John C. O'Horo

The Risk of Bloodstream Infection Associated with Peripherally Inserted Central Catheters Compared with Central Venous Catheters in Adults: A Systematic Review and Meta-Analysis

BACKGROUND Peripherally inserted central catheters (PICCs) are associated with central line-associated bloodstream infection (CLABSI). The magnitude of this risk relative to central venous catheters (CVCs) is unknown. OBJECTIVE To compare risk of CLABSI between PICCs and CVCs. METHODS MEDLINE, CinAHL, Scopus, EmBASE, and Cochrane CENTRAL were searched. Full-text studies comparing the risk of CLABSI between PICCs and CVCs were included. Studies involving adults 18 years of age or older who underwent insertion of a PICC or a CVC and reported CLABSI were included in our analysis. Studies were evaluated using the Downs and Black scale for risk of bias. Random effects meta-analyses were used to generate summary estimates of CLABSI risk in patients with PICCs versus CVCs. RESULTS Of 1,185 studies identified, 23 studies involving 57,250 patients met eligibility criteria. Twenty of 23 eligible studies reported the total number of CLABSI episodes in patients with PICCs and CVCs. Pooled meta-analyses of these studies revealed that PICCs were associated with a lower risk of CLABSI than were CVCs (relative risk [RR], 0.62; 95% confidence interval [CI], 0.40-0.94). Statistical heterogeneity prompted subgroup analysis, which demonstrated that CLABSI reduction was greatest in outpatients (RR [95% CI], 0.22 [0.18-0.27]) compared with hospitalized patients who received PICCs (RR [95% CI], 0.73 [0.54-0.98]). Thirteen of the included 23 studies reported CLABSI per catheter-day. Within these studies, PICC-related CLABSI occurred as frequently as CLABSI from CVCs (incidence rate ratio [95% CI], 0.91 [0.46-1.79]). LIMITATIONS Only 1 randomized trial met inclusion criteria. CLABSI definition and infection prevention strategies were variably reported. Few studies reported infections by catheter-days. CONCLUSIONS Although PICCs are associated with a lower risk of CLABSI than CVCs in outpatients, hospitalized patients may be just as likely to experience CLABSI with PICCs as with CVCs. Consideration of risks and benefits before PICC use in inpatient settings is warranted.

The Efficacy of Daily Bathing with Chlorhexidine for Reducing Healthcare-Associated Bloodstream Infections: A Meta-analysis

DESIGN Systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies to assess the efficacy of daily bathing with chlorhexidine (CHG) for prevention of healthcare-associated bloodstream infections (BSIs). SETTING Medical, surgical, trauma, and combined medical-surgical intensive care units (ICUs) and long-term acute care hospitals. PARTICIPANTS Inpatients. METHODS Data on patient population, diagnostic criteria for BSIs, form and concentration of topical CHG, incidence of BSIs, and study design were extracted. RESULTS One randomized controlled trial and 11 nonrandomized controlled trials reporting a total of 137,392 patient-days met the inclusion criteria; 291 patients in the CHG arm developed a BSI over 67,775 patient-days, compared with 557 patients in the control arm over 69,617 catheter-days. CHG bathing resulted in a reduced incidence of BSIs: the pooled odds ratio using a random-effects model was 0.44 (95% confidence interval, 0.33-0.59; [Formula: see text]). Statistical heterogeneity was moderate, with an I(2) of 58%. For the subgroup of studies that examined central line-associated BSIs, the odds ratio was 0.40 (95% confidence interval, 0.27-0.59). CONCLUSIONS Daily bathing with CHG reduced the incidence of BSIs, including central line-associated BSIs, among patients in the medical ICU. Further studies are recommended to determine the optimal frequency, method of application, and concentration of CHG as well as the comparative effectiveness of this strategy relative to other preventive measures available for reducing BSIs. Future studies should also examine the efficacy of daily CHG bathing in non-ICU populations at risk for BSI.

Molecular Techniques for Diagnosis of Clostridium difficile Infection: Systematic Review and Meta-analysis

OBJECTIVE To assess the usefulness of 2 rapid molecular diagnostic techniques, polymerase chain reaction (PCR) and loop-mediated isothermal amplification (LAMP), in Clostridium difficile infection (CDI). METHODS We conducted a systematic review and meta-analysis to evaluate the accuracy of PCR and LAMP in diagnosis of CDI, including studies that used toxigenic culture or cytotoxicity assay as reference standard. RESULTS A search of PubMed and CinAHL medical databases yielded 25 PCR studies, including 11,801 samples that met inclusion criteria and 6 heterogeneous studies that evaluated LAMP. With toxigenic culture as a standard, pooled sensitivity was 0.92 (95% confidence interval [CI], 0.91-0.94); specificity, 0.94 (95% CI, 0.94-0.95); and diagnostic odds ratio, 378 (95% CI, 260-547). With cytotoxicity as a standard, pooled sensitivity was 0.87 (95% CI, 0.84-0.90); specificity, 0.97 (95% CI, 0.97-0.98); and diagnostic odds ratio, 370 (95% CI, 226-606). CONCLUSION Polymerase chain reaction is a highly accurate test for identifying CDI. Heterogeneity in LAMP studies did not allow meta-analysis; however, further research into this promising method is warranted.

Is the Gram Stain Useful in the Microbiologic Diagnosis of VAP? A Meta-analysis

In a meta-analysis examining respiratory specimen Gram stain for diagnosis of ventilator-associated pneumonia, absence of bacteria on Gram stain had a high negative predictive value, but a positive Gram stain correlated poorly with organisms recovered in culture. Rapid and accurate diagnosis of ventilator-associated pneumonia (VAP) is a major challenge and no generally accepted gold standard exists for VAP diagnosis. We conducted a meta-analysis to examine the role of respiratory specimen Gram stain to diagnose VAP, and the correlation with final culture results. In 21 studies, pooled sensitivity of Gram stain for VAP was 0.79 (95% confidence interval [CI], .77-0.81; P < .0001) and specificity was 0.75 (95% CI, .73-.78; P < .0001). Negative predictive value of Gram stain for a VAP prevalence of 20%-30% was 91%, suggesting that VAP is unlikely with a negative Gram stain but the positive predictive value of Gram stain was only 40%. Pooled kappa was 0.42 for gram-positive organisms and 0.34 for gram-negative organisms, suggesting fair concordance between organisms on Gram stain and recovery by culture. Therefore, a positive Gram stain should not be used to narrow anti-infective therapy until culture results become available.

Bedside diagnosis of dysphagia: A systematic review

Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each databases earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

An appraisal of published usability evaluations of electronic health records via systematic review.

Objective: In this systematic review, we aimed to evaluate methodological and reporting trends present in the current literature by investigating published usability studies of electronic health records (EHRs). Methods: A literature search was conducted for articles published through January 2015 using MEDLINE (Ovid), EMBASE, Scopus, and Web of Science, supplemented by citation and reference list reviews. Studies were included if they tested the usability of hospital and clinic EHR systems in the inpatient, outpatient, emergency department, or operating room setting. Results: A total of 4848 references were identified for title and abstract screening. Full text screening was performed for 197 articles, with 120 meeting the criteria for study inclusion. Conclusion: A review of the literature demonstrates a paucity of quality published studies describing scientifically valid and reproducible usability evaluations at various stages of EHR system development. A lack of formal and standardized reporting of EHR usability evaluation results is a major contributor to this knowledge gap, and efforts to improve this deficiency will be one step of moving the field of usability engineering forward.

Arterial catheter-related bloodstream infection: incidence, pathogenesis, risk factors and prevention

BACKGROUND Arterial catheters are essential in critical care for haemodynamic and blood gas monitoring. The risk of infection remains ill defined. AIMS To delineate the incidence, pathogenesis and risk factors for arterial catheter-related bloodstream infection (BSI). METHODS Arterial catheters in two randomized trials in 1998-2000 were studied prospectively. One trial studied the effect of a 1% chlorhexidine-75% alcohol solution for cutaneous antisepsis for intravascular catheters, and the other trial studied the efficacy of a chlorhexidine-impregnated sponge dressing, both for prevention of catheter-related BSI. At catheter removal, skin of the insertion site, catheter segments, hub and infusate were cultured quantitatively in all cases. Catheter-related BSI was confirmed by concordance between isolates from the catheter and from blood cultures by restriction-fragment DNA subtyping. Risk factors for arterial catheter-related BSI were determined using univariate analysis. FINDINGS Of 834 arterial catheters studied (3273 catheter-days), 109 (13%) were colonized and 11 caused bacteraemia (1.3%, 3.4 per 1000 catheter-days). The majority of catheter-related BSIs were acquired extraluminally from skin of the insertion site (63%). The risk of arterial catheter-related BSI was comparable with that for short-term non-cuffed central venous catheters (2.7%, 5.9 per 1000 CVC-days). CONCLUSION In patients in intensive care with cryptogenic sepsis or bacteraemia, arterial catheter-related BSI must also be suspected and excluded. The most common route of infection is extraluminal; as such, novel technologies shown to prevent bloodstream infection with CVCs, such as chlorhexidine for cutaneous antisepsis and chlorhexidine-impregnated dressings, may also be of benefit with arterial catheters.

Carbapenem-resistant Enterobacteriaceae and endoscopy: An evolving threat

BACKGROUND Several clusters of Carbapenem-resistant Enterobacteriaceae (CRE) infections associated with contaminated endoscopes have recently been reported. Interim guidelines for mitigating endoscope-associated transmission have been proposed, but there has not been a systematic appraisal of CRE prevention practices. METHODS We conducted a systematic review of endoscope-associated CRE infection episodes, abstracting information on outbreak detection, mitigation, outcomes, and corrective steps taken to prevent recurrence. RESULTS Seven distinct outbreaks were identified in the published literature, and 5 of these were associated with duodenal endoscopy, with the remaining 2 associated with cystoscopy and ureteroscopy. Several investigators noted difficulties in cleaning protocols surrounding difficult to access components, such as the elevator on duodenoscopes. The published investigations did not report any failures of sterilization. It is unclear if routine reprocessing was ineffective, or difficult to execute properly. CONCLUSIONS Meticulous cleaning protocols and increased surveillance are necessary to prevent and detect future outbreaks of CRE and to determine whether more stringent measures, such as sterilization, are needed for duodenoscopes.

Potentially Modifiable Risk Factors for Long-Term Cognitive Impairment After Critical Illness: A Systematic Review

&NA; Long‐term cognitive impairment is common in survivors of critical illness. Little is known about the etiology of this serious complication. We sought to summarize current scientific knowledge about potentially modifiable risk factors during intensive care unit (ICU) treatment that may play a substantial role in the development of long‐term cognitive impairment. All searches were run on October 1, 2017. The search strategy included Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effect, Scopus, and Web of Science, and included MeSH headings and keywords related to intensive care, critical care, and cognitive disorders. Searches were restricted to adult subjects. Inclusion required follow‐up cognitive evaluation at least 2 months after ICU discharge. Studies assessing patients with cardiac arrest, traumatic brain injury, and cardiac surgery history were excluded. The search strategy resulted in 3180 studies. Of these, 28 studies (.88%) met our inclusion criteria and were analyzed. Delirium and duration of delirium were associated with long‐term cognitive impairment after ICU admission in 6 of 9 studies in which this factor was analyzed. Weaker and more inconsistent associations have been reported with hypoglycemia, hyperglycemia, fluctuations in serum glucose levels, and in‐hospital acute stress symptoms. Instead, most of the studies did not find significant associations between long‐term cognitive impairment and mechanical ventilation; use of sedatives, vasopressors, or analgesic medications; enteral feeding; hypoxia; extracorporeal membrane oxygenation; systolic blood pressure; pulse rate; or length of ICU stay. Prolonged delirium may be a risk factor for long‐term cognitive impairment after critical illness, though this association has not been entirely consistent across studies. Other potentially preventable factors have not been shown to have strong or consistent associations with long‐term cognitive dysfunction in survivors of critical illness.

Intensive care unit readmission prevention checklist: is it worth the effort?

RATIONALE, AIMS AND OBJECTIVES Checklists have been adopted by various institutions to improve patient outcomes. In particular, readmission prevention checklists may be of potential value to improve patient care and reduce medical costs. As a result, a prior quality improvement study was conducted to create an intensive care unit readmission prevention checklist. The previous pilot demonstrated zero readmissions when the readmission prevention checklist was utilized but yielded low compliance (30%). Thus, a subsequent quality initiative was undertaken to refine the readmission prevention checklist with the primary aim of improved compliance while maintaining a reduced readmission rate that was observed with the original quality improvement study. METHOD A single-centre, cross-sectional study for assessing baseline data and a prospective observational study to assess the effectiveness of a refined readmission prevention checklist tool in a 20-bed tertiary medical-surgical intensive care unit at an academic medical centre in Rochester, MN was conducted. Medical patients admitted through the emergency department, upon direct transfer from outside facility, and post-operative surgical patients at our institution were included. A refined readmission prevention checklist tool was administered during an 8-week pilot period for medical and post-operative surgical patients. RESULTS The refined readmission prevention checklist resulted in an even lower compliance (10.5%) from the initial phase likely resulting from utilization of a paper readmission prevention checklist in an electronic medical environment. Moreover, the refined readmission prevention checklist demonstrated a 22% unplanned readmission rate for patients in which the tool was utilized. CONCLUSIONS In conclusion, the findings of the current quality improvement study may serve to rethink the process of health care delivery that applies paper tools in an electronic medical environment.