Aaron M. Milstone

Chlorhexidine: Expanding the Armamentarium for Infection Control and Prevention

Health care-associated infections (HAIs) result in increased patient morbidity and utilization of health care resources. Rates of HAI are increasing despite advances in health care technology. Limited antimicrobial agents and a dry drug pipeline make novel prevention efforts critical. Chlorhexidine, an antiseptic solution that has been used worldwide since the 1950s, is a safe and effective product with broad antiseptic activity. Novel uses of chlorhexidine-containing products are being implemented to promote antisepsis and prevent bacterial colonization and infection. We review some of the many infection control applications of chlorhexidine in the battle against HAI, such as general skin cleansing, skin decolonization, preoperative showering and bathing, vascular catheter site preparation, impregnated catheter site dressings, impregnated catheters, and oral decontamination. As mandatory public reporting and pay for performance force infection control issues to the forefront, chlorhexidine-containing products may provide a vast armamentarium for the control and prevention of HAI.

Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their methicillin-resistant Staphylococcus aureus (MRSA) prevention efforts. This document updates “Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial

BACKGROUND Bacteraemia is an important cause of morbidity and mortality in critically ill children. Our objective was to assess whether daily bathing in chlorhexidine gluconate (CHG) compared with standard bathing practices would reduce bacteraemia in critically ill children. METHODS In an unmasked, cluster-randomised, two-period crossover trial, ten paediatric intensive-care units at five hospitals in the USA were randomly assigned a daily bathing routine for admitted patients older than 2 months, either standard bathing practices or using a cloth impregnated with 2% CHG, for a 6-month period. Units switched to the alternative bathing method for a second 6-month period. 6482 admissions were screened for eligibility. The primary outcome was an episode of bacteraemia. We did intention-to-treat (ITT) and per-protocol (PP) analyses. This study is registered with ClinicalTrials.gov (identifier NCT00549393). FINDINGS 1521 admitted patients were excluded because their length of stay was less than 2 days, and 14 refused to participate. 4947 admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64-4·61) compared with standard practices (4·93 per 1000 days, 3·91-6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42-1·20). In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27-4·58) compared with standard practices (4·93 per 1000 days, 3·91-6·15; aIRR 0·64, 0·42-0·98). No serious study-related adverse events were recorded, and the incidence of CHG-associated skin reactions was 1·2 per 1000 days (95% CI 0·60-2·02). INTERPRETATION Critically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine. Furthermore, the treatment was well tolerated. FUNDING Sage Products, US National Institutes of Health.

Catheter Duration and Risk of CLA-BSI in Neonates With PICCs

OBJECTIVE: To determine whether the risk of central line-associated bloodstream infections (CLA-BSIs) remained constant over the duration of peripherally inserted central venous catheters (PICCs) in high-risk neonates. PATIENT AND METHODS: We performed a retrospective cohort study of NICU patients who had a PICC inserted between January 1, 2006, and December 31, 2008. A Poisson regression model with linear spline terms to model time since PICC insertion was used to evaluate potential changes in the risk of CLA-BSI while adjusting for other variables. RESULTS: Six hundred eighty-three neonates were eligible for analysis. There were 21 CLA-BSIs within a follow-up period of 10 470 catheter-days. The incidence of PICC-associated CLA-BSI was 2.01 per 1 000 catheter-days (95% confidence interval [CI]: 1.24–3.06). The incidence rate of CLA-BSIs increased by 14% per day during the first 18 days after PICC insertion (incidence rate ratio [IRR]: 1.14 [95% CI: 1.04–1.25]). From days 19 through 35 after PICC insertion, the trend reversed (IRR: 0.8 [95% CI: 0.66–0.96]). From days 36 through 60 after PICC insertion, the incidence rate of CLA-BSI again increased by 33% per day (IRR: 1.33 [95% CI: 1.12–1.57]). There was no statistically significant association between the risk of CLA-BSI and gestational age groups, birth weight groups, or chronological age groups. CONCLUSIONS: Our data suggest that catheter duration is an important risk factor for PICC-associated CLA-BSI in the NICU. A significant daily increase in the risk of CLA-BSI after 35 days may warrant PICC replacement if intravascular access is necessary beyond that period.

Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: Extending risk analyses outside the intensive care unit

BACKGROUND Increasingly, peripherally inserted central venous catheters (PICCs) are placed for prolonged intravenous access. Few data exist regarding risk factors for central line-associated bloodstream infection (CLABSI) complicating PICCs in hospitalized children, especially children hospitalized outside the intensive care unit (ICU). METHODS We identified all children with a PICC inserted at The Johns Hopkins Hospital (Baltimore, MD) from 1 January 2003 through 31 December 2009 and used Poisson regression models to identify risk factors for PICC-associated CLABSIs. RESULTS A total of 2592 PICCs were placed in 1819 children. One hundred sixteen CLABSIs occurred over 44,972 catheter-days (incidence rate [IR], 2.58 cases per 1000 catheter-days; 95% confidence interval [CI], 2.07-3.00 cases per 1000 catheter-days). Independent predictors of CLABSI in the entire cohort included PICC dwell time of > 21 days (IR ratio [IRR], 1.53; 95% CI, 1.05-2.26), parenteral nutrition as indication for insertion (IRR, 2.24; 95% CI, 1.31-3.84), prior PICC-associated CLABSI (IRR, 2.48; 95% CI, 1.18-5.25), underlying metabolic condition (IRR, 2.07; 95% CI, 1.14-3.74), and pediatric ICU exposure during hospitalization (IRR, 1.80; 95% CI, 1.18-2.75). Risk factors for CLABSI in children without PICU exposure included younger age, underlying malignancy and metabolic conditions, PICCs inserted in the lower extremity, and a prior PICC-associated CLABSI. CONCLUSIONS Prolonged catheter dwell time, pediatric ICU exposure, and administration of parenteral nutrition as the indication for PICC insertion are important predictors of PICC-associated CLABSI in hospitalized children. A careful assessment of these risk factors may be important for future success in preventing CLABSIs in hospitalized children with PICCs.

Risk Factors for Peripherally Inserted Central Venous Catheter Complications in Children

IMPORTANCE Peripherally inserted central venous catheters (PICCs) are prone to infectious, thrombotic, and mechanical complications. These complications are associated with morbidity, so data are needed to inform quality improvement efforts. OBJECTIVES To characterize the epidemiology of and to identify risk factors for complications necessitating removal of PICCs in children. DESIGN Cohort study. SETTING Johns Hopkins Childrens Center, Baltimore, Maryland. PARTICIPANTS Hospitalized children who had a PICC inserted outside of the neonatal intensive care unit (ICU) from January 1, 2003, through December 31, 2009. MAIN OUTCOME MEASURES Complications necessitating PICC removal as recorded by the PICC Team. RESULTS During the study period, 2574 PICCs were placed in 1807 children. Complications necessitating catheter removal occurred in 534 PICCs (20.8%) during 46 021 catheter-days (11.6 complications per 1000 catheter-days). These included accidental dislodgement (4.6%), infection (4.3%), occlusion (3.7%), local infiltration (3.0%), leakage (1.5%), breakage (1.4%), phlebitis (1.2%), and thrombosis (0.5%). From 2003 to 2009, complications decreased by 15% per year (incidence rate ratio [IRR], 0.85; 95% CI, 0.81-0.89). In adjusted analysis, all noncentral PICC tip locations-midline (IRR 4.59, 95% CI, 3.69-5.69), midclavicular (2.15; 1.54-2.98), and other (3.26; 1.72-6.15)-compared with central tip location were associated with an increased risk of complications. Pediatric ICU exposure and age younger than 1 year were independently associated with complications necessitating PICC removal. CONCLUSIONS AND RELEVANCE Noncentral PICC tip locations, younger age, and pediatric ICU exposure were independent risk factors for complications necessitating PICC removal. Despite reductions in PICC complications, further efforts are needed to prevent PICC-associated complications in children.

Chlorhexidine use in the Neonatal Intensive Care Unit: Results from a National Survey

Infection prevention guidelines do not endorse chlorhexidine gluconate (CHG) use in neonates who are less than 2 months old. A survey of US neonatology program directors revealed that most neonatal intensive care units use CHG, often with some restrictions. Prospective studies are needed to further address concerns regarding the safety of CHG in patients in the neonatal intensive care unit.

Timing of preoperative antibiotic prophylaxis: a modifiable risk factor for deep surgical site infections after pediatric spinal fusion.

Background: Deep surgical site infections (SSI) after spinal fusion are healthcare-associated infections that result in increased morbidity, hospital stay, and health care costs. Risk factors for these infections among children are poorly characterized. Methods: We performed a case-control study nested within a cohort of all children, from birth to 18 years of age, who underwent spinal fusion at Johns Hopkins Hospital between July 1, 2000 and June 30, 2006. Results: Thirty-six deep SSI were identified. The incidence of deep SSI was 3.4%. Infection was diagnosed a median of 15 days after surgery (interquartile range, 9–28). Significant risk factors for deep SSI included inappropriate timing of preoperative antibiotic prophylaxis, previous spine surgery, presence of a complex underlying medical condition, age, >10 vertebrae fused, and an increased estimated blood loss per kilogram body weight. After controlling for previous spine surgery, number of vertebrae fused, and complex underlying medical condition, inappropriate timing of preoperative antibiotic prophylaxis administration was a significant independent risk factor for deep SSI (odds ratio: 3.5; 95% confidence interval: 1.7–7.3; P = 0.001). Discussion: Timing of preoperative antibiotic prophylaxis is an independent and modifiable risk factor for deep SSI after pediatric spinal fusion. Our findings suggest that all pediatric patients undergoing pediatric spinal fusion should have preoperative antibiotic prophylaxis given within 60 minutes before incision to reduce the risk of SSI and the morbidity and costs associated with hardware removal and repeat spinal fusion.

Implementation of a Central Line Maintenance Care Bundle in Hospitalized Pediatric Oncology Patients

OBJECTIVE: To investigate whether a multidisciplinary, best-practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population. METHODS: We performed a prospective, interrupted time series study of a best-practice bundle addressing all areas of central line care: reduction of entries, aseptic entries, and aseptic procedures when changing components. Based on a continuous quality improvement model, targeted interventions were instituted to improve compliance with each of the bundle elements. CLABSI rates and epidemiological data were collected for 10 months before and 24 months after implementation of the bundle and compared in a Poisson regression model. RESULTS: CLABSI rates decreased from 2.25 CLABSIs per 1000 central line days at baseline to 1.79 CLABSIs per 1000 central line days during the intervention period (incidence rate ratio [IRR]: 0.80, P = .58). Secondary analyses indicated CLABSI rates were reduced to 0.81 CLABSIs per 1000 central line days in the second 12 months of the intervention (IRR: 0.36, P = .091). Fifty-nine percent of infections resulted from Gram-positive pathogens, 37% of patients with a CLABSI required central line removal, and patients with Hickman catheters were more likely to have a CLABSI than patients with Infusaports (IRR: 4.62, P = .02). CONCLUSIONS: A best-practice central line maintenance care bundle can be implemented in hospitalized pediatric oncology patients, although long ramp-up times may be necessary to reap maximal benefits. Further research is needed to determine if this CLABSI rate reduction can be sustained and spread.

Financial Impact of Surgical Site Infections on Hospitals: The Hospital Management Perspective

IMPORTANCE Surgical site infections (SSIs) may increase health care costs, but few studies have conducted an analysis from the perspective of hospital administrators. OBJECTIVE To determine the change in hospital profit due to SSIs. DESIGN Retrospective study of data from January 1, 2007, to December 31, 2010. SETTING The study was performed at 4 of The Johns Hopkins Health System acute care hospitals in Maryland: Johns Hopkins Bayview (560 beds); Howard County General Hospital (238 beds); The Johns Hopkins Hospital (946 beds); and Suburban Hospital (229 beds). PARTICIPANTS Eligible patients for the study included those patients admitted to the 4 hospitals between January 1, 2007, and December 31, 2010, with complete data and the correct International Classification of Diseases, Ninth Revision code, as determined by the infection preventionist. Infection preventionists performed complete medical record review using National Healthcare Safety Network definitions to identify SSIs. Patients were stratified using the All Patient Refined Diagnosis Related Groups to estimate the change in hospital profit due to SSIs. EXPOSURE Surgical site infections. MAIN OUTCOMES AND MEASURES The outcomes of the study were the difference in daily total charges, length of stay (LOS), 30-day readmission rate, and profit for patients with an SSI when compared with patients without an SSI. The hypothesis, formulated prior to data collection, that patients with an SSI have higher daily total costs, a longer LOS, and higher 30-day readmission rates than patients without an SSI, was tested using a nonpaired Mann-Whitney U test, an analysis of covariance, and a Pearson χ2 test. Hospital charges were used as a proxy for hospital cost. RESULTS The daily total charges, mean LOS, and 30-day readmission rate for patients with an SSI compared with patients without an SSI were