Article

Team-Based Prevention of Catheter-Related Infections

New England Journal of Medicine (Impact Factor: 55.87). 01/2007; 355(26):2781-3. DOI: 10.1056/NEJMe068230
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editorials
The new england journal of medicine
Team-Based Prevention of Catheter-Related Infections
Richard P. Wenzel, M.D., and Michael B. Edmond, M.D.
17,000 Deaths
(35%) directly
related to catheter-
associated infections
24,300 Deaths (50%)
among patients with a catheter-
related bloodstream infection
48,600 Patients in ICUs have catheter-
related bloodstream infections
(5 infections per 1000 catheter-days)
9.7 Million catheter-days in ICUs (54% of ICU days)
18 Million ICU days (11% of total hospital days)
36 Million patients admitted to acute care hospitals
(164 million hospital days)
Attributable (maximum avoidable)
mortality and mortality maximally
influenced by use of
effective antibiotics
Total (crude)
mortality
Figure 1. Annual Patient Stays in the 6000 Acute Care Hospitals and Associ-
ated ICUs in the United States.
About half the days patients spend in ICUs (ICU days) are associated with
the use of a central venous catheter and therefore with a risk of subsequent
bloodstream infection (five infections per 1000 catheter-days).
Each year, 36 million patients are admitted to
acute care hospitals in the United States, staying
for 164 million days.
1
Eleven percent (18 million
days) of these hospitalizations are spent in inten-
sive care units (ICUs). For 54% of the days (9.7
million) that patients are in ICUs, central venous
catheters remain in place for the infusion of med-
ications and fluids. Regrettably, the use of these
devices results in 48,600 associated bloodstream
infections (5 per 1000 catheter-days).
2
The leading
pathogens, in descending order, are coagulase-
negative staphylococci, Staphylococcus aureus, entero-
coccus species, and candida species. Morbidity is
significant with bloodstream infections. At least
5% of patients whose condition meets the criteria
for sepsis will have the acute respiratory distress
syndrome, and at least 15 to 20% will have dis-
seminated intravascular coagulation, acute renal
failure, or shock, alone or in combination, while
in the hospital.
The epidemiologic concept of attributable mor-
tality has been advanced to distinguish deaths
directly due to catheter-related bloodstream in-
fection from those due to the underlying disease.
In historical cohort studies in which infected pa-
tients are tightly matched to noninfected control
subjects, estimates of excess (attributable) deaths
in ICUs have been as high as 35% (17,000 deaths
yearly).
3
These figures represent the portion of
the total deaths that can be maximally influenced
by the use of effective antimicrobial agents or
maximally prevented (
Fig. 1
).
Cumulative data on pathogenesis focus on the
role of contamination by organisms residing on
the hands of health care workers and the skin
of patients. Microorganisms gain access to the
bloodstream intraluminally through the connect-
ing ports of the catheter or extraluminally at the
exit site, at the interface between the catheter and
the patient’s skin. Since bacteria and yeast can
traverse both the inner and outer surfaces of the
catheter, the use of chemically bonded materials
has been recommended to reduce infection rates.
On the basis of current data on pathogenesis,
prevention strategies have become a major issue
in the quality of care.
In 1966, Avedis Donabedian elegantly defined
the architecture of quality-assurance programs
as having three platforms: structure, process, and
outcome.
4
This seminal partition influenced
medical care worldwide. Early quality-assurance
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programs in U.S. hospitals were centered on in-
fection-control activities. Specifically, the efforts
of the Centers for Disease Control and Prevention
(CDC) in the 1970s sparked the development of
infection-control expertise, the use of uniform
definitions of nosocomial infections, and concur-
rent surveillance activities. Subsequently, the Study
on the Efficacy of Nosocomial Infection Control
identified structures and processes linked to re-
duced infection rates.
5
In the classic 1972 book titled Effectiveness and
Efficiency, Archie Cochrane stressed the impor-
tance of cost–benefit analysis and randomized,
controlled clinical trials for prioritizing invest-
ments in health care.
6
He used the wordeffi-
ciency” to mean the benefits measured in com-
munity practice, in contrast to observations from
clinical trials. Given a world with limited resourc-
es, Cochrane recommended medical interventions
only when the evidence of their value was sub-
stantial.
In 1988, an independent panel of experts was
charged by the Agency for Healthcare Research
and Quality with systematically reviewing inter-
vention studies and grading the evidence of im-
proved outcomes: level A indicated high-quality,
randomized, controlled trials or meta-analyses;
level B, well-designed, nonrandomized clinical
trials, clinical cohort studies, and case–control
studies; and level C, expert consensus or opinion.
A similar system was adopted by the University of
Oxford Centre for Evidence-Based Medicine, which
designated levels 1a and 1b for systematic reviews
of multiple and individual randomized clinical
trials, respectively. Subsequently, the CDC modi-
fied this classification, designating a category of
IA for interventions “strongly recommended for
implementation and strongly supported by well-
designed experimental, clinical or epidemiological
studies.
7
Against this background, in this issue of the
Journal Pronovost and colleagues describe a re-
markable interventional cohort study involving
103 ICUs in 67 hospitals with more than 375,000
catheter-days of observation.
8
Five of the CDC’s
category IA recommendations were championed
by local team leaders at the ICUs, and during the
18 months after implementation of the study in-
tervention, the median rate of catheter-related
bloodstream infection fell from 2.7 (mean, 7.7)
to 0 (mean, 1.4) per 1000 catheter-days — a 66%
reduction.
In this study, the structure of the intervention
involved daily commitment to a culture of safety,
ongoing surveillance by trained infection-control
personnel, and a supportive central education
program. The five components of the intervention
involved the following processes: appropriate
hand hygiene, use of chlorhexidine for skin prep-
aration, use of full-barrier precautions during the
insertion of central venous catheters, use of the
subclavian vein as the preferred site for insertion
of the catheter, and the removal of unnecessary
central venous catheters.
The improved outcomes were very likely causal-
ly related to these processes. The improvement
temporally followed the implementation of the
intervention, there was biologic plausibility, and
the outcomes had a large effect that was sustained
over months. The lack of randomization, control
subjects, and microbiologic data and the uncer-
tainty about the effect of other specific interven-
tions might suggest an across-the-board improve-
ment that was due more to attention being focused
on an important issue than to the specific inter-
ventions. Yet even if we ascribed 15 percentage
points to such an effect,
9
a 50% reduction in the
rate of infection would still remain.
This quasi-experimental study would warrant
the designation of level B evidence by the U.S.
Preventive Services Task Force and the Centre
for Evidence-Based Medicine. We would like to
have known the validity of the institutional sur-
veillance systems, the frequency of use of chem-
ically bonded (with antimicrobial agents) vascu-
lar catheters during the study period, the rate of
compliance with specific recommendations, and
the influence on mortality. Yet the real-world ef-
ficiency — in Cochrane’s lexicon — of the inter-
vention was extraordinary, an “A” according to
most standards. The story is compelling and the
costs and efforts so relatively minor that the five
components of the intervention should be widely
adopted. We can no longer accept the variations
in safety culture, behavior, or systems of practice
that have plagued medical care for decades. Imag-
ine the effect if all 6000 acute care hospitals in
the United States were to show a similar commit-
ment and discipline.
There is much to criticize about U.S. health
care, including its fragmentation, high costs, im-
personal delivery, and adverse events. In contrast, a
focus on quality could be a unifying concept, part
of a new, team-based professionalism using evi-
dence-based systems and caring behavior that con-
sistently lead to safety and comfort for patients.
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editor i al s
n engl j med 355;26 www.nejm.org december 28, 2006
2783
Dr. Wenzel reports serving on advisory boards for Pfizer and
Replidyne and receiving research support from Pfizer. No other
potential conflict of interest relevant to this article was reported.
From the Department of Internal Medicine, Virginia Common-
wealth University, Richmond.
National Hospital Discharge Survey: 2002 annual summary
with detailed diagnosis and procedure data. Series 13. No. 158.
Hyattsville, MD: National Center for Health Statistics, 2005.
(DHHS publication no. (PHS) 2005-1729.)
National Nosocomial Infections Surveillance System. Nation-
al Nosocomial Infections Surveillance (NNIS) System Report,
data summary from January 1992 through June 2004, issued
October 2004. Am J Infect Control 2004;32:470-85.
Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream in-
fection in critically ill patients: excess length of stay, extra costs,
and attributable mortality. JAMA 1994;271:1598-601.
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Haley RW, Culver DH, White JW, et al. The efficacy of infec-
tion surveillance and control programs in preventing nosocomial
infections in US hospitals. Am J Epidemiol 1985;121:182-205.
Cochrane AL. Effectiveness and efficiency: random reflec-
tions on health services. London: Nuffield Provincial Hospitals
Trust, 1972.
Guidelines for the prevention of intravascular catheter-related
infections. MMWR Recomm Rep 2002;51(RR10):1-29.
Pronovost P, Needham D, Berenholtz S, et al. An interven-
tion to decrease catheter-related bloodstream infections in the
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5.
6.
7.
8.
9.
Targeted Therapy for Metastatic Breast Cancer
Hyman B. Muss, M.D.
Metastatic breast cancer is incurable, so most on-
cologists favor sequential chemotherapy with one
agent at a time over concurrent therapy with mul-
tiple agents.
1
The use of single agents on a se-
quential basis can control the growth of metas-
tases and improve the quality of life without a
detrimental effect on survival. This conventional
practice is about to change as a result of the de-
velopment of new targeted agents for cancer.
2
These targeted therapies — drugs that are
specifically designed to block one or more critical
pathways involved in cancer-cell growth and
metastases — have led to major advances in the
treatment of breast cancer and other malignant
conditions. The development of these therapies
stems from advances in molecular biology that
have permitted the identification of qualitative
and quantitative differences in gene expression
between cancer cells and normal cells.
3
The new
agents range from antibodies that form complex-
es with antigens on the surface of the cancer cell
to small molecules that have been engineered to
block key enzymatic reactions. The interaction of
the antibody or drug with its target inhibits path-
ways that are essential for cell proliferation or
metastasis or activates pathways that culminate
in cell death (apoptosis). Since these targets are
usually specific for or overexpressed in cancer
cells, the new agents generally have fewer side
effects than most conventional chemotherapeutic
agents, and when the targeted agents are com-
bined with single-agent chemotherapy, toxicity is
only minimally increased. Thus, combinations
of targeted and conventional chemotherapeutic
agents may improve the response to treatment
without a major increase in side effects.
The epidermal growth factor receptor stands at
the origin of a major signaling pathway involved
in the growth of breast cancer.
4
Two of the four
transmembrane glycoprotein receptors in this
pathway, epidermal growth factor receptor type 1
(HER1) and epidermal growth factor receptor
type 2 (HER2, also referred to as HER2/neu or
ErbB2), are promising targets for new treatments.
In about 20% of patients with breast cancer, the
tumor overexpresses HER2. Trastuzumab, a hu-
manized monoclonal antibody that targets the
extracellular domain of HER2, is effective as ad-
juvant therapy and as treatment for metastatic
disease in patients with HER2-positive breast
cancer. Lapatinib, an orally administered small-
molecule inhibitor of the tyrosine kinase domains
of HER1 and HER2, has antitumor activity when
used as a single agent in patients with HER2-
positive inf lammatory breast cancer or HER2-pos-
itive breast cancer with central nervous system
(CNS) metastases that are refractory to trastu-
zumab. This finding is important because HER2-
positive tumors frequently spread to the CNS,
where the tumor is sheltered from trastuzumab
and most chemotherapeutic agents.
In this issue of the Journal, Geyer and col-
leagues report on a study that expands the indi-
cations for lapatinib.
5
In their trial, 324 patients
with locally advanced or metastatic breast cancer
that had progressed after initial chemotherapy
plus trastuzumab were randomly assigned to re-
ceive treatment with the oral fluorouracil prodrug
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    • "There have been a range of strategies to prevent or reduce intravenous catheter related complications . These include: optimising patency through continuous infusion or intermittent flushes with either normal saline, heparin, antibiotic and/or ethanol locks (Goode et al., 1991; Peterson and Kirchhoff, 1991; Randolph et al., 1998); less frequent catheter and infusion set changes (Bregenzer et al., 1998; Cornely et al., 2002; Homer and Holmes, 1998; Rickard et al., 2012; White, 2001); placement of in-line filters (Chee and Tan, 2002; Roberts et al., 1994); and designated intravenous therapy teams (da Silva et al., 2010; Wenzel and Edmond, 2006). Despite these interventions, catheter failure before the end of treatment is all too common. "
    [Show abstract] [Hide abstract] ABSTRACT: Up to 85% of hospital in-patients will require some form of vascular access device to deliver essential fluids, drug therapy, nutrition and blood products, or facilitate sampling. The failure rate of these devices is unacceptably high, with 20–69% of peripheral intravenous catheters and 15–66% of central venous catheters failing due to occlusion, depending on the device, setting and population. A range of strategies have been developed to maintain device patency, including intermittent flushing. However, there is limited evidence informing flushing practice and little is known about the current flushing practices.
    Full-text · Article · Jul 2015 · International journal of nursing studies
  • Source
    • "There have been a range of strategies to prevent or reduce intravenous catheter related complications . These include: optimising patency through continuous infusion or intermittent flushes with either normal saline, heparin, antibiotic and/or ethanol locks (Goode et al., 1991; Peterson and Kirchhoff, 1991; Randolph et al., 1998); less frequent catheter and infusion set changes (Bregenzer et al., 1998; Cornely et al., 2002; Homer and Holmes, 1998; Rickard et al., 2012; White, 2001); placement of in-line filters (Chee and Tan, 2002; Roberts et al., 1994); and designated intravenous therapy teams (da Silva et al., 2010; Wenzel and Edmond, 2006). Despite these interventions, catheter failure before the end of treatment is all too common. "
    [Show abstract] [Hide abstract] ABSTRACT: Peripheral venous catheters (PVCs) are the simplest and most frequently used method for drug, fluid, and blood product administration in the hospital setting. It is estimated that up to 90% of patients in acute care hospitals require a PVC; however, PVCs are associated with inherent complications, which can be mechanical or infectious. There have been a range of strategies to prevent or reduce PVC-related complications that include optimizing patency through the use of flushing. Little is known about the current status of flushing practice. This observational study quantified preparation and administration time and identified adherence to principles of Aseptic Non-Touch Technique and organizational protocol on PVC flushing by using both manually prepared and prefilled syringes.
    Full-text · Article · Mar 2014 · Journal of infusion nursing: the official publication of the Infusion Nurses Society
  • Source
    • "Central venous lines are used extensively in intensive care units (ICUs) but may occasionally result in central line associated bloodstream infections (CLABSIs). In the United States, about 48,600 CLABSIs occur in ICUs each year [1]. These infections impose a significant economic burden, with additional estimated costs ranging from US $4,000 to US $36,000 per episode [2] [3] [4]. "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: Central line associated bloodstream infections (CLABSIs) impose a significant economic burden for patients admitted to the intensive care unit for adults (AICU). The objectives of the study were to evaluate the excess length of stay and extra costs attributable to CLABSIs diagnosed in the AICU. Methods: Cases were selected as patients admitted to AICU from 2006 through 2009, who developed a CLABSI episode. These were matched (1:1) with appropriate controls. Matching criteria were selected to exclude other factors that could influence cost and care practices. The length of stay and resources used between AICU admission and discharge and until hospital discharge or death were measured. Incremental costs and lengths of stay were calculated for each pair of patients. Results: Thirty cases and 30 controls were included in the study. A CLABSI episode resulted in an additional 10.5 days in the AICU and 9.1 days after AICU discharge, totaling an additional 19.6 days. The incremental cost associated with a CLABSI episode was US $65,993 in the AICU and US $23,893 after AICU discharge, totaling an incremental cost of US $89,886. Conclusions: By avoiding CLABSI events, cost offsets would be expected for payers with revenue losses to providers. An approach of sharing the gains resulting from preventive measures could be used to incentivize providers to maintain those investments, benefiting patients who will have a reduced risk of CLABSI development. © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR).
    Full-text · Article · Dec 2012
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