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García-Rodríguez JF, Mariño-Callejo A. The factors associated with the trend in incidence of Bacteraemia and associated mortality over 30 years. BMC Infect Dis 2023; 23:69. [PMID: 36737678 PMCID: PMC9897612 DOI: 10.1186/s12879-023-08018-0] [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: 11/03/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Studies have reported increased incidence of BSI over the past decades and indicate that it is necessary to investigate the causes. The aim of this study was to determine the factors affecting trends in the incidence of bacteraemias and associated mortality. METHODS We conducted a retrospective cohort study assessing prospectively collected data of all clinically significant bacteraemias between 1991 and 2020 in a 450-bed hospital. We determined the evolution of bacteraemia-associated incidence, adjusted 30-day mortality and performed multivariable logistic regression to compare the evolution of variables associated with mortality between 5-year periods. RESULTS 6777 episodes were included, 59.7% males, age 66.5 ± 18.2, 39.4% ≥ 75 years. The incidence total increased: 43.8/100,000/year in 1991-1995 to 205 in 2016-2020; community-acquired bacteraemia (24.9 to 139) and hospital-acquired (0.36/1000 inpatients-days to 1.09). Bacteraemia with source in vascular catheter, urinary and biliary tract increased. The 30-day mortality rate of patients was 1179/6777 (17.4%) in the whole series and population-adjusted mortality incidence increased from 11.4/100,000 in 1991-1996 to 28.4 in 2016-2020 (RR 2.49, 95% CI 2.01-3.08). Mortality was higher in men (18.2% vs 16.3%) and those over 74 years (22.2% vs 14.3%). Appropriate empirical antimicrobial treatment improved (66.5% to 73.1%), 30-day mortality of patients decreased from 26.1 to 13.9%. When comparing the evolution of the factors associated with mortality between 1991 and 1996 vs 2016-2020, the frequency of some variables associated with higher mortality increased: male sex (OR 1.38, 95% CI 1.10-1,74), age (OR 1.02, 1.01-10.3), immunosuppressive treatment (OR 3.1, 2.09-4.6), polymicrobial bacteraemia (OR 1.76, 1.12-2.79), and others decreased: severe sepsis/septic shock (OR 0.70, 0.52-0.93), spontaneous bacterial peritonitis in cirrhosis (OR 0.06, 0.02-0.23), endocarditis (OR 0.54, 0.35-0.83); on the other hand, the frequency of factors associated with lower mortality increased: urinary (OR 1.67, 95% CI 1.23-2.27) and bile tract source (OR 1.59, 1.04-2.43), and adequate empirical treatment (OR 1.42, 95% CI 1.10-1.83). CONCLUSIONS The incidence of bacteraemia increased due to more elderly, co-morbid patients undergoing procedures and more device related bacteraemia. The percentage of mortality decreased because adequate empirical treatment improved, decreased spontaneous bacterial peritonitis in cirrhosis and endocarditis, and increased bacteraemia of urinary and biliary tract source.
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Affiliation(s)
- J. F. García-Rodríguez
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Ferrol, Sergas. Ferrol, 15405 A Coruña, Spain ,C/ San Amaro 10-12, 6º Derecha, Ferrol, 15403 A Coruña, Spain
| | - A. Mariño-Callejo
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Ferrol, Sergas. Ferrol, 15405 A Coruña, Spain
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van der Kooi TII, Smid EA, Koek MBG, Geerlings SE, Bode LGM, Hopmans TEM, de Greeff SC. The effect of an intervention bundle to prevent central venous catheter-related bloodstream infection in a national programme in the Netherlands. J Hosp Infect 2023; 131:194-202. [PMID: 36414165 DOI: 10.1016/j.jhin.2022.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Central venous catheters (CVCs) can lead to central line-related bloodstream infections (CRBSIs). A six-item bundle was introduced in 2009 to prevent CRBSI in Dutch hospitals. AIM This study aimed to determine the impact of an intervention bundle on CRBSI risk. METHODS Data were obtained from hospitals participating in the national CRBSI surveillance between 2009 and 2019. Bundle compliance was evaluated as a total ('overall') bundle (all six items) and as an insertion bundle (four items) and a maintenance bundle (two daily checks). We estimated the impact of the overall and partial bundles, using multi-level Cox regression. FINDINGS Of the 66 hospitals in the CRBSI surveillance 56 (84.8%) recorded annual bundle (non)compliance for >80% of the CVCs, for one to nine years. In these 56 hospitals CRBSI incidence decreased from 4.0 to 1.6/1000 CVC days. In the intensive care units (ICUs), compliance was not associated with CRBSI risk (hazard ratio (HR) for the overall, insertion and maintenance bundle were 1.14 (95% confidence interval 0.80-1.64), 1.05 (0.56-1.95) and 1.13 (0.79-1.62)), respectively. Outside the ICU the non-significant association of compliance with the overall bundle (HR 1.36 (0.96-1.93)) resulted from opposite effects of the insertion bundle, associated with decreased risk (HR 0.50 (0.30-0.85)) and the maintenance bundle, associated with increased risk (HR 1.68 (1.19-2.36)). CONCLUSION Following a national programme to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, bundle compliance was not associated with CRBSI risk, but outside the ICU improved compliance with the insertion bundle resulted in a decreased CRBSI risk.
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Affiliation(s)
- T I I van der Kooi
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, the Netherlands.
| | - E A Smid
- Nextens, Book and Periodical Publishing, Amsterdam, the Netherlands
| | - M B G Koek
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, the Netherlands
| | - S E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity, Amsterdam Public Health, the Netherlands
| | - L G M Bode
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | - T E M Hopmans
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, the Netherlands
| | - S C de Greeff
- National Institute for Public Health and the Environment, Centre for Infectious Disease Control, Bilthoven, the Netherlands
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3
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García-Rodríguez JF, Bardán-García B, Juiz-González PM, Vilariño-Maneiro L, Álvarez-Díaz H, Mariño-Callejo A. Long-Term Carbapenems Antimicrobial Stewardship Program. Antibiotics (Basel) 2020; 10:antibiotics10010015. [PMID: 33375237 PMCID: PMC7823722 DOI: 10.3390/antibiotics10010015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022] Open
Abstract
Objective. To evaluate clinical and antibiotic resistance impact of carbapenems stewardship programs. Methods: descriptive study, pre-post-intervention, between January 2012 and December 2019; 350-bed teaching hospital. Prospective audit and feedback to prescribers was carried out between January 2015 and December 2019. We evaluate adequacy of carbapenems prescription to local guidelines and compare results between cases with accepted or rejected intervention. Analysis of antibiotic-consumption and hospital-acquired multidrug-resistant (MDR) bloodstream infections (BSIs) was performed. Results: 1432 patients were followed. Adequacy of carbapenems prescription improved from 49.7% in 2015 to 80.9% in 2019 (p < 0.001). Interventions on prescription were performed in 448 (31.3%) patients without carbapenem-justified treatment, in 371 intervention was accepted, in 77 it was not. Intervention acceptance was associated with shorter duration of all antibiotic treatment and inpatient days (p < 0.05), without differences in outcome. During the period 2015–2019, compared with 2012–2014, decreased meropenem consumption (Rate Ratio 0.58; 95%CI: 0.55–0.63), candidemia and hospital-acquired MDR BSIs rate (RR 0.62; 95%CI: 0.41–0.92, p = 0.02), and increased cefepime (RR 2; 95%CI: 1.77–2.26) and piperacillin-tazobactam consumption (RR 1.17; 95%CI: 1.11–1.24), p < 0.001. Conclusions: the decrease and better use of carbapenems achieved could have clinical and ecological impact over five years, reduce inpatient days, hospital-acquired MDR BSIs, and candidemia, despite the increase in other antibiotic-consumption.
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Affiliation(s)
- José Francisco García-Rodríguez
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Ferrol, Sergas, 15405 Ferrol, Spain; (L.V.-M.); (H.Á.-D.); (A.M.-C.)
- Correspondence:
| | - Belén Bardán-García
- Department of Pharmacy, University Hospital of Ferrol, Sergas, 15405 Ferrol, Spain;
| | | | - Laura Vilariño-Maneiro
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Ferrol, Sergas, 15405 Ferrol, Spain; (L.V.-M.); (H.Á.-D.); (A.M.-C.)
| | - Hortensia Álvarez-Díaz
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Ferrol, Sergas, 15405 Ferrol, Spain; (L.V.-M.); (H.Á.-D.); (A.M.-C.)
| | - Ana Mariño-Callejo
- Infectious Diseases Unit, Department of Internal Medicine, University Hospital of Ferrol, Sergas, 15405 Ferrol, Spain; (L.V.-M.); (H.Á.-D.); (A.M.-C.)
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4
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Franco-Sadud R, Schnobrich D, Mathews BK, Candotti C, Abdel-Ghani S, Perez MG, Rodgers SC, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E1-E22. [PMID: 31561287 DOI: 10.12788/jhm.3287] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
Abstract
PREPROCEDURE 1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation. TECHNIQUES General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques. POSTPROCEDURE 21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise. TRAINING 23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
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Affiliation(s)
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Benji K Mathews
- Department of Hospital Medicine, Regions Hospital, Health Partners, St. Paul, Minnesota
| | - Carolina Candotti
- Division of Hospital Medicine, University of California Davis, Davis, California
| | - Saaid Abdel-Ghani
- Department of Hospital Medicine, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Martin G Perez
- Department of Hospital Medicine, Memorial Hermann Northeast Hospital, Humble, Texas
| | - Sophia Chu Rodgers
- Division of Pulmonary Critical Care Medicine, Lovelace Health Systems, Albuquerque, New Mexico
| | - Michael J Mader
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Nilam J Soni
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
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5
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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.
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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
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6
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Meropenem antimicrobial stewardship program: clinical, economic, and antibiotic resistance impact. Eur J Clin Microbiol Infect Dis 2018; 38:161-170. [PMID: 30367313 DOI: 10.1007/s10096-018-3408-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/16/2018] [Indexed: 12/13/2022]
Abstract
There are few prospective studies with sufficient duration in time to evaluate clinical and antibiotic resistance impact of antibiotic stewardship programs (ASP). This is a descriptive study between January 2012 and December 2017, pre-post intervention. A meropenem ASP was initiated in January 2015; in patients who started treatment with meropenem, an infectious disease physician performed treatment recommendations to prescribers. Prospective information was collected to evaluate adequacy of meropenem prescription to local guidelines and to compare results between cases with accepted or rejected intervention. Analysis was performed to verify variables associated with intervention acceptance and with any significant change in meropenem consumption, hospital-acquired multidrug-resistant (MDR) bloodstream infections (BSIs), and 30-day all-cause crude death in MDR BSIs. Adequacy of meropenem prescription and de-escalation from meropenem treatment to narrower-spectrum antibiotic improved progressively over time, after ASP implementation (p < 0.001). Interventions on prescription were performed in 330 (38.7%) patients without meropenem justified treatment; in 269, intervention was accepted and in 61 not. Intervention acceptance was associated with shorter duration of treatment, cost, and inpatient days (p < 0.05); intervention rejection was not associated with severity of patient. During the period 2015-2017, meropenem consumption decreased compared with 2012-2014 (rate ratio [RR] 0.67; 95% CI 0.58-0.77, p < 0.001). Also decreased were hospital-acquired MDR BSI rate (RR 0.63; 95% CI 0.38-1.02, p = 0,048) and 30-day all-cause crude death in MDR BSIs (RR 0.45; 95% CI 0.14-1.24, p = 0.096), coinciding in time with ASP start-up. The decrease and better use of meropenem achieved had a sustained clinical, economic, and ecological impact, reducing costs and mortality of hospital-acquired MDR BSIs.
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Guembe M, Pérez-Granda MJ, Capdevila JA, Barberán J, Pinilla B, Bouza E. Impact of a training program on adherence to recommendations for care of venous lines in internal medicine departments in Spain. Eur J Clin Microbiol Infect Dis 2018; 37:1163-1168. [PMID: 29569044 DOI: 10.1007/s10096-018-3236-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
Abstract
A high percentage of venous lines (VLs) are placed in non-ICU patients, particularly those treated in the internal medicine department (IMD). We assessed adherence to VL care after a training program aimed at nurses and clinicians attending patients admitted to Spanish IMDs. We performed a multicenter prospective observational point prevalence study in 14 Spanish IMDs in 2013 and 2016. We included all adult patients (> 18 years) admitted to IMDs on the study day and reviewed nursing records for patients with VL in place before and after a 1-year training program during 2015. Answers from an interview with head nurses of the IMDs regarding commonly used practices in the daily management of VLs were also compared. A total of 638 and 693 patients were seen during each period, respectively, and 530 and 598 patients had ≥ 1 VL implanted (83.1 vs. 86.3%). Catheters were considered unnecessary in 12.8 and 15.0% of cases (p = 0.28). Daily recording of the need for catheter use increased from 43.8 to 71.8% (p < 0.001). Furthermore, daily monitoring of the insertion site remained very frequent (94.4 vs. 92.2%; p = 0.16). The date of insertion was recorded in 86.3 and 85.5% of cases (p = 0.73), and no combination of closed connectors with open caps increased from 74.8 to 90.3% (p < 0.001). Overall, head nurses' knowledge improved in 4 out of 14 recommendations assessed (28.6%). A simple and easy program for training on management of VLs in Spanish IMDs was associated with improved quality of care.
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Affiliation(s)
- María Guembe
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - María Jesús Pérez-Granda
- Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Antonio Capdevila
- Grupo de Trabajo en Enfermedades Infecciosas de la Sociedad Española de Medicina Interna (GTEI-SEMI), Madrid, Spain.,Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | - José Barberán
- Grupo de Trabajo en Enfermedades Infecciosas de la Sociedad Española de Medicina Interna (GTEI-SEMI), Madrid, Spain.,Department of Internal Medicine, Hospital de Montepríncipe, Madrid, Spain
| | - Blanca Pinilla
- Grupo de Trabajo en Enfermedades Infecciosas de la Sociedad Española de Medicina Interna (GTEI-SEMI), Madrid, Spain.,Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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8
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Saliba P, Hornero A, Cuervo G, Grau I, Jimenez E, García D, Tubau F, Martínez-Sánchez JM, Carratalà J, Pujol M. Mortality risk factors among non-ICU patients with nosocomial vascular catheter-related bloodstream infections: a prospective cohort study. J Hosp Infect 2017; 99:48-54. [PMID: 29128346 DOI: 10.1016/j.jhin.2017.11.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 11/03/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Vascular catheter-related bloodstream infections (CRBSIs) are highly preventable hospital-acquired infections and a major threat to patient safety. While there is significant information regarding CRBSI outcome among intensive care unit (ICU) patients, data regarding non-ICU patients are scarce. AIM To determine the risk factors associated with 30-day mortality among non-ICU patients with nosocomial CRBSIs. METHODS Prospective cohort study of non-ICU patients with nosocomial CRBSIs in a tertiary care centre between January 2004 and December 2014. The primary outcome was 30-day mortality, defined as death from any cause within 30 days of CRBSI. Follow-up was performed 30 days after CRBSI onset. Time until death was the dependent variable in Cox regression analysis. FINDINGS In total, 546 cases of CRBSI were identified. The mean age of patients was 64.5 years [interquartile range (IQR) 55-75 years], 66% were male, and the mean Charlson score was 3.59 (IQR 2-5). Of the 546 cases, 58.4% resulted from central venous catheters and 41.6% from peripheral venous catheters. The causative agents were Gram-positive cocci (70.1% of cases), Gram-negative bacilli (31.1%) and Candida spp. (1%). Mortality within 30 days was 13.9%, with no significant changes over the study period. Independent risk factors for 30-day mortality were Charlson score ≥4 [hazard ratio (HR) 1.80, 95% confidence interval (CI) 1.19-2.73], Staphylococcus aureus infection (HR 2.67, 95% CI 1.61-4.43) and Candida spp. infection (HR 6.1, 95% CI 2.08-18.04). Age; area of admission; type, use and site of vascular catheter; and administration of appropriate empirical antibiotic treatment were not independent risk factors for 30-day mortality. CONCLUSION Nosocomial CRBSIs outside ICUs are associated with high risk of mortality, particularly among patients with a higher Charlson score and bloodstream infections caused by Staphylococcus aureus and Candida spp.
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Affiliation(s)
- P Saliba
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain; Universitat Internacional de Catalunya, Barcelona, Spain
| | - A Hornero
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain
| | - G Cuervo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain
| | - I Grau
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain
| | - E Jimenez
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain
| | - D García
- Department of Microbiology, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - F Tubau
- Department of Microbiology, Hospital Universitari de Bellvitge, Barcelona, Spain; CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | | | - J Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain
| | - M Pujol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain.
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9
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Laan BJ, Spijkerman IJB, Godfried MH, Pasmooij BC, Maaskant JM, Borgert MJ, Opmeer BC, Vos MC, Geerlings SE. De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study. BMC Infect Dis 2017; 17:53. [PMID: 28068924 PMCID: PMC5223587 DOI: 10.1186/s12879-016-2154-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/22/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy. METHODS In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated. DISCUSSION This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications. TRIAL REGISTRATION Dutch trial registry: NTR6015 . Registered 9 August 2016.
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Affiliation(s)
- Bart J Laan
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Ingrid J B Spijkerman
- Department of Medical Microbiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mieke H Godfried
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Berend C Pasmooij
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jolanda M Maaskant
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Medical Faculty, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marjon J Borgert
- Department of Internal Medicine, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Brent C Opmeer
- Clinical Research Unit, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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10
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Curran E. Needleless connectors: the vascular access catheter's microbial gatekeeper. J Infect Prev 2016; 17:234-240. [PMID: 28989484 PMCID: PMC5102078 DOI: 10.1177/1757177416657164] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/29/2016] [Indexed: 11/17/2022] Open
Abstract
Needleless connectors (NCs) are essential devices which connect to the end of vascular catheters and enable catheter access for infusion and aspiration. There are various different designs which make it difficult for purchasers to identify the features which present the least risk and greatest safety. The NC is the microbial gatekeeper for vascular catheters; how it is disinfected pre access determines if, and how many, organisms enter and how quickly biofilm will form. This paper will consider these design variations and how differences in antiseptic testing methods have made it difficult to determine the best antiseptic practice pre access. One specific design characteristic is considered: the fluid pathway. The NC's fluid pathway creates a flow which can be either direct to produce a laminar flow or indirect which creates a turbulent flow. At present, the evidence does not support there being an advantage for a specific fluid pathway design in reducing infection risks.
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11
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Batista KCDO, Tipple AFV, Leão-Vasconcelos LSNDO, Ribeiro EL, Prado MAD. Contaminação de torniquetes para punção intravenosa periférica. ACTA PAUL ENFERM 2015. [DOI: 10.1590/1982-0194201500072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo Identificar a presença de contaminação em torniquetes para punção intravenosa periférica e caracterizar o perfil dosStaphylococcus spp. e leveduras isolados. Métodos Estudo transversal que inseriu análise de 18 torniquetes para punção intravenosa periférica em uso no hospital. Os torniquetes foram imersos em caldo BHI por 24h e cultivados em meios seletivos para isolamento e identificação de Staphylococcus spp. e leveduras. O método disco-difusão foi empregado para analisar o perfil de suscetibilidade dosStaphylococcus spp. aos antimicrobianos. Resultados Treze (72,2%) torniquetes apresentaram crescimento de algum micro-organismo sendo 11 (52,4%) Staphylococcus coagulase-negativo, dois (9,5%) Staphylococcusaureus, quatro (19%)Rodothorulamucilaginosa, três (14,3%)Candidaalbicans. 61,5% dosStaphylococcus spp. apresentaram resistência a oxacilina. Os profissionais da equipe não relataram protocolos para limpeza, desinfecção ou substituição controlada destes materiais na instituição. Conclusão Foi identificada a contaminação de torniquetes por micro-organismos patogênicos com perfil de resistência aos antibióticos muito utilizados em instituições hospitalares.
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12
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Marang-van de Mheen PJ, van Bodegom-Vos L. Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement. BMJ Qual Saf 2015; 25:118-29. [DOI: 10.1136/bmjqs-2014-003787] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 07/01/2015] [Indexed: 11/04/2022]
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13
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Guembe M, Pérez-Granda MJ, Capdevila JA, Barberán J, Pinilla B, Martín-Rabadán P, Bouza E. Nationwide study on the use of intravascular catheters in internal medicine departments. J Hosp Infect 2015; 90:135-41. [PMID: 25824558 DOI: 10.1016/j.jhin.2015.01.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 01/30/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of intravascular catheters (IVCs) in intensive care units (ICUs) has been well assessed in recent years. However, a high proportion of these devices are placed in patients outside the ICU, particularly in internal medicine departments (IMDs), where data on the quality of care are scarce. AIM To assess the use and management of IVCs in IMDs in Spain. METHODS We performed a point prevalence study of all adult inpatients on 47 IMDs from hospitals of different sizes on one day in June 2013. A local co-ordinator was appointed to assess patients and collect data from each site. FINDINGS Out of the 2080 adult patients hospitalized on the study day, 1703 (81.9%) had one or more IVCs (95.4% of which were peripheral devices). Infection was detected at the insertion site in 92 catheters (5.0%); 87 patients (5.2%) had signs of sepsis, but only one case was considered to be catheter-related. The local co-ordinators estimated that 19% of the catheters in place were no longer necessary. A daily record of the need for a catheter was available in only 40.6% of cases. CONCLUSION Our study shows clear opportunities for improvement regarding catheter use and care in Spanish IMDs. Strategies similar to those applied in ICUs should be implemented in IMDs.
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Affiliation(s)
- M Guembe
- Department of Clinical Microbiology and Infectious Diseases, HGU Gregorio Marañón, Madrid, Spain.
| | - M J Pérez-Granda
- Cardiac Surgery Postoperative Care Unit, HGU Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias ‒ CIBERES (CB06/06/0058), Madrid, Spain
| | - J A Capdevila
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain; Study Group of Infections of the Sociedad Española de Medicina Interna (SEMI), Spain
| | - J Barberán
- Department of Internal Medicine, Hospital de Montepríncipe, Madrid, Spain; Study Group of Infections of the Sociedad Española de Medicina Interna (SEMI), Spain
| | - B Pinilla
- Department of Internal Medicine, HGU Gregorio Marañón, Madrid, Spain
| | - P Martín-Rabadán
- Department of Clinical Microbiology and Infectious Diseases, HGU Gregorio Marañón, Madrid, Spain
| | - E Bouza
- Department of Clinical Microbiology and Infectious Diseases, HGU Gregorio Marañón, Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; Study Group of Infections of the Sociedad Española de Medicina Interna (SEMI), Spain; CIBER Enfermedades Respiratorias ‒ CIBERES (CB06/06/0058), Madrid, Spain
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14
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Chopra V, Govindan S, Kuhn L, Ratz D, Sweis RF, Melin N, Thompson R, Tolan A, Barron J, Saint S. Do clinicians know which of their patients have central venous catheters?: a multicenter observational study. Ann Intern Med 2014; 161:562-7. [PMID: 25329204 PMCID: PMC4997807 DOI: 10.7326/m14-0703] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown. OBJECTIVE To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients. DESIGN Multicenter, cross-sectional study. SETTING 3 academic medical centers in the United States. PATIENTS Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings. MEASUREMENTS To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests. RESULTS 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003). LIMITATIONS Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded. CONCLUSION Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted. PRIMARY FUNDING SOURCE None.
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15
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Tang HJ, Lin HL, Lin YH, Leung PO, Chuang YC, Lai CC. The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis 2014; 14:356. [PMID: 24985729 PMCID: PMC4085375 DOI: 10.1186/1471-2334-14-356] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/25/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Knowledge about the impact of each central line insertion bundle on central line-associated bloodstream infection (CLABSI) is limited. METHODS A quality-improvement intervention, including education, central venous catheter (CVC) insertion bundle, process and outcome surveillance, have been introduced since March 2013. Outcome surveillances, including CLABSI per 1,000 catheter-days, CLABSI per 1,000 inpatient-days, and catheter utilization rates (days of catheter use divided by total inpatient-days), were measured. As a baseline measurement for a comparison, we retrospectively collected data from March 1, 2012 to December 31, 2012. RESULTS During this 10-month period, there were a total of 687 CVC insertions, and 627 (91.2%) insertions were performed by intensivists. The rate of CLABSI significantly declined from 1.65 per 1000 catheter-day during the pre-intervention period to 0.65 per 1000 catheter-day post-intervention period (P=0.039). CLABSI more likely developed in subjects in which a maximal sterile barrier was not used compared with subjects in which it was used (P=0.03). Moreover, CVC inserted by non-intensivists were more likely to become infected than CVC inserted by intensivists (P=0.010). CONCLUSIONS This multidisciplinary infection control intervention, including a central line insertion care bundle, can effectively reduce the rate of CLABSI. The impact of different care bundle varies, and a maximal sterile barrier precaution during catheter insertion is an essential component of the care line insertion bundle.
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Affiliation(s)
- Hung-Jen Tang
- Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Hsin-Lan Lin
- Department of Nursing, Chi Mei Medical Center, Liouying, Tainan, Taiwan
- Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Yu-Hsiu Lin
- The Committee of Infection Control, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Pak-On Leung
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Yin-Ching Chuang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Internal Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
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