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Effect of Nurse Staffing and Antimicrobial-Impregnated Central Venous Catheters on the Risk for Bloodstream Infections in Intensive Care Units

Published online by Cambridge University Press:  02 January 2015

Juan Alonso-Echanove ,
Jonathan R. Edwards ,
Michael J. Richards ,
Patrick Brennan ,
Richard A. Venezia ,
Janet Keen ,
Vivian Ashline ,
Kathy Kirkland ,
Ellen Chou  and
Mark Hupert
...Show all authors
Juan Alonso-Echanove
Affiliation:
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Jonathan R. Edwards
Affiliation:
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Michael J. Richards
Affiliation:
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Patrick Brennan
Affiliation:
Infection Control Department, University of Pennsylvania, Philadelphia, Pennsylvania
Richard A. Venezia
Affiliation:
Department of Epidemiology, Albany Medical Center, Albany, New York
Janet Keen
Affiliation:
Epidemiology/Infection Control Department, University Hospital of Augusta, Augusta, Georgia
Vivian Ashline
Affiliation:
Epidemiology/Infection Control Department, University Hospital of Augusta, Augusta, Georgia
Kathy Kirkland
Affiliation:
Department of Medicine, Duke University Medical Center, Durham, North Carolina
Ellen Chou
Affiliation:
Infection Control Program, The Gennessee Hospital, via Health, Rochester, New York
Mark Hupert
Affiliation:
Infection Control Department, University of Pennsylvania, Philadelphia, Pennsylvania
Abigail V. Veeder
Affiliation:
Department of Epidemiology, Albany Medical Center, Albany, New York
Janice Speas
Affiliation:
Infection Control Department, Saint Joseph's Hospital of Atlanta, Atlanta, Georgia
Judy Kaye
Affiliation:
Infection Control Department, Saint Joseph's Hospital of Atlanta, Atlanta, Georgia
Kailash Sharma
Affiliation:
Epidemiology/Infection Control Department, University Hospital of Augusta, Augusta, Georgia
Aliki Martin
Affiliation:
Department of Medicine, Duke University Medical Center, Durham, North Carolina
V. Dianne Moroz
Affiliation:
Infection Control Program, The Gennessee Hospital, via Health, Rochester, New York
Robert P. Gaynes*
Affiliation:
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
*
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Mailstop E-55, 1600 Clifton Road NE, Centers for Disease Control and Prevention, Atlanta, GA 30333
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Abstract

Background:

Defining risk factors for central venous catheter (CVC)-associated bloodstream infections (BSIs) is critical to establishing prevention measures, especially for factors such as nurse staffing and antimicrobial-impregnated CVCs.

Methods:

We prospectively monitored CVCs, nurse staffing, and patient-related variables for CVC-associated BSIs among adults admitted to eight ICUs during 2 years.

Results:

A total of 240 CVC-associated BSIs (2.8%) were identified among 4,535 patients, representing 8,593 CVCs. Antimicrobial-impregnated CVCs reduced the risk for CVC-associated BSI only among patients whose CVC was used to administer total parenteral nutrition (TPN, 2.6 CVC-associated BSIs per 1,000 CVC-days vs no TPN, 7.5 CVC-associated BSIs per 1,000 CVC-days; P = .006). Among patients not receiving TPN, there was an increase in the risk of CVC-associated BSI in patients cared for by “float” nurses for more than 60% of the duration of the CVC. In multivariable analysis, risk factors for CVC-associated BSIs were the use of TPN in non-antimicrobial-impregnated CVCs (P = .0001), patient cared for by a float nurse for more than 60% of CVC-days (P = .0019), no antibiotics administered to the patient within 48 hours of insertion (P = .0001), and patient unarousable for 70% or more of the duration of the CVC (P = .0001). Peripherally inserted central catheters (PICCs) were associated with a lower risk for CVC-associated BSI (P = .0001).

Conclusions:

Antimicrobial-impregnated CVCs reduced the risk of CVC-associated BSI by 66% in patients receiving TPN. Limiting the use of float nurses for ICU patients with CVCs and the use of PICCs may also reduce the risk of CVC-associated BSI.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 24 , Issue 12 , December 2003 , pp. 916 - 925
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2003 

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References

1. Mermel, LA. Erratum: prevention of intravascular catheter-related infections. Ann Intern Med 2000;133:5.Google Scholar
2. Mermel, LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132:391–402.10.7326/0003-4819-132-5-200003070-00009Google Scholar
3. Richards, MJ, Edwards, JR, Culver, DH, Gaynes, RP. Nosocomial infections in coronary care units in the United Slates. Am J Cardiol 1998;82:789–793.10.1016/S0002-9149(98)00450-0Google Scholar
4. Richards, MJ, Edwards, JR, Culver, DH, Gaynes, RP. Nosocomial infections in medical intensive care units in the United States. Crit Care Med 1999;27:887–892.10.1097/00003246-199905000-00020Google Scholar
5. Richards, MJ, Edwards, JR, Culver, DH, Gaynes, RP. Nosocomial infections in pediatric intensive care units in the United States. Pediatrics 1999;103:e39.10.1542/peds.103.4.e39Google Scholar
6. Girou, E, Pinsard, M, Auriant, I, Canonne, M. Influence of the severity of illness measured by the Simplified Acute Physiology Score (SAPS) on occurrence of nosocomial infections in ICU patients. J Hosp Infect 1996;34:131–137.10.1016/S0195-6701(96)90138-3Google Scholar
7. Keita-Perse, O, Gaynes, RR. Severity of illness scoring systems to adjust nosocomial infection rates: a review and commentary. Am J Infect Control 1996;24:429–434.10.1016/S0196-6553(96)90036-XGoogle Scholar
8. Mermel, LA, Parenteau, S, Tow, SM. The risk of midline catheterization in hospitalized patients: a prospective study. Ann Intern Med 1995;123:841–844.10.7326/0003-4819-123-11-199512010-00005Google Scholar
9. Mermel, LA, McCormick, RD, Springman, SR, Maki, DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med 1991;91:197S–205S.10.1016/0002-9343(91)90369-9Google Scholar
10. Mueller, BU, Skelton, J, Callender, DP, et al. A prospective randomized trial comparing the infectious and noninfectious complications of an externalized catheter versus a subcutaneously implanted device in cancer patients. J Clin Oncol 1992;10:1943–1948.10.1200/JCO.1992.10.12.1943Google Scholar
11. Raad, I, Davis, S, Becker, M, et al. Low infection rate and long durability of nontunneled silastic catheters: a safe and cost-effective alternative for long-term venous access. Arch Intern Med 1993;153:1791–1796.10.1001/archinte.1993.00410150073007Google Scholar
12. Richet, H, Hubert, B, Nitemberg, G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol 1990;28:2520–2525.Google Scholar
13. Hagley, MT, Martin, B, Gast, P, Traeger, SM. Infectious and mechanical complications of central venous catheters placed by percutaneous venipuncture and over guidewires. Crit Care Med 1992;20:1426–1430.10.1097/00003246-199210000-00011Google Scholar
14. Eyer, S, Brummitt, C, Crossley, K, Siegel, R Cerra, F. Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med 1990;18:1073–1079.10.1097/00003246-199010000-00005Google Scholar
15. Snyder, RH, Archer, FJ, Endy, T, et al. Catheter infection: a comparison of two catheter maintenance techniques. Ann Surg 1988;208:651–653.10.1097/00000658-198811000-00018Google Scholar
16. Cook, D, Randolph, A, Kernerman, P, et al. Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 1997;25:1417–1424.10.1097/00003246-199708000-00033Google Scholar
17. Cobb, DK, High, KP, Sawyer, RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992;327:1062–1068.10.1056/NEJM199210083271505Google Scholar
18. Mermel, L. Central venous catheter-related infections and their prevention: is there enough evidence to recommend tunneling for short-term use? Crit Care Med 1998;26:1315–1316.10.1097/00003246-199808000-00011Google Scholar
19. Randolph, AG, Cook, DJ, Gonzales, CA, Brun-Buisson, C. Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials. Crit Care Med 1998;26:1452–1457.10.1097/00003246-199808000-00038Google Scholar
20. Timsit, JF, Bruneel, F, Cheval, C, et al. Use of tunneled femoral catheters to prevent catheter-related infection: a randomized, controlled trial. Ann Intern Med 1999;130:729–735.10.7326/0003-4819-130-9-199905040-00004Google Scholar
21. Clark-Christoff, N, Watters, VA, Sparks, W, Snyder, P, Grant, JP. Use of triple-lumen subclavian catheters for administration of total parenteral nutrition. JPEN J Parenter Enteral Nutr 1992;16:403–407.10.1177/0148607192016005403Google Scholar
22. Farkas, JC, Liu, N, Bleriot, JP, Chevret, S, Goldstein, FW, Carlet, J. Single- versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population. Am J Med 1992;93:277–282.10.1016/0002-9343(92)90233-2Google Scholar
23. Gil, RT, Kruse, JA, Thill-Baharozian, MC, Carlson, RW. Triple- vs single-lumen central venous catheters: a prospective study in a critically ill population. Arch Intern Med 1989;149:1139–1143.10.1001/archinte.1989.00390050105021Google Scholar
24. Yeung, C, May, J, Hughes, R. Infection rate for single lumen v triple lumen subclavian catheters. Infect Control Hosp Epidemiol 1988;9:154–158.10.1086/645820Google Scholar
25. Linares, J, Sitges-Serra, A, Garau, J, Perez, JL, Martin, R. Pathogenesis of catheter sepsis: a prospective study with quantitative and semiquantitative cultures of catheter hub and segments. J Clin Microbiol 1985;21:357–360.10.1128/jcm.21.3.357-360.1985Google Scholar
26. Lucet, JC, Hayon, J, Bruneel, F, Dumoulin, JL, Joly-Guillou, ML. Microbiological evaluation of central venous catheter administration hubs. Infect Control Hosp Epidemiol 2000;21:40–42.10.1086/501696Google Scholar
27. Sitges-Serra, A, Jaurrieta, E, Linares, J, Perez, JL, Garau, J. Bacteria in total parenteral nutrition catheters: where do they come from? Lancet 1983;1:531.10.1016/S0140-6736(83)92219-5Google Scholar
28. Sitges-Serra, A, Puig, P, Linares, J, et al. Hub colonization as the initial step in an outbreak of catheter-related sepsis due to coagulase negative staphylococci during parenteral nutrition. JPEN J Parenter Enteral Nutr 1984;8:668–672.10.1177/0148607184008006668Google Scholar
29. Sitges-Serra, A, Linares, J, Perez, JL, Jaurrieta, E, Lorente, L. A randomized trial on the effect of tubing changes on hub contamination and catheter sepsis during parenteral nutrition. JPEN J Parenter Enteral Nutr 1985;9:322–325.10.1177/0148607185009003322Google Scholar
30. Inoue, Y, Nezu, R, Matsuda, H, et al. Prevention of catheter-related sepsis during parenteral nutrition: effect of a new connection device. JPEN J Parenter Enteral Nutr 1992;16:581–585.10.1177/0148607192016006581Google Scholar
31. Armstrong, CW, Mayhall, CG, Miller, KB, et al. Prospective study of catheter replacement and other risk factors for infection of hyperalimentation catheters. J Infect Dis 1986;154:808–816.10.1093/infdis/154.5.808Google Scholar
32. Murphy, LM, Lipman, TO. Central venous catheter care in parenteral nutrition: a review. JPEN J Parenter Enteral Nutr 1987;11:190–201.10.1177/014860718701100220Google Scholar
33. Raad, II, Hohn, DC, Gilbreath, BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994;15:231–238.10.2307/30145574Google Scholar
34. Darouiche, RO, Raad, II, Heard, SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med 1999;340:1–8.10.1056/NEJM199901073400101Google Scholar
35. Heard, SO, Wagle, M, Vijayakumar, E, et al. Influence of triple-lumen central venous catheters coated with Chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. Arch Intern Med 1998;158:81–87.10.1001/archinte.158.1.81Google Scholar
36. Kamal, GD, Pfaller, MA, Rempe, LE, Jebson, PJ. Reduced intravascular catheter infection by antibiotic bonding: a prospective, randomized, controlled trial. JAMA 1991;265:2364–2368.10.1001/jama.1991.03460180070035Google Scholar
37. Maki, DG, Stolz, SM, Wheeler, S, Mermel, LA. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: a randomized, controlled trial. Ann Intern Med 1997;127:257–266.10.7326/0003-4819-127-4-199708150-00001Google Scholar
38. Raad, I, Darouiche, R, Dupuis, J, et al. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: a randomized, double-blind trial. Ann Intern Med 1997;127:267–274.10.7326/0003-4819-127-4-199708150-00002Google Scholar
39. Veenstra, DL, Saint, S, Saha, S, Lumley, T, Sullivan, SD. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis. JAMA 1999;281:261–267.10.1001/jama.281.3.261Google Scholar
40. Veenstra, DL, Saint, S, Sullivan, SD. Cost-effectiveness of antiseptic-impregnated central venous catheters for the prevention of catheter-related bloodstream infection. JAMA 1999;282:554–560.10.1001/jama.282.6.554Google Scholar
41. Archibald, LK, Manning, ML, Bell, LM, Banerjee, S, Jarvis, WR. Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit. Pediatr Infect Dis J 1997;16:1045–1048.10.1097/00006454-199711000-00008Google Scholar
42. Arnow, P, Allyn, PA, Nichols, EM, Hill, DL, Pezzlo, M, Bartlett, RH. Control of methicillin-resistant Staphylococcus aureus in a burn unit: role of nurse staffing. Journal of Trauma-Injury Infection & Critical Care 1982;22:954–959.10.1097/00005373-198211000-00012Google Scholar
43. Fridkin, SK, Pear, SM, Williamson, TH, Galgiani, JN, Jarvis, WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996;17:150–158.Google Scholar
44. Garfield, M, Jeffrey, R, Ridley, S. An assessment of the staffing level required for a high-dependency unit. Anaesthesia 2000;55:137–143.Google Scholar
45. Haley, RW, Bregman, DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982;145:875–885.10.1093/infdis/145.6.875Google Scholar
46. Haley, RW, Cushion, NB, Tenover, FC, et al. Eradication of endemic methicillin-resistant Staphylococcus aureus infections from a neonatal intensive care unit J Infect Dis 1995;171:614–624.10.1093/infdis/171.3.614Google Scholar
47. Mayhall, CG, Lamb, VA, Gayle, WE Jr, Haynes, BW Jr. Enterobacter cloacae septicemia in a burn center: epidemiology and control of an outbreak. J Infect Dis 1979;139:166–171.10.1093/infdis/139.2.166Google Scholar
48. Robert, J, Fridkin, SK, Blumberg, HM, et al. The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit. Infect Control Hosp Epidemiol 2000;21:12–17.10.1086/501690Google Scholar
49. Garner, JS, Jarvis, WR, Emori, TG, Horan, TC, Hughes, JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128–140.Google Scholar
50. Horan, TC, Gaynes, RP, Martone, WJ, Jarvis, WR, Emori, TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606–608.10.2307/30148464Google Scholar
51. Snydman, DR, Murray, SA, Kornfeld, SJ, Majka, JA, Ellis, CA. Total parenteral nutrition-related infections: prospective epidemiologic study using semiquantitative methods. Am J Med 1982;73:695–699.10.1016/0002-9343(82)90412-0Google Scholar
52. Nehme, AE. Nutritional support of the hospitalized patient: the team concept. JAMA 1980;243:1906–1908.Google Scholar
53. Faubion, WC, Wesley, JR, Khalidi, N, Silva, J. Total parenteral nutrition catheter sepsis: impact of the team approach. JPEN J Parenter Enteral Nutr 1986;10:642–645.10.1177/0148607186010006642Google Scholar
54. Nelson, DB, Kien, CL, Mohr, B, Frank, S, Davis, SD. Dressing changes by specialized personnel reduce infection rates in patients receiving central venous parenteral nutrition. JPEN J Parenter Enteral Nutr 1986;10:220–222.10.1177/0148607186010002220Google Scholar
55. Marin, MG, Lee, JC, Skurnick, JH. Prevention of nosocomial bloodstream infections: effectiveness of antimicrobial-impregnated and heparin-bonded central venous catheters. Crit Care Med 2000;28:3332–3338.10.1097/00003246-200009000-00035Google Scholar
56. Buerhaus, PI, Staiger, DO, Auerbach, DI. Implications of an aging registered nurse workforce. JAMA 2000;283:2948–2954.Google Scholar
57. Raad, I, Davis, S, Becker, M, et al. Low infection rate and long durability of nontunneled silastic catheters: a safe and cost-effective alternative for long-term venous access. Arch Intern Med 1993;153:1791–1796.Google Scholar
58. Cardella, JF, Cardella, K, Bacci, N, Fox, PS, Post, JH. Cumulative experience with 1,273 peripherally inserted central catheters at a single institution. J Vase Interv Radiol 1996;7:5–13.Google Scholar
59. Sofocleous, CT, Schur, I, Cooper, SG, Quintas, JC, Brody, L, Shelin, R. Sonographically guided placement of peripherally inserted central venous catheters: review of 355 procedures. AJR Am J Roentgenol 1998;170:1613–1616.10.2214/ajr.170.6.9609183Google Scholar
60. Black, IH, Blosser, SA, Murray, WB. Central venous pressure measurements: peripherally inserted catheters versus centrally inserted catheters. Crit Care Med 2000;28:3833–3836.10.1097/00003246-200012000-00014Google Scholar
61. Abi-Nader, JA. Peripherally inserted central venous catheters in critical care patients. Heart Lung 1993;22:428–434.Google Scholar
62. Griffiths, VR, Philpot, P. Peripherally inserted central catheters (PICCs): do they have a role in the care of the critically ill patient? Intensive Critical Care Nursing 2002;18:37–47.Google Scholar
63. Raad, II, Hachem, RY, Abi-Said, D, et al. A prospective crossover randomized trial of novobiocin and rifampin prophylaxis for the prevention of intravascular catheter infections in cancer patients treated with interleukin-2. Cancer 1998;82:403–411.Google Scholar
64. Spafford, PS, Sinkin, RA, Cox, C, Reubens, L, Powell, KR. Prevention of central venous catheter-related coagulase-negative staphylococcal sepsis in neonates. J Pediatr 1994;125:259–263.Google Scholar
65. Kacica, MA, Horgan, MJ, Ochoa, L, Sandler, R, Lepow, ML, Venezia, RA. Prevention of gram-positive sepsis in neonates weighing less than 1500 grams. J Pediatr 1994;125:253–258.Google Scholar
66. Bock, SN, Lee, RE, Fisher, B, et al. A prospective randomized trial evaluating prophylactic antibiotics to prevent triple-lumen catheter-related sepsis in patients treated with immunotherapy. J Clin Oncol 1990;8:161–169.10.1200/JCO.1990.8.1.161Google Scholar
67. Al-Sibai, MB, Harder, EJ, Faskin, RW, Johnson, GW, Padmos, MA. The value of prophylactic antibiotics during the insertion of long-term indwelling silastic right atrial catheters in cancer patients. Cancer 1987;60:1891–1895.10.1002/1097-0142(19871015)60:8<1891::AID-CNCR2820600836>3.0.CO;2-Z3.0.CO;2-Z>Google Scholar
68. Schwartz, C, Henrickson, KJ, Roghmann, K, Powell, K. Prevention of bacteremia attributed to luminal colonization of tunneled central venous catheters with vancomycin-susceptible organisms. J Clin Oncol 1990;8:1591–1597.10.1200/JCO.1990.8.9.1591Google Scholar
69. Ranson, MR, Oppenheim, BA, Jackson, A, Kamthan, AG, Scarffe, JH. Double-blind placebo controlled study of vancomycin prophylaxis for central venous catheter insertion in cancer patients. J Hosp Infect 1990;15:95–102.10.1016/0195-6701(90)90025-JGoogle Scholar
70. McKee, R, Dunsmuir, R, Whitby, M, Garden, OJ. Does antibiotic prophylaxis at the time of catheter insertion reduce the incidence of catheter-related sepsis in intravenous nutrition? J Hosp Infect 1985;6:419–425.Google Scholar
71. Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance (NNIS) System report: data summary from January 1992 to April 2000, issued June 2000. Am J Infect Control 2000;28:429–448.10.1067/mic.2000.110544Google Scholar