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Preventing Infections Related to Central Venous and Arterial Catheters
Linköping University, Department of Clinical and Experimental Medicine, Infectious Diseases. Linköping University, Faculty of Health Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Central venous catheters (CVCs) are indispensable in modern medical practice. Serious complications associated with CVC use include catheter-related infection (CRI) and catheter related-bloodstream infection (CRBSI) both of which contribute to morbidity, mortality and healthcare costs. Several studies have shown that implementation of basic hygiene routines, for CVC insertion and care, can significantly reduce the number of CRBSIs. However, there are limited data on the long-term effects after such an intervention. CVC infections, in terms of incidences and microorganisms, vary between different units and countries. Studies from Scandinavian hospitals are rare and not published recently. It has been stated that arterial catheters (ACs) are less prone to be responsible for CRI and CRBSI when compared with CVCs. However, recent studies outside Scandinavia have shown that they cause infections in significant numbers. The general view has been that nosocomial Candida infections in ICU patients evolve from the patient’s endogenous flora. However, a few studies have indicated that transmission of Candida spp. can occur between patients on an ICU as is well-described for certain bacteria. Candida spp. are among the most common microorganisms responsible for CRI/CRBSI.

The aim of this thesis was to study the incidences of, and microorganisms related to CVC (Study 1) and AC (Study 2) infections after implementation of evidence-based routines for insertion and care. The populations studied were patients with CVCs treated throughout the entire hospital (Studies 1 and 4) and patients with ACs treated on the ICU (Study 2). The aim was further to analyse risk factors contributing to these infections (Studies 1, 2 and 4). We also evaluated the long-term effects and endurance, of evidence-based routines, assessed as temporal variations in CVC colonisation and infections over a six-year period (Study 4). As we found that Candida spp. were common causes of CRI/CRBSI in Study 1, we decided to see if transmission of Candida spp. possibly occurred between patients on our ICU (Study 3).

We found low incidence rates, compared to international studies, for CRI and CRBSI related to the 495 CVCs studied over a short period (16 months, Study 1) and the 2045 CVCs studied over long-term follow-up (six years, Study 4). We found no cases of AC-CRBSI but a low number of AC-CRI in the 600 ACs studied. The type of microorganisms responsible for infections related to CVCs and ACs were similar to those found in international studies. However, the proportion of Candida spp. was high in Studies 1 and 4 evaluating CVC infections. There was no difference in the CVC-catheterisation time for CRI/CRBSI caused by Candida spp. as compared to CRI/CRBSI caused by bacteria. Risk factors for CRI associated with CVCs were chronic haemodialysis (Study 1), all haemodialysis in general (Study 4) and CVCs inserted via the internal jugular vein as compared to the subclavian vein (Study 4). Risk factors for CRI related to ACs were colonisation or infection of a simultaneous CVC and immunosuppression. Genotypes of Candida albicans and Candida glabrata had a heterogeneous distribution between ICU patients over time. Comparison with a reference group and cluster analysis indicated that transmission of Candida spp. between ICU patients is possible.

In, conclusion, we have found, after implementation of evidence-based routines for CVC and AC insertion and care, low incidences of CRI and CRBSI associated with these catheters. Furthermore, we found that transmission of Candida spp. between patients on the ICU is possible.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 71 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1360
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-89955ISBN: 978-91-7519-661-9 (print)OAI: oai:DiVA.org:liu-89955DiVA: diva2:610571
Public defence
2013-04-12, Originalet, Qulturum, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-03-12 Created: 2013-03-12 Last updated: 2013-03-12Bibliographically approved
List of papers
1. Central venous catheter infections at a county hospital in Sweden: A prospective analysis of colonization, incidence of infection and risk factors
Open this publication in new window or tab >>Central venous catheter infections at a county hospital in Sweden: A prospective analysis of colonization, incidence of infection and risk factors
2006 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, Vol. 50, no 4, 451-460 p.Article in journal (Refereed) Published
Abstract [en]

Background: Catheter-related infection (CRI) is one of the most serious complications of the use of central venous catheters (CVCs), with an incidence of 2-30/1000 days in different studies. No major prospective study has evaluated the rate of CRI in Scandinavia. Since 1999, we have had a thorough programme for the insertion and care of all CVCs used at our hospital and its outpatient clinics. The purpose of this survey was to study the incidence of catheter tip colonization and CRI and their risk factors, and to compare these data with previous non-Scandinavian studies. Methods: We studied prospectively 605 CVCs in 456 patients in relation to insertion data, patient and catheter characteristics, catheterization time and microbiological cultures. Risk factors were analysed by multivariate analysis. Results: Four hundred and ninety-five (82%) of all CVCs were assessed completely. The total catheterization time was 9010 days. The incidence of positive tip culture was 7.66/1000 days, and the predominant microorganism was coagulase-negative staphylococci. The incidence of CRI was 1.55/1000 days, and the only significant risk factor was the duration of catheterization with a relative risk of 1.009 per day [95% confidence interval (CI), 1.003-1.015]. Of the 14 cases with CRI, six were associated with candida species, and five of these were diagnosed in the intensive care unit. Conclusion: In comparison with non-Scandinavian studies, our practice of strict basic hygiene routines for CVC insertion and care is associated with a low incidence of CRI. However, there was a high proportion of candida species amongst these infections. The only risk factor for CRI was the duration of catheterization. © Acta Anaesthesiologica Scandinavica 2006.

Keyword
Candida species, Catheter-related infection, Central venous catheter (CVC), Nosocomial infection
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-50078 (URN)10.1111/j.1399-6576.2006.00974.x (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2013-03-12
2. Low incidence of arterial catheter infections in a Swedish intensive care unit: risk factors for colonisation and infection
Open this publication in new window or tab >>Low incidence of arterial catheter infections in a Swedish intensive care unit: risk factors for colonisation and infection
2010 (English)In: Journal of Hospital Infection, ISSN 0195-6701, E-ISSN 1532-2939, Vol. 76, no 2, 130-134 p.Article in journal (Refereed) Published
Abstract [en]

There is growing concern that arterial catheters (ACs) cause catheter-related infections (CRIs). Limited data are available concerning risk factors for AC-CRI and there are no studies concerning incidence and micro-organisms from northern Europe. The aims of this study were to determine the incidence of, and micro-organisms responsible for, AC colonisation and AC-CRI in a Swedish intensive care unit (ICU), and to determine risk factors contributing to AC colonisation and AC-CRI. We prospectively studied all patients (N=539) receiving ACs (N=691) in a mixed ICU of a county hospital. Six hundred (87%) of all ACs were assessed completely. The total catheterisation time for 482 patients was 2567 days. The incidence of positive tip culture was 7.8 per 1000 catheter-days, with the predominant micro-organism being coagulase-negative staphylococci (CoNS). The incidence of AC-CRI was 2.0 per 1000 catheter-days (with no cases of bacteraemia). All AC-CRIs were caused by CoNS. Multivariate analysis revealed that immunosuppression, central venous catheter (CVC) colonisation and CVC infection were significant risk factors for AC-CRI. We conclude that AC colonisation and infection with systemic symptoms occur at a low rate in our ICU which supports our practice of basic hygiene routines for the prevention of AC-CRI. Colonisation and infection of a simultaneous CVC seem to be risk factors. The role of contemporaneous colonisation and infection of multiple bloodstream catheters has received little attention previously. Further studies are needed to verify the significance of this finding.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-59067 (URN)10.1016/j.jhin.2010.05.021 (DOI)
Available from: 2010-09-08 Created: 2010-09-08 Last updated: 2013-03-12
3. Possible transmission of Candida albicans on an intensive care unit: intensive care unit:
Open this publication in new window or tab >>Possible transmission of Candida albicans on an intensive care unit: intensive care unit:
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Nosocomial transmission of Candida spp. has not fully been explored and previous studies have shown conflicting results.

Aim: To evaluate the possible nosocomial transmission of Candida spp. on an intensive care unit (ICU).

Methods: We conducted a prospective study over 19 month, including all patients on our ICU with growth of Candida spp. from surveillance and directed cultures. Molecular typing, with rep-PCR (DiversiLab) was used to define genotype relationships between the C. albicans and C. glabrata isolates. Candida isolates obtained from blood cultures taken from patients in our county outside the ICU, were used as a reference. Temporal cluster analysis was performed to evaluate genotype distribution over time.

Findings: Seventy-seven patients with 78 ICU stays, representing twelve per cent of all ICU stays, were found to harbour 180 isolates of Candida spp. Molecular typing revealed 27 C. albicans genotypes and ten of C. glabrata. Possible clustering, indicated by overlapping stays of patients with indistinguishable candida genotypes was observed on seven occasions with C. albicans and on two occasions with C. glabrata. Two C. albicans genotypes were found significantly more often in the ICU group compared to the reference group. Moreover, C. albicans genotypes isolated from more than one patient were significantly more often found in the ICU group. Temporal cluster analysis revealed a significantly increased number of pairs with indistinguishable genotypes at a 21-dayinterval, indicating clustering.

Conclusion: This study indicates transmission of C. albicans between ICU patients based on genotyping and temporal cluster analysis.

Keyword
Candida, Molecular typing, Intensive care unit, nosocomial infections
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-89953 (URN)
Available from: 2013-03-12 Created: 2013-03-12 Last updated: 2013-03-12Bibliographically approved
4. Sustained low incidence of central venous catheter-related infections in a Swedish county hospital following implementation of a hygiene program: a six year follow-up study
Open this publication in new window or tab >>Sustained low incidence of central venous catheter-related infections in a Swedish county hospital following implementation of a hygiene program: a six year follow-up study
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: There are limited data on the long term-effects of implementing a central venous catheter (CVC) program for prevention of CVC infections. The aims of this study were to evaluate the incidence of CVC colonization, catheter-related infections (CRI), catheter-related bloodstream infections (CRBSI), and their risk factors, over a six year period.

Methods: A continuous prospective study aiming to include all CVCs used at our hospital during the years 2004-2009, evaluating colonization, CRI, CRBSI and possible risk factors.

Results: 2772 CVCs were used during the study period. Data on culture results and catheterization time were available for 2045 CVCs used in 1674 patients. The incidences of colonization, CRI and CRBSI were 7.0, 2.2 and 0.6 per 1000 CVC-days. Analysis of quarterly incidences revealed one occasion with increasing infection rates. Catheterization time was a risk factor for CRI, but not for CRBSI. Other risk factors for CRI were hemodialysis, CVC use in the internal jugular vein compared to the subclavian vein. Hemodialysis was the only risk factor for CRBSI.

Conclusion: We found that that a CRI prevention program adhered to by the entire staff at a county hospital is successful in keeping CVC infections at a low rate over a long period of time.

Keyword
Catheter-related bloodstream infection; Central venous catheter; Nosocomial infection
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-89954 (URN)
Available from: 2013-03-12 Created: 2013-03-12 Last updated: 2013-03-12Bibliographically approved

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