This study of community-based nursing homes used the Comprehensive Unit-based Safety Program (CUSP) toolkit for CAUTI, developed as part of the Agency for Healthcare Research and Quality Safety Program for Long-Term Care. The intervention targeted urinary catheter removal, aseptic insertion, incontinence care planning, and various training programs for staff, patients, and family. The intervention reduced UTIs, perhaps indicating success in aseptic techniques, but did not reduce overall catheter utilization. The authors theorized that catheter utilization in nursing homes across the country was already relatively low at the start of the study, leaving little room for further reductions. Intravascular Catheters With respect to intravascular catheters, certain patient safety practices can be used to reduce the risk of infection when vascular access cannot be avoided. The practices focus on the use of antibiotics or specialized catheters that contain antimicrobial substances. The section below discusses these practices in further detail and their implications for antimicrobial resistance and other potential patient harm. The CDC guidelines for preventing intravascular catheter-related infections provide recommendations for antibiotic and antiseptic use. In general, for intravascular catheters, the CDC does not recommend the use of systemic antimicrobial prophylaxis. Instead, the CDC recommends the use of certain antiseptic ointments at the catheter exit site for dialysis catheters and recommends antibiotic locking solutions in certain situations. Regarding site placement of central venous catheters (CVCs), one systematic review of published ICU infection outbreaks found strong evidence to support the use of subclavian insertion sites compared with jugular or femoral sites to reduce the risk of CLABSI. 79 This practice is strongly supported by the CDC guidelines to avoid use of jugular or femoral insertion sites. As with most medical procedures that are physically invasive, sanitary practices are necessary and may reduce the risk of infected wounds and invasive infections. While no study specifically addressed sanitary practices as an intervention, the CDC guidelines include detailed instructions on appropriate infection control procedures for intravascular catheters. The strongest CDC recommendations include: • Using sterile gloves when inserting arterial, central, and midline vascular catheters • Frequently performing hand hygiene • Using sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site • Using chlorhexidine antisepsis for insertion sites in specific cases (see guidelines for details)
One method of combating invasive infections associated with catheters is to reduce and restrict the growth of bacteria within the catheter itself. Bacteria often form biofilms within catheters that can inhibit catheter function and increase the risk of infection. In addition to preventing bacterial infections and biofilm formation, antibiotic lock (ABL) therapy reduces costs and vein damage associated with device replacement. ABL therapy is the insertion of a concentrated antibiotic solution into a catheter lumen (its internal channel or tube) to prevent the development of microbial biofilm on catheter surfaces. In a study by Dixon et al. (2012), ABL therapy, as an adjunct to systemic antibiotic therapy, vs. systemic antibiotic therapy alone in patients with tunneled hemodialysis catheters, reduced CLABSI incidence by over 50% and reduced treatment failure and relapses in the study group compared with the control group. 80 The CDC recommends that ABL prophylaxis only be used for hemodialysis patients with long-term catheters who have a history of multiple CLABSIs despite appropriate aseptic techniques during catheter care and insertion. Catheter Innovations To Reduce Risk of Infection Various catheter materials have been studied to determine their effectiveness at reducing biofilm formation and preventing catheter-related infections. Urinary catheters can be made of hydrophilic materials—which reduce friction during insertion, thus reducing the need for lubrication and the risk of urethral damage—or impregnated with antimicrobial chemicals to prevent colonization of the catheter with bacteria or fungi. Catheters can be constructed of latex, silicone, or other components; however, antimicrobial silver alloys may bind more readily to latex than to other materials. Three technologies have been found to be successful in laboratory experiments: gum arabic capped-silver nanoparticle-coated devices; catheters impregnated with rifampicin, triclosan, and trimethoprim; and CVCs impregnated with minocycline and rifampicin (M/R) + chlorohexidine (CHX). Gel reservoir and hydrophilic catheters may be safer than traditional sterile noncoated catheters. Silver-impregnated catheters have mixed evidence of efficacy. Catheters impregnated with both silver and chlorohexidine have been demonstrated to reduce colonization and CLABSIs, especially in settings with high background rates of CLABSIs and are highly recommended by CDC if the CVC is expected to stay in place for more than 5 days. Another innovation for increasing catheter safety is the use of needleless connectors. If needleless connectors are used, the CDC strongly recommends that an antiseptic be used to scrub the access port and that it be accessed only with sterile devices. The CDC acknowledges the benefits of antibiotic- impregnated or antiseptic-impregnated urinary catheters in certain situations but also addresses
a mix or lack of evidence demonstrating that they reduce UTI. The CDC also states that silicone and hydrophilic catheters may be preferable in certain situations (e.g., hydrophilic catheter use for intermittent catheterization). Reducing Ventilator-Associated Infections Supraglottic suction refers to suctioning that removes bacteria-laden secretions to reduce the risk of aspiration pneumonia or upper-respiratory tract pneumonia. A systematic literature review by Doyle et al. (2011) found that the current literature supported the PSP of supraglottic suction in a patient’s endotracheal tube. 79 The authors also found overall support in the literature for bed elevation of 30 to 45 degrees for mechanically ventilated patients. They also found supporting evidence for selectively decontaminating patients’ digestive tract to prevent VAPs. All three of these PSPs— supraglottic suction, bed elevation, and selective decontamination—aim to reduce aspiration of bacteria in respiratory fluid and thus reduce pneumonia in ventilated patients. Subglottic secretion suctioning is a similar method to reduce ventilator-associated infections and was found by one randomized control study to be associated with lower rates of VAP and overall lower length of required ventilation. The same systematic literature review found only mixed evidence to support using topical antibiotics to decontaminate the oropharynx of patients on mechanical ventilation. The Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) guidelines, “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals,” state that there is moderate evidence to support the use of endotracheal tubes with a subglottic suction catheter for patients ventilated for more than 2 to 3 days but do not recommend closed/inline endotracheal suctioning. 81 These guidelines also note that the quality of evidence was low to support the bed elevation discussed by Doyle et al. and that the quality of evidence was high for selective oral or digestive decontamination. The guidelines suggest the following additional PSPs for adult patients: • Assessing the readiness to extubate daily • Interrupting sedation daily • Performing spontaneous breathing trials with sedatives turned off • Changing the ventilation circuit only if visibly soiled or malfunctioning PSPs with moderate quality of evidence include managing patients without sedation whenever possible, facilitating early mobility, administering regular oral care with chlorhexidine, and providing prophylactic probiotics. Evaluation and Monitoring of Device Use To reduce duration of device use, clinicians often must regularly reevaluate the need for the device andmonitor any changes (e.g., the patient’s dependence on the device).
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