CLABSI Prevention & Management
Mermel LA, Bouza AM, Craven DE, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009:49;1-45.
O’Grady NP, Burns AM, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011:39;S1-34.
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32. Landmark large scale study of 103 ICUs in the state of Michigan demonstrated that implementation of an evidence based protocol led to a significant and sustainable 66% relative reduction of catheter-related infections. The protocol centered on 5 steps, comprising the now widely used “central line bundle” (see IHI.org), including hand hygiene, full-barrier precautions during line insertion, skin cleansing with chlorhexidine, avoiding the femoral site if possible, and removal of unnecessary catheters.
Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015; 373:1220-9. This study randomized 3027 patients to internal jugular, subclavian, or femoral venous sites in a 1:1:1, or 1:1 fashion depending on the number of sites available. Subclavian lines had a lower rate of infectious complications and a higher rate of mechanical complications than either femoral or internal jugular sites. Concerns include the inconsistent use of ultrasound for subclavian lines, and the potential bias of determining if 2 vs. 3 sites were “suitable”. Interestingly, femoral and internal jugular lines had similar rates of infectious complications.
VAP Prevention
Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999;354:1851-8. This study found that supine position is an independent risk factor for VAP and that positioning at 45 degrees reduces the risk, especially in patients receiving tube feeds.
van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006;34:396-402. In this seven-day study cited by HOB-elevation skeptics, a randomized trial of over 200 patients found no reduction in VAP with HOB elevation, though the angle difference between intervention and control patients was small (28° vs 10° at day one, 23° vs 16° at day seven).
De Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009; 360:20-31. Previous smaller, single-center studies found selective digestive tract decontamination (SDD) improves ICU survival, but concern for antibiotic resistance and the generalizability of previous studies have kept this approach from gaining widespread acceptance. This large (5,939 patients) multicenter Dutch study found SDD and selective oropharyngeal decontamination (SOD) reduced mortality by about 3% after logistic regression. There was no emergence of resistant organisms, but the duration of monitoring was limited to the 6 months of the study.
General Measures
Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013; 368:2255-2265. A cluster randomized trial comparing the effects of 1) MRSA screening and targeted isolation, 2) MRSA screening with targeted isolation plus treatment, and 3) universal decolonization treatment. Treatment consisted of chlorhexidine baths and nasal mupirocin. Universal decolonization treatment significantly reduced overall bloodstream infections with non significant decreases in MRSA-positive cultures and MRSA bloodstream infections. Strengths include multiple centers (43) and large number of patients (> 43,000). Weaknesses include lack of monitoring for chlorhexidine resistance, inconsistent use of isolation, and unclear definition of “clinical MRSA positive culture”.
Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care–associated infections: a randomized clinical trial. JAMA 2015; 313:369-378. This was a cluster randomized, controlled trial comparing the daily use of chlorhexidine-impregnated bathing cloths with non-antimicrobial cloths in multiple ICUs. There was no significant difference in the compound primary outcome of CLABSI, CAUTI, VAP, or C difficile infections (intervention 2.86 vs control 2.90, p= 0.95). In contrast to prior studies, these findings do not support daily chlorhexidine bathing of ICU patients. Critics note that the mean LOS was briefer and background MDRO prevalence higher in prior studies, one of which included BMT units. Other concerns include lack of adherence data and blinding.
