Just Accepted by The Journal of Maternal-Fetal & Neonatal Medicine Prevention of central venous catheter-related infection in the neonatal unit: a literature review Jacqueline E. Taylor, Susan J. McDonald, Kenneth Tan doi: 10.3109/14767058.2014.949663
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
Abstract Central venous catheter infections are the leading cause of healthcare associated bloodstream infections and contribute significantly to mortality and morbidity in neonatal intensive care units. Moreover, infection poses significant economic consequence which increased hospital costs and increased length of hospital stay. Prevention strategies are detailed in guidelines published by the Centers for Disease Control and Prevention (CDC) in the United States, nevertheless, recent surveys in neonatal units in the United States and Australia and New Zealand demonstrate these are not always followed. This review discusses the numerous evidence-based strategies to prevent catheter infections including hand hygiene, maximal sterile barriers during insertion, skin disinfection, selection of insertion site, dressings, aseptic non touch technique, disinfection of catheter hubs / ports, administration set management, prompt removal of catheter, antibiotic locks, systemic antibiotic prophylaxis and chlorhexidine bathing. Furthermore, it will describe different strategies that can be implemented into clinical practice to reduce infection rates. These include the use of care bundles including checklists, education and the use of CVC teams.
© 2014 Informa UK Ltd. This provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles do not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosages, the method and duration of administration, and contraindications. It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner. There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article. Any use of the Just Accepted articles is subject to the express understanding that the papers have not yet gone through the full quality control process prior to publication.
TITLE: Prevention of central venous catheter-related infection in the neonatal unit: a literature review
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
AUTHORS: Taylor, Jacqueline E1, 2, McDonald, Susan J1, 3, Tan, Kenneth 2, 4 Institutions: 1 La Trobe University, Bundoora, Australia; 2 Monash Newborn, Monash Medical Centre, Clayton, Australia; 3 Midwifery Professorial Unit, Mercy Hospital for Women, Melbourne, Australia 4 Monash Institute of Medical research, Monash University, Clayton, Australia
CORRESPONDENTS TO: Jacqueline Taylor Monash Medical Centre Level 5 246 Clayton Rd Clayton Victoria, 3168, Australia 0061395945196
Abstract
Central venous catheter infections are the leading cause of healthcare associated bloodstream infections and contribute significantly to mortality and morbidity in neonatal intensive care units. Moreover, infection poses significant economic consequence which increased hospital costs and increased length of hospital stay. Prevention strategies are detailed in guidelines published by the Centers for Disease Control and Prevention (CDC) in the United States, nevertheless, recent surveys in neonatal units in the United States and Australia and New Zealand demonstrate these are not always followed. This review discusses the numerous evidence-based strategies to
1
prevent catheter infections including hand hygiene, maximal sterile barriers during insertion, skin disinfection, selection of insertion site, dressings, aseptic non touch technique, disinfection of catheter hubs / ports, administration set management, prompt removal of catheter, antibiotic locks, systemic antibiotic prophylaxis and chlorhexidine bathing. Furthermore, it will describe different strategies that can be implemented into clinical practice to reduce infection rates. These
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
include the use of care bundles including checklists, education and the use of CVC teams.
Keywords Infant, newborn; intensive care, neonatal; catheterisation, central venous, catheter-associated infections; catheter-related infection; infection prevention Introduction
A central venous catheter (CVC) is defined as “an intravascular catheter that terminates at or close to the heart or in one of the great vessels such as the aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, common iliac veins, femoral veins, and in neonates, the umbilical artery/veins” [1]. CVCs commonly used in neonates include umbilical venous catheters (UVC) and peripherally inserted central catheters (PICC), less frequently used CVCs include central catheters inserted over a wire (e.g. femoral line) and subcutaneously tunnelled catheters (e.g. Broviac and Hickman) [2].
CVCs have become an essential part of neonatal care and are used for; (1) the administration of fluids and parenteral nutrition; (2) the administration of medications; and (3) when long term venous access is required and peripheral access is not an option. The larger bore catheters can also be used for central venous pressure monitoring, extracorporeal membrane oxygenation or exchange transfusion [2]. However, these catheters are not without complications and CVCs are the leading risk behind healthcare associated bloodstream infections [1]. Catheter-related infections occur when micro-organisms adhere to the intraluminal or extraluminal surface of the
2
catheter. Micro-organisms can enter the catheter from colonisation of the catheter ports (hubs) and insertion sites, contaminated intravenous fluids and injection devices and from haematogenous dissemination from other sources of infection [3].
Central line associated bloodstream infections (CLABSI) reported to the National Health
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
Surveillance Network in 2012, demonstrated extremely low birth weight infants have an increased risk of infection. Infants weighing 750g or less rates are 2.5/1000 catheter days decreasing to 0.6/1000 per catheter days for infants greater than >1501g [4]. These rates may underestimate the actual rate of CLABSI as it is rare for two blood culture to be obtained in the neonatal population. Other studies reported wide variation in the infection rates ranging from 0-29% of catheters placed and from 2 to 49 per 1000 catheter days [5-11]. Neonates weighing < 1000g have an increased risk of mortality, with attributable mortality ranging from 4 to 20%, [12] and an increased need for intensive care, mechanical ventilation, bronchopulmonary dysplasia, necrotising enterocolitis, retinopathy of prematurity and prolonged hospitalisation [12-15]. These infections pose significant economic consequence. While there are no estimations of the costs of CLABSI in neonates, in 2001, Mahieu et al, demonstrated hospital acquired infections increase overall cost per patient by €11750 and the stay in neonatal intensive care increased by an average of 24 days [16]. Payne et al, study of blood stream infection in infants with a birth weight
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
Abstract Central venous catheter infections are the leading cause of healthcare associated bloodstream infections and contribute significantly to mortality and morbidity in neonatal intensive care units. Moreover, infection poses significant economic consequence which increased hospital costs and increased length of hospital stay. Prevention strategies are detailed in guidelines published by the Centers for Disease Control and Prevention (CDC) in the United States, nevertheless, recent surveys in neonatal units in the United States and Australia and New Zealand demonstrate these are not always followed. This review discusses the numerous evidence-based strategies to prevent catheter infections including hand hygiene, maximal sterile barriers during insertion, skin disinfection, selection of insertion site, dressings, aseptic non touch technique, disinfection of catheter hubs / ports, administration set management, prompt removal of catheter, antibiotic locks, systemic antibiotic prophylaxis and chlorhexidine bathing. Furthermore, it will describe different strategies that can be implemented into clinical practice to reduce infection rates. These include the use of care bundles including checklists, education and the use of CVC teams.
© 2014 Informa UK Ltd. This provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles do not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosages, the method and duration of administration, and contraindications. It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner. There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article. Any use of the Just Accepted articles is subject to the express understanding that the papers have not yet gone through the full quality control process prior to publication.
TITLE: Prevention of central venous catheter-related infection in the neonatal unit: a literature review
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
AUTHORS: Taylor, Jacqueline E1, 2, McDonald, Susan J1, 3, Tan, Kenneth 2, 4 Institutions: 1 La Trobe University, Bundoora, Australia; 2 Monash Newborn, Monash Medical Centre, Clayton, Australia; 3 Midwifery Professorial Unit, Mercy Hospital for Women, Melbourne, Australia 4 Monash Institute of Medical research, Monash University, Clayton, Australia
CORRESPONDENTS TO: Jacqueline Taylor Monash Medical Centre Level 5 246 Clayton Rd Clayton Victoria, 3168, Australia 0061395945196
Abstract
Central venous catheter infections are the leading cause of healthcare associated bloodstream infections and contribute significantly to mortality and morbidity in neonatal intensive care units. Moreover, infection poses significant economic consequence which increased hospital costs and increased length of hospital stay. Prevention strategies are detailed in guidelines published by the Centers for Disease Control and Prevention (CDC) in the United States, nevertheless, recent surveys in neonatal units in the United States and Australia and New Zealand demonstrate these are not always followed. This review discusses the numerous evidence-based strategies to
1
prevent catheter infections including hand hygiene, maximal sterile barriers during insertion, skin disinfection, selection of insertion site, dressings, aseptic non touch technique, disinfection of catheter hubs / ports, administration set management, prompt removal of catheter, antibiotic locks, systemic antibiotic prophylaxis and chlorhexidine bathing. Furthermore, it will describe different strategies that can be implemented into clinical practice to reduce infection rates. These
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
include the use of care bundles including checklists, education and the use of CVC teams.
Keywords Infant, newborn; intensive care, neonatal; catheterisation, central venous, catheter-associated infections; catheter-related infection; infection prevention Introduction
A central venous catheter (CVC) is defined as “an intravascular catheter that terminates at or close to the heart or in one of the great vessels such as the aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, common iliac veins, femoral veins, and in neonates, the umbilical artery/veins” [1]. CVCs commonly used in neonates include umbilical venous catheters (UVC) and peripherally inserted central catheters (PICC), less frequently used CVCs include central catheters inserted over a wire (e.g. femoral line) and subcutaneously tunnelled catheters (e.g. Broviac and Hickman) [2].
CVCs have become an essential part of neonatal care and are used for; (1) the administration of fluids and parenteral nutrition; (2) the administration of medications; and (3) when long term venous access is required and peripheral access is not an option. The larger bore catheters can also be used for central venous pressure monitoring, extracorporeal membrane oxygenation or exchange transfusion [2]. However, these catheters are not without complications and CVCs are the leading risk behind healthcare associated bloodstream infections [1]. Catheter-related infections occur when micro-organisms adhere to the intraluminal or extraluminal surface of the
2
catheter. Micro-organisms can enter the catheter from colonisation of the catheter ports (hubs) and insertion sites, contaminated intravenous fluids and injection devices and from haematogenous dissemination from other sources of infection [3].
Central line associated bloodstream infections (CLABSI) reported to the National Health
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Newcastle on 09/14/14 For personal use only.
Surveillance Network in 2012, demonstrated extremely low birth weight infants have an increased risk of infection. Infants weighing 750g or less rates are 2.5/1000 catheter days decreasing to 0.6/1000 per catheter days for infants greater than >1501g [4]. These rates may underestimate the actual rate of CLABSI as it is rare for two blood culture to be obtained in the neonatal population. Other studies reported wide variation in the infection rates ranging from 0-29% of catheters placed and from 2 to 49 per 1000 catheter days [5-11]. Neonates weighing < 1000g have an increased risk of mortality, with attributable mortality ranging from 4 to 20%, [12] and an increased need for intensive care, mechanical ventilation, bronchopulmonary dysplasia, necrotising enterocolitis, retinopathy of prematurity and prolonged hospitalisation [12-15]. These infections pose significant economic consequence. While there are no estimations of the costs of CLABSI in neonates, in 2001, Mahieu et al, demonstrated hospital acquired infections increase overall cost per patient by €11750 and the stay in neonatal intensive care increased by an average of 24 days [16]. Payne et al, study of blood stream infection in infants with a birth weight
