- Department of Intensive and Perioperative Care Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| |
Collapse
|
13
|
Abstract
These practice guidelines update the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the American Society of Anesthesiologists in 2011 and published in 2012. These updated guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist and may also serve as a resource for other physicians, nurses, or healthcare providers who manage patients with central venous catheters.
Supplemental Digital Content is available in the text.
Collapse
|
14
|
Complication and Failures of Central Vascular Access Device in Adult Critical Care Settings. Crit Care Med 2019; 46:1998-2009. [PMID: 30095499 DOI: 10.1097/ccm.0000000000003370] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To examine the proportion and rate of central venous access device failure and complications across central venous access device types in adult intensive care. DATA SOURCES A systematic search was undertaken in the electronic databases Cochrane Central Register of Controlled Trials, Embase, U.S. National Library of Medicine National Institutes of Health, and Cumulative Index to Nursing and Allied Health in September 2017. STUDY SELECTION Included studies were of observational (prospective and retrospective) or interventional design and reported central venous access device failure and complications in adult ICU settings. Studies were excluded if they were published prior to November 2006 or not reported in English. Two reviewers independently screened articles, assessed eligibility, extracted data, and assessed risk of bias. DATA EXTRACTION Data were extracted on the primary outcome, central venous access device failure, and secondary outcomes: central venous access device complications (central line-associated bloodstream infection, catheter-related bloodstream infection, catheter-related thrombosis, occlusion, catheter removal due to suspected infection, dislodgement, breakage, and local infection). Patient and device data and study details to assess the study quality were also extracted. DATA SYNTHESIS A total of 63 studies involving 50,000 central venous access devices (396,951 catheter days) were included. Central venous access device failure was 5% (95% CI, 3-6%), with the highest rates and proportion of failure in hemodialysis catheters. Overall central line-associated bloodstream infection rate was 4.59 per 1,000 catheter days (95% CI, 2.31-6.86), with the highest rate in nontunneled central venous access devices. Removal of central venous access device due to suspected infection was high (17%; 20.4 per 1,000 catheter days; 95% CI, 15.7-25.2). CONCLUSIONS Central venous access device complications and device failure is a prevalent and significant problem in the adult ICU, leading to substantial patient harm and increased healthcare costs. The high proportion of central venous access devices removed due to suspicion of infection, despite low overall central line-associated bloodstream infection and catheter-related bloodstream infection rates, indicates a need for robust practice guidelines to inform decision-making surrounding removal of central venous access devices suspected of infection.
Collapse
|
15
|
Chlorhexidine-impregnated dressing for the prophylaxis of central venous catheter-related complications: a systematic review and meta-analysis. BMC Infect Dis 2019; 19:429. [PMID: 31096918 PMCID: PMC6524337 DOI: 10.1186/s12879-019-4029-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023] Open
Abstract
Background Several randomized controlled trials (RCTs) evaluated the role of Chlorhexidine-impregnated dressing for prophylaxis of central venous catheter (CVC) related complications, but the results remained inconsistent, updated meta-analyses on this issue are warranted. Methods A meta-analysis on the RCTs comparing Chlorhexidine-impregnated dressing versus other dressing or no dressing for prophylaxis of central venous catheter-related complications was performed. A comprehensive search of major databases was undertaken up to 30 Dec 2018 to identify related studies. Pooled odd ratio (OR) and mean differences (MDs) with 95% confidence intervals (CI) were calculated using either a fixed-effects or random-effects model. Subgroup analysis was performed to identify the source of heterogeneity, and funnel plot and Egger test was used to identify the publication bias. Results A total of 12 RCTs with 6028 patients were included. The Chlorhexidine-impregnated dressings provided significant benefits in reducing the risk of catheter colonization (OR = 0.46, 95% CI: 0.36 to 0.58), decreasing the incidence of catheter-related bloodstream infection (CRBSI) (OR = 0.60, 95% CI: 0.42 to 0.85). Subgroup analysis indicated that the Chlorhexidine-impregnated dressings were conducive to reduce the risk of catheter colonization and CRBSI within the included RCTs with sample size more than 200, but the differences weren’t observed for those with sample less than 200. No publication bias was observed in the Egger test for the risk of CRBSI. Conclusions Chlorhexidine-impregnated dressing is beneficial to prevent CVC-related complications. Future studies are warranted to assess the role and cost-effectiveness of Chlorhexidine-impregnated dressings.
Collapse
|
16
|
Eggimann P, Pagani JL, Dupuis-Lozeron E, Ms BE, Thévenin MJ, Joseph C, Revelly JP, Que YA. Sustained reduction of catheter-associated bloodstream infections with enhancement of catheter bundle by chlorhexidine dressings over 11 years. Intensive Care Med 2019; 45:823-833. [PMID: 30997542 PMCID: PMC6534662 DOI: 10.1007/s00134-019-05617-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/06/2019] [Indexed: 11/24/2022]
Abstract
Background Prospective randomized controlled studies have demonstrated that addition of chlorhexidine (CHG) dressings reduces the rate of catheter (central venous and arterial)-associated bloodstream infections (CABSIs). However, studies confirming their impact in a real-world setting are lacking. Methods We conducted a real-world data study evaluating the impact of incrementally introducing chlorhexidine dressings (sponge or gel) in addition to an ongoing catheter bundle on the rates of CABSI, expressed as incidence density rates per 1000 catheter-days measured as part of a surveillance program. Poisson regression models were used to compare infection rates over time. Both dressings were used simultaneously during one of the five study periods. Results From 2006 to 2014, 18,286 patients were admitted (91,292 ICU-days and 155,242 catheter-days). We recorded 111 CABSIs. We observed a progressive but significant decrease of CABSI rates from 1.48 (95% CI 1.09–2.01) without CHG dressings to 0.69 (95% CI 0.43–1.09) and 0.23 (95% CI 0.11–0.48) episodes per 1000 catheter-days when CHG sponge and CHG gel dressings were used (p = 0.0007; p < 0.001). A non-significant lower rate of infections occurred with CHG gel compared with CHG sponge dressings. An identical low rate of allergic skin reactions (0.3/1000 device-days) was observed with both types of CHX dressings. Post-study data until 2018 confirmed a sustained decrease of infection rates over 11 years. Conclusions The addition of chlorhexidine dressings to all CVC and arterial lines to an ongoing catheter bundle was associated with a sustained 11-year reduction of all catheter-associated bloodstream infections. This large real-world data study further supports the current recommendations for the systematic use of CHG dressings on all catheters of ICU patients. Electronic supplementary material The online version of this article (10.1007/s00134-019-05617-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Philippe Eggimann
- Service of Adult Intensive Care Medicine, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland. .,Department of Locomotor Apparatus, Centre Hospitalier Universitaire Vaudois (CHUV), Bugnon 46, BH 14-309, 1211, Lausanne, Switzerland.
| | - Jean-Luc Pagani
- Service of Adult Intensive Care Medicine, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Elise Dupuis-Lozeron
- Unit of Population Epidemiology, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Marie-Josèphe Thévenin
- Service of Hospital Preventive Medicine, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Christine Joseph
- Service of Adult Intensive Care Medicine, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Jean-Pierre Revelly
- Service of Adult Intensive Care Medicine, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Yok-Ai Que
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
17
|
Okuda KI, Yoshii Y, Yamada S, Chiba A, Hironaka I, Hori S, Yanaga K, Mizunoe Y. Detection of bacterial DNA from central venous catheter removed from patients by next generation sequencing: a preliminary clinical study. Ann Clin Microbiol Antimicrob 2018; 17:44. [PMID: 30577829 PMCID: PMC6303997 DOI: 10.1186/s12941-018-0297-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/17/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Catheter-related infection (CRI) is one of the serious challenges in clinical practice. This preliminary clinical study aimed to examine whether next-generation sequencing (NGS) targeting 16S rDNA, which was PCR-amplified directly from the tip of a central venous catheter (CVC), can be used to identify causative pathogens in CRI, compared to the culture method. METHODS Hospitalized patients, from whom a CVC had just been removed, were prospectively enrolled and divided into the CRI-suspected and routine removal groups. DNA was extracted from the sonication fluid of CVC specimens derived from patients. For analysis of bacterial composition by NGS, the V3-V4 fragments of bacterial 16S rDNA were PCR-amplified, followed by index PCR and paired-end sequencing on an Illumina MiSeq device. Conventional culture methods were also performed in the CRI-suspected group. RESULTS Of CVCs collected from the 156 enrolled patients (114 men; mean age 65.6 years), a total of 14 specimens [nine out of 31 patients suspected with CRI and five out of 125 patients without infection symptoms (routine removal group)] were PCR-positive. In five patients with definite CRI, Staphylococcus was the most frequently detected genus by NGS (4/5 specimens), although no pathogens were detected by NGS in the one remaining specimen. The genera identified by NGS were consistent with those from conventional culture tests. There was high agreement between NGS and the culture method in the CRI-suspected group, with sensitivity and specificity values of 80.0% and 76.9%, respectively; meanwhile, the false-positive rate of NGS was as low as 4.0% in the routine removal group. Moreover, several genera, besides the genus identified by culture test, were detected in each patient with definite CRI and surgical site infection (SSI). Additionally, in one patient with SSI, Enterococcaceae were detected not only by NGS but also by abdominal abscess drainage culture. CONCLUSIONS NGS targeting 16S rDNA was able to analyze the bacterial composition of CVC specimens and detect causative pathogens in patients with CRI and was therefore suggested as a promising diagnostic tool for CRI.
Collapse
Affiliation(s)
- Ken-Ichi Okuda
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan. .,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Yutaka Yoshii
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.,Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Satomi Yamada
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akio Chiba
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ippei Hironaka
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Seiji Hori
- Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Infectious Disease and Control, The Jikei University School of Medicine, Tokyo, Japan
| | - Katsuhiko Yanaga
- Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshimitsu Mizunoe
- Department of Bacteriology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.,Jikei Center for Biofilm Science and Technology, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
18
|
Treatment of central line-associated bloodstream infections. Crit Care 2018; 22:303. [PMID: 30445990 PMCID: PMC6240203 DOI: 10.1186/s13054-018-2249-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/29/2018] [Indexed: 02/02/2023] Open
|
19
|
Cost-effectiveness analysis of chlorhexidine-alcohol versus povidone iodine-alcohol solution in the prevention of intravascular-catheter-related bloodstream infections in France. PLoS One 2018; 13:e0197747. [PMID: 29799871 PMCID: PMC5969756 DOI: 10.1371/journal.pone.0197747] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/06/2018] [Indexed: 11/20/2022] Open
Abstract
Objective To perform a cost-effectiveness analysis of skin antiseptic solutions (chlorhexidine-alcohol (CHG) versus povidone iodine-alcohol solution (PVI)) for the prevention of intravascular-catheter-related bloodstream infections (CRBSI) in intensive care unit (ICU) in France based on an open-label, multicentre, randomised, controlled trial (CLEAN). Design A 100-day time semi-markovian model was performed to be fitted to longitudinal individual patient data from CLEAN database. This model includes eight health states and probabilistic sensitivity analyses on cost and effectiveness were performed. Costs of intensive care unit stay are based on a French multicentre study and the cost-effectiveness criterion is the cost per patient with catheter-related bloodstream infection avoided. Patients 2,349 patients (age≥18 years) were analyzed to compare the 1-time CHG group (CHG-T1, 588 patients), the 4-time CHG group (CHG-T4, 580 patients), the 1-time PVI group (PVI-T1, 587 patients), and the 4-time PVI group (PVI-T4, 594 patients). Intervention 2% chlorhexidine-70% isopropyl alcohol (chlorhexidine-alcohol) compared to 5% povidone iodine-69% ethanol (povidone iodine-alcohol). Results The mean cost per alive, discharged or dead patient was of €23,798 (95% confidence interval: €20,584; €34,331), €21,822 (€18,635; €29,701), €24,874 (€21,011; €31,678), and €24,201 (€20,507; €29,136) for CHG-T1, CHG-T4, PVI-T1, and PVI-T4, respectively. The mean number of patients with CRBSI per 1000 patients was of 3.49 (0.42; 12.57), 6.82 (1.86; 17.38), 26.04 (14.64; 42.58), and 23.05 (12.32; 39.09) for CHG-T1, CHG-T4, PVI-T1, and PVI-T4, respectively. In comparison to the 1-time PVI solution, the 1-time CHG solution avoids 22.55 CRBSI /1,000 patients, and saves €1,076 per patient. This saving is not statistically significant at a 0.05 level because of the overlap of 95% confidence intervals for mean costs per patient in each group. Conversely, the difference in effectiveness between the CHG-T1 solution and the PVI-T1 solution is statistically significant. Conclusions The CHG-T1 solution is more effective at the same cost than the PVI-T1 solution. CHG-T1, CHG-T4 and PVI-T4 solutions are statistically comparable for cost and effectiveness. This study is based on the data from the RCT from 11 French intensive care units registered with www.clinicaltrials.gov (NCT01629550).
Collapse
|
20
|
A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill. Intensive Care Med 2018; 44:742-759. [PMID: 29754308 DOI: 10.1007/s00134-018-5212-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/05/2018] [Indexed: 12/14/2022]
Abstract
Intravascular catheters are inserted into almost all critically ill patients. This review provides up-to-date insight into available knowledge on epidemiology and diagnosis of complications of central vein and arterial catheters in ICU. It discusses the optimal therapy of catheter-related infections and thrombosis. Prevention of complications is a multidisciplinary task that combines both improvement of the process of care and introduction of new technologies. We emphasize the main component of the prevention strategies that should be used in critical care and propose areas of future investigation in this field.
Collapse
|
21
|
Rodríguez-Acelas AL, de Abreu Almeida M, Engelman B, Cañon-Montañez W. Risk factors for health care-associated infection in hospitalized adults: Systematic review and meta-analysis. Am J Infect Control 2017; 45:e149-e156. [PMID: 29031433 DOI: 10.1016/j.ajic.2017.08.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/25/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Health care-associated infections (HAIs) are a public health problem that increase health care costs. This article aimed to systematically review the literature and meta-analyze studies investigating risk factors (RFs) independently associated with HAIs in hospitalized adults. METHODS Electronic databases (MEDLINE, Embase, and LILACS) were searched to identify studies from 2009-2016. Pooled risk ratios (RRs) or odds ratios (ORs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated and compared across the groups. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS Of 867 studies, 65 met the criteria for review, and the data of 18 were summarized in the meta-analysis. The major RFs independently associated with HAIs were diabetes mellitus (RR, 1.76; 95% CI, 1.27-2.44), immunosuppression (RR, 1.24; 95% CI, 1.04-1.47), body temperature (MD, 0.62; 95% CI, 0.41-0.83), surgery time in minutes (MD, 34.53; 95% CI, 22.17-46.89), reoperation (RR, 7.94; 95% CI, 5.49-11.48), cephalosporin exposure (RR, 1.77; 95% CI, 1.30-2.42), days of exposure to central venous catheter (MD, 5.20; 95% CI, 4.91-5.48), intensive care unit (ICU) admission (RR, 3.76; 95% CI, 1.79-7.92), ICU stay in days (MD, 21.30; 95% CI, 19.81-22.79), and mechanical ventilation (OR, 12.95; 95% CI, 6.28-26.73). CONCLUSIONS Identifying RFs that contribute to develop HAIs may support the implementation of strategies for their prevention, therefore maximizing patient safety.
Collapse
|
22
|
Baldesi O, Bailly S, Ruckly S, Lepape A, L'Heriteau F, Aupee M, Boussat S, Bervas C, Machut A, Berger-Carbonne A, Savey A, Timsit JF. ICU-acquired candidaemia in France: Epidemiology and temporal trends, 2004-2013 - A study from the REA-RAISIN network. J Infect 2017; 75:59-67. [PMID: 28366686 DOI: 10.1016/j.jinf.2017.03.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/02/2017] [Accepted: 03/02/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Candidaemia is a life-threatening infectious disease, associated with septic shock, multiple organ failure, and a high mortality rate. In France, reported data on the incidence of ICU-acquired candidaemia and the causative Candida species are scarce. The objective of this study was to determine temporal trends in epidemiology and risk factors of intensive care unit-acquired candidaemia (ICU-Cand) and ICU mortality among a very large population of ICU patients. METHOD Demographics, patient risk factors, invasive device exposure and nosocomial infection in ICU patient were collected from 2004 to 2013 in a national network of 213 ICUs: REA-RAISIN. Incidence and risk factors for candidaemia and ICU mortality were assessed. RESULTS Out of 246,459 ICU patients, 851 developed an ICU-cand, representing 0.3 per 1000 patients-days. The incidence rose sharply over time. Candida albicans was the main species. The overall and ICU mortality was 52.4% in ICU-cand patients. The main risk factors of ICU-cand were length of stay, severity of illness and antimicrobial therapy at ICU admission, immune status and use of invasive procedure. ICU-cand was an independent risk factor of mortality (OR: 1.53; 95%CI [1.40-1.70]); in a sub-group analysis, independent effects on mortality were observed with C. albicans (OR: 1.45 [1.23-1.71]), Candida tropicalis (OR: 2.11 [1.31-3.39]) and "other" Candida species (OR: 1.64 [1.09-2.45]). CONCLUSION ICU candidaemia ranked sixth among bloodstream infections, and its average annual incidence was 0.3 per 1000 patients days. Despite of new therapy and international recommendation, the incidence rose sharply during the study period, and ICU mortality remained high.
Collapse
Affiliation(s)
- Olivier Baldesi
- Centre Hospitalier Intercommunal Aix-Pertuis, Aix en Provence, France
| | - Sébastien Bailly
- UMR 1137 - IAME Team 5 - DeSCID: Decision SCiences in Infectious Diseases, Control and Care INSERM Université Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | - Stéphane Ruckly
- UMR 1137 - IAME Team 5 - DeSCID: Decision SCiences in Infectious Diseases, Control and Care INSERM Université Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | - Alain Lepape
- Unité de recherche clinique Soins critiques, Lyon, France
| | | | | | | | | | | | - Anne Berger-Carbonne
- Unité Infections associées aux soins et Résistance aux Antibiotiques, Direction Maladies Infectieuses - Santé publique France - Saint Maurice, Paris, France
| | - Anne Savey
- CCLIN Sud-Est - HCL - CNRS UMR 5558 Université de Lyon 1, Lyon, France
| | - Jean François Timsit
- UMR 1137 - IAME Team 5 - DeSCID: Decision SCiences in Infectious Diseases, Control and Care INSERM Université Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France; AP-HP - Medical and Infectious Diseases ICU, Université Paris Diderot/Hôpital Bichat, Paris, France.
| | | |
Collapse
|
23
|
Complications of intravascular catheters in ICU: definitions, incidence and severity. A randomized controlled trial comparing usual transparent dressings versus new-generation dressings (the ADVANCED study). Intensive Care Med 2016; 42:1753-1765. [PMID: 27734108 DOI: 10.1007/s00134-016-4582-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/28/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To describe all post-insertion complications involving most used intravascular access, and to determine whether the use of a new-generation transparent dressing (3M™ IV Advanced) might reduce their number and impact on ICU patient outcomes. METHODS Patients older than 18, with an expected length of stay ≥48 h and requiring at least one central venous catheter (CVC), arterial catheter (AC), haemodialysis catheter (HDC), pulmonary arterial catheters (PAC) or peripheral venous catheter (PVC) were randomized into two groups: a new-generation transparent dressing, or the hospital's classical transparent dressing, and were followed daily for any infectious and non-infectious complications. Complications were graduated for severity by an independent international multicentre multidisciplinary panel of practitioners using a Delphi process. RESULTS We included 628 patients, 2214 catheters (873 PVCs, 630 CVCs, 512 ACs and 199 HDCs and PACs) and 4836 dressings. Overall incidence rate was of 60.9/1000 catheter-days. The most common complication was dysfunction (34.6/1000 catheter-days), mainly for PVCs (16/1000 catheter-days) and ACs (12.9/1000 catheter-days). Infectious complications incidence rate in CVCs and ACs was of 14.5/1000, mostly due to colonization (14.2/1000 catheter-days). Thrombosis incidence was of 3.8/1000 catheter-days with severe and very severe complications in 16 cases (1.8/1000 catheter-days) and one thrombosis-related death. 3M™ IV Advanced dressing did not decrease the rate of catheters with at least a minor complication [57.37/1000 vs. 57.52/1000 catheter-days, HR 1.03, CI (0.84-1.27), p = 0.81]. Incidence rates for each single complication remained equivalent: infectious [HR 0.93 (0.62-1.40), p = 0.72], deep thrombosis [HR 0.90 (0.39-2.06), p = 0.80], extravasation and phlebitis [HR 1.40 (0.69-2.82), p = 0.35], accidental removal [1.07 (0.56-2.04), p = 0.84] and dysfunction [HR 1.04 (0.80-1.35), p = 0.79]. CONCLUSION The ADVANCED study showed the overall risk of complications to intravascular catheters in ICU patients being dysfunction, infection and thrombosis. The 3M™ IV Advanced dressing did not decrease complication rates as compared to standard dressings.
Collapse
|
24
|
Perin DC, Erdmann AL, Higashi GDC, Sasso GTMD. Evidence-based measures to prevent central line-associated bloodstream infections: a systematic review. Rev Lat Am Enfermagem 2016; 24:e2787. [PMID: 27598378 PMCID: PMC5016007 DOI: 10.1590/1518-8345.1233.2787] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 02/29/2016] [Indexed: 12/19/2022] Open
Abstract
Objective: to identify evidence-based care to prevent CLABSI among adult patients hospitalized in ICUs. Method: systematic review conducted in the following databases: PubMed, Scopus, Cinahl, Web of Science, Lilacs, Bdenf and Cochrane Studies addressing care and maintenance of central venous catheters, published from January 2011 to July 2014 were searched. The 34 studies identified were organized in an instrument and assessed by using the classification provided by the Joanna Briggs Institute. Results: the studies presented care bundles including elements such as hand hygiene and maximal barrier precautions; multidimensional programs and strategies such as impregnated catheters and bandages and the involvement of facilities in and commitment of staff to preventing infections. Conclusions: care bundles coupled with education and the commitment of both staff and institutions is a strategy that can contribute to decreased rates of central line-associated bloodstream infections among adult patients hospitalized in intensive care units.
Collapse
Affiliation(s)
- Daniele Cristina Perin
- MSc. in Nursing Care Management, RN, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Alacoque Lorenzini Erdmann
- PhD, Full Professor, Departamento de Enfermagem, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | | | | |
Collapse
|
25
|
A comparative evaluation of antimicrobial coated versus nonantimicrobial coated peripherally inserted central catheters on associated outcomes: A randomized controlled trial. Am J Infect Control 2016; 44:636-41. [PMID: 27240799 DOI: 10.1016/j.ajic.2015.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) are a common life-threatening risk factor associated with central venous catheters (CVCs). Research has demonstrated benefit in reducing CLABSIs when CVCs coated with antimicrobials are inserted. The impact of chlorhexidine (CHG)-impregnated versus non-CHG peripherally inserted central catheters (PICCs) on risk of CLABSI is unknown. Venous thromboembolism (VTE) is also a complication associated with CVCs. This study compares the impact of both PICC lines on these outcomes. METHODS Patients in 3 high-risk units were randomly assigned to receive either a CHG-impregnated or non-CHG PICC line. Laboratory data were collected and reviewed daily on all study patients. The PICC dressing site was assessed daily. Medical record documentation was reviewed to determine presence of CLABSI or VTE. RESULTS There were 167 patients who completed the study. Three patients developed CLABSI (2 in the CHG group, and 1 in the non-CHG group), and 3 patients developed VTE (2 in the non-CHG group, and 1 in the CHG group). No significant relationship was noted between the type of PICC line on development of a CLABSI (P = .61) or VTE (P > .99). A significant difference was noted in moderate bleeding (P ≤ .001) requiring thrombogenic dressing in the patients who had the CHG PICC line. CONCLUSIONS No differences were noted in the development of CLABSI and VTE between the CHG and non-CHG groups.
Collapse
|
26
|
Maunoury F, Motrunich A, Palka-Santini M, Bernatchez SF, Ruckly S, Timsit JF. Cost-Effectiveness Analysis of a Transparent Antimicrobial Dressing for Managing Central Venous and Arterial Catheters in Intensive Care Units. PLoS One 2015; 10:e0130439. [PMID: 26086783 PMCID: PMC4472776 DOI: 10.1371/journal.pone.0130439] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/20/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To model the cost-effectiveness impact of routine use of an antimicrobial chlorhexidine gluconate-containing securement dressing compared to non-antimicrobial transparent dressings for the protection of central vascular lines in intensive care unit patients. DESIGN This study uses a novel health economic model to estimate the cost-effectiveness of using the chlorhexidine gluconate dressing versus transparent dressings in a French intensive care unit scenario. The 30-day time non-homogeneous markovian model comprises eight health states. The probabilities of events derive from a multicentre (12 French intensive care units) randomized controlled trial. 1,000 Monte Carlo simulations of 1,000 patients per dressing strategy are used for probabilistic sensitivity analysis and 95% confidence intervals calculations. The outcome is the number of catheter-related bloodstream infections avoided. Costs of intensive care unit stay are based on a recent French multicentre study and the cost-effectiveness criterion is the cost per catheter-related bloodstream infections avoided. The incremental net monetary benefit per patient is also estimated. PATIENTS 1000 patients per group simulated based on the source randomized controlled trial involving 1,879 adults expected to require intravascular catheterization for 48 hours. INTERVENTION Chlorhexidine Gluconate-containing securement dressing compared to non-antimicrobial transparent dressings. RESULTS The chlorhexidine gluconate dressing prevents 11.8 infections /1,000 patients (95% confidence interval: [3.85; 19.64]) with a number needed to treat of 85 patients. The mean cost difference per patient of €141 is not statistically significant (95% confidence interval: [€-975; €1,258]). The incremental cost-effectiveness ratio is of €12,046 per catheter-related bloodstream infection prevented, and the incremental net monetary benefit per patient is of €344.88. CONCLUSIONS According to the base case scenario, the chlorhexidine gluconate dressing is more cost-effective than the reference dressing. TRIAL REGISTRATION This model is based on the data from the RCT registered with www.clinicaltrials.gov (NCT01189682).
Collapse
Affiliation(s)
| | | | | | | | | | - Jean-François Timsit
- Grenoble University Hospital, Grenoble, France
- IAME UMR1137-Team 5 Decision Sciences in Infectious Disease Prevention, Control and Care, Paris Diderot University-Inserm, Sorbonne Paris Cité, Paris, France
- Paris Diderot University—Bichat University hospital—Medical and Infectious Diseases Intensive care unit, Paris, France
| |
Collapse
|
27
|
Gagneux-Brunon A, Timsit J, Lepape A, Berthelot P. Vascular catheter-related infection claims to health insurance company: often preventable. Clin Microbiol Infect 2014; 20:O1084-7. [DOI: 10.1111/1469-0691.12684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/10/2014] [Accepted: 05/15/2014] [Indexed: 12/16/2022]
|
28
|
Timsit JF, Soubirou JF, Voiriot G, Chemam S, Neuville M, Mourvillier B, Sonneville R, Mariotte E, Bouadma L, Wolff M. Treatment of bloodstream infections in ICUs. BMC Infect Dis 2014; 14:489. [PMID: 25431091 PMCID: PMC4289315 DOI: 10.1186/1471-2334-14-489] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/03/2014] [Indexed: 11/24/2022] Open
Abstract
Bloodstream infections (BSIs) are frequent in ICU and is a prognostic factor of severe sepsis. Community acquired BSIs usually due to susceptible bacteria should be clearly differentiated from healthcare associated BSIs frequently due to resistant hospital strains. Early adequate treatment is key and should use guidelines and direct examination of samples performed from the infectious source. Previous antibiotic therapy knowledge, history of multi-drug resistant organism (MDRO) carriage are other major determinants of first choice antimicrobials in heathcare-associated and nosocomial BSIs. Initial antimicrobial dose should be adapted to pharmacokinetic knowledge. In general, a high dose is recommended at the beginning of treatment. If MDRO is suspected combination antibiotic therapy is mandatory because it increase the spectrum of treatment. Most of time, combination should be pursued no more than 2 to 5 days. Given the negative impact of useless antimicrobials, maximal effort should be done to decrease the antibiotic selection pressure. De-escalation from a broad spectrum to a narrow spectrum antimicrobial decreases the antibiotic selection pressure without negative impact on mortality. Duration of therapy should be shortened as often as possible especially when organism is susceptible, when the infection source has been totally controlled.
Collapse
|
29
|
Saunders L, Perennec-Olivier M, Jarno P, L’Hériteau F, Venier AG, Simon L, Giard M, Thiolet JM, Viel JF. Improving prediction of surgical site infection risk with multilevel modeling. PLoS One 2014; 9:e95295. [PMID: 24835189 PMCID: PMC4023946 DOI: 10.1371/journal.pone.0095295] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 03/25/2014] [Indexed: 11/19/2022] Open
Abstract
Background Surgical site infection (SSI) surveillance is a key factor in the elaboration of strategies to reduce SSI occurrence and in providing surgeons with appropriate data feedback (risk indicators, clinical prediction rule). Aim To improve the predictive performance of an individual-based SSI risk model by considering a multilevel hierarchical structure. Patients and Methods Data were collected anonymously by the French SSI active surveillance system in 2011. An SSI diagnosis was made by the surgical teams and infection control practitioners following standardized criteria. A random 20% sample comprising 151 hospitals, 502 wards and 62280 patients was used. Three-level (patient, ward, hospital) hierarchical logistic regression models were initially performed. Parameters were estimated using the simulation-based Markov Chain Monte Carlo procedure. Results A total of 623 SSI were diagnosed (1%). The hospital level was discarded from the analysis as it did not contribute to variability of SSI occurrence (p = 0.32). Established individual risk factors (patient history, surgical procedure and hospitalization characteristics) were identified. A significant heterogeneity in SSI occurrence between wards was found (median odds ratio [MOR] 3.59, 95% credibility interval [CI] 3.03 to 4.33) after adjusting for patient-level variables. The effects of the follow-up duration varied between wards (p<10−9), with an increased heterogeneity when follow-up was <15 days (MOR 6.92, 95% CI 5.31 to 9.07]). The final two-level model significantly improved the discriminative accuracy compared to the single level reference model (p<10−9), with an area under the ROC curve of 0.84. Conclusion This study sheds new light on the respective contribution of patient-, ward- and hospital-levels to SSI occurrence and demonstrates the significant impact of the ward level over and above risk factors present at patient level (i.e., independently from patient case-mix).
Collapse
Affiliation(s)
- Lauren Saunders
- Coordination Centre for Nosocomial Infection Control, Western Regions, Rennes, France
- Department of Public Health, Faculty of Medicine, Rennes, France
| | | | - Pascal Jarno
- Coordination Centre for Nosocomial Infection Control, Western Regions, Rennes, France
| | - François L’Hériteau
- Coordination Centre for Nosocomial Infection Control, Northern Regions, Paris, France
| | - Anne-Gaëlle Venier
- Coordination Centre for Nosocomial Infection Control, South-Western Regions, Bordeaux, France
| | - Loïc Simon
- Coordination Centre for Nosocomial Infection Control, Eastern Regions, Nancy, France
| | - Marine Giard
- Coordination Centre for Nosocomial Infection Control, South-Eastern Regions, Lyon, France
| | | | - Jean-François Viel
- Department of Public Health, Faculty of Medicine, Rennes, France
- * E-mail:
| | | |
Collapse
|
30
|
Hammarskjöld F, Berg S, Hanberger H, Taxbro K, Malmvall BE. Sustained low incidence of central venous catheter-related infections over six years in a Swedish hospital with an active central venous catheter team. Am J Infect Control 2014; 42:122-8. [PMID: 24485369 DOI: 10.1016/j.ajic.2013.09.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 09/20/2013] [Accepted: 09/20/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are limited data on the long-term effects of implementing a central venous catheter (CVC) program for prevention of CVC infections. The aims of this study were to evaluate the incidence of CVC colonization, catheter-related infections (CRI), catheter-related bloodstream infections (CRBSI), and their risk factors over a 6-year period in a hospital with an active CVC team. METHODS We conducted a continuous prospective study aiming to include all CVCs used at our hospital during the years 2004 to 2009, evaluating colonization, CRI, CRBSI, and possible risk factors. RESULTS A total of 2,772 CVCs was used during the study period. Data on culture results and catheterization time were available for 2,045 CVCs used in 1,674 patients. The incidences of colonization, CRI, and CRBSI were 7.0, 2.2, and 0.6 per 1,000 CVC-days, respectively. Analysis of quarterly incidences revealed 1 occasion with increasing infection rates. Catheterization time was a risk factor for CRI but not for CRBSI. Other risk factors for CRI were hemodialysis and CVC use in the internal jugular vein compared with the subclavian vein. Hemodialysis was the only risk factor for CRBSI. CONCLUSION We found that a CRI prevention program led by an active CVC team and adhered to by the entire staff at a county hospital is successful in keeping CVC infections at a low rate over a long period of time.
Collapse
Affiliation(s)
- Fredrik Hammarskjöld
- Department of Anesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden; Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden.
| | - Sören Berg
- Division of Cardiothoracic Anesthesia and Intensive Care, Department of Medical and Health Science, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Håkan Hanberger
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - Knut Taxbro
- Department of Anesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden
| | - Bo-Eric Malmvall
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden; Futurum the Academy for Health Care, Jönköping County Council, Jönköping, Sweden
| |
Collapse
|
31
|
Timsit JF, Bouadma L, Mimoz O, Parienti JJ, Garrouste-Orgeas M, Alfandari S, Plantefeve G, Bronchard R, Troche G, Gauzit R, Antona M, Canet E, Bohe J, Herrault MC, Schwebel C, Ruckly S, Souweine B, Lucet JC. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med 2014; 188:1232-9. [PMID: 24127770 DOI: 10.1164/rccm.201303-0460oc] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE When subclavian access is not possible, controversy exists between the internal jugular and femoral sites for the choice of central-venous access in intensive care unit patients. OBJECTIVES To compare infection and colonization rates of short-term jugular and femoral catheters. METHODS Using data from two multicenter studies, we compared femoral and internal jugular for the risks of catheter-related bloodstream infection, major catheter-related infection, and catheter-tip colonization. We also compared the rates of dressing disruption and skin colonization. We used marginal structural models with inverse probability of treatment weighting to adjust on indication bias. MEASUREMENTS AND MAIN RESULTS We included 2,128 patients (2,527 catheters and 19,481 catheter-days). We found no difference in catheter-related bloodstream infection (internal jugular 1.0 vs. femoral 1.1 per 1,000 catheter-days; hazard ratio [HR], 0.63 [0.25-1.63]; P = 0.34), major catheter-related infection (internal jugular 1.8 vs. femoral 1.4 per 1,000 catheter-days; HR, 0.91 [0.38-2.18]; P = 0.34), and colonization (internal jugular 11.6 vs. femoral 12.9 per 1,000 catheter-days; HR, 0.80 [0.25-1.63]; P = 0.15). However, colonization was higher with femoral for female (HR, 0.39 [0.24-0.63]; P < 0.001) and, at the significance limit, catheter maintained for more than 4 days (HR, 0.73 [0.53-1.01]; P = 0.05). The absence of benefit of internal jugular before Day 5 was related to a higher skin colonization at the internal jugular site for catheters removed before Day 5. After the fourth day, dressing disruption became more frequent with femoral catheters and may explain the subsequent risk of catheter colonization. Differences in cutaneous and catheter colonization between internal jugular and femoral was suppressed by the use of chlorhexidine-impregnated dressings. CONCLUSIONS Femoral and internal jugular accesses lead to similar risks of catheter infection. Internal jugular might be preferred for female, nonchlorhexidine-impregnated dressings users, and when catheters are left in place more than 4 days. Both sites are acceptable when a subclavian approach is not feasible. Clinical trial registered with www.clinicaltrials.gov (NCT00417235 and NCT01189682).
Collapse
Affiliation(s)
- Jean-François Timsit
- 1 Grenoble 1 (Joseph Fourier) University, U823 "Outcome of Cancers and Critical Illness," Albert Bonniot Institute, La Tronche, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
|
33
|
Year in review in Intensive Care Medicine 2012. II: Pneumonia and infection, sepsis, coagulation, hemodynamics, cardiovascular and microcirculation, critical care organization, imaging, ethics and legal issues. Intensive Care Med 2013; 39:345-64. [PMID: 23291735 PMCID: PMC3578723 DOI: 10.1007/s00134-012-2804-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 12/13/2012] [Indexed: 12/16/2022]
|
34
|
Is it possible to achieve a target of zero central line associated bloodstream infections? Curr Opin Infect Dis 2012; 25:650-7. [DOI: 10.1097/qco.0b013e32835a0d1a] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|