Naomi P. O'Grady

Guidelines for the Prevention of Intravascular Catheter–Related Infections

Naomi P. O’Grady, Mary Alexander, E. Patchen Dellinger, Julie L. Gerberding, Stephen O. Heard, Dennis G. Maki, Henry Masur, Rita D. McCormick, Leonard A. Mermel, Michele L. Pearson, Issam I. Raad, Adrienne Randolph, and Robert A. Weinstein National Institutes of Health, Bethesda, Maryland; Infusion Nurses Society, Cambridge, and University of Massachusetts Medical School, Worcester, and The Children’s Hospital, Boston, Massachusetts; University of Washington, Seattle; Office of the Director, Centers for Disease Control and Prevention (CDC), and Division of Healthcare Quality Promotion, National Center for Infectious Diseases, CDC, Atlanta, Georgia; University of Wisconsin Medical School and Hospital and Clinics, Madison; Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode Island; MD Anderson Cancer Center, Houston, Texas; and Cook County Hospital and Rush Medical College, Chicago, Illinois

Guidelines for the Management of Intravascular Catheter-Related Infections

These guidelines from the Infectious Diseases Society of America (IDSA), the American College of Critical Care Medicine (for the Society of Critical Care Medicine), and the Society for Healthcare Epidemiology of America contain recommendations for the management of adults and children with, and diagnosis of infections related to, peripheral and nontunneled central venous catheters (CVCs), pulmonary artery catheters, tunneled central catheters, and implantable devices. The guidelines, written for clinicians, contain IDSA evidence-based recommendations for assessment of the quality and strength of the data. Recommendations are presented according to the type of catheter, the infecting organism, and the associated complications. Intravascular catheter-related infections are a major cause of morbidity and mortality in the United States. Coagulase-negative staphylococci, Staphylococcus aureus, aerobic gram-negative bacilli, and Candida albicans most commonly cause catheter-related bloodstream infection. Management of catheter-related infection varies according to the type of catheter involved. After appropriate cultures of blood and catheter samples are done, empirical i.v. antimicrobial therapy should be initiated on the basis of clinical clues, the severity of the patients acute illness, underlying disease, and the potential pathogen(s) involved. In most cases of nontunneled CVC-related bacteremia and fungemia, the CVC should be removed. For management of bacteremia and fungemia from a tunneled catheter or implantable device, such as a port, the decision to remove the catheter or device should be based on the severity of the patients illness, documentation that the vascular-access device is infected, assessment of the specific pathogen involved, and presence of complications, such as endocarditis, septic thrombosis, tunnel infection, or metastatic seeding. When a catheter-related infection is documented and a specific pathogen is identified, systemic antimicrobial therapy should be narrowed and consideration given for antibiotic lock therapy, if the CVC or implantable device is not removed. These guidelines address the issues related to the management of catheter-related bacteremia and associated complications. Separate guidelines will address specific issues related to the prevention of catheter-related infections. Performance indicators for the management of catheter-related infection are included at the end of the document. Because the pathogenesis of catheter-related infections is complicated, the virulence of the pathogens is variable, and the host factors have not been well defined, there is a notable absence of compelling clinical data to make firm recommendations for an individual patient. Therefore, the recommendations in these guidelines are intended to support, and not replace, good clinical judgment. Also, a section on selected, unresolved clinical issues that require further study and research has been included. There is an urgent need for large, well-designed clinical studies to delineate management strategies more effectively, which will improve clinical outcomes and save precious health care resources.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patients individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panels recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Guidelines for the prevention of intravascular catheter-related infections.

BACKGROUND Although many catheter-related bloodstream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented. OBJECTIVE To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs. DATA SOURCES The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. STUDIES INCLUDED Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations. OUTCOME MEASURES Reduction in CRBSI, catheter colonization, or catheter-related infection. SYNTHESIS The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). CONCLUSION Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

New insights into the biology of the acute phase response.

Innate or natural immunity is a highly conserved defense mechanism against infection found in all multicellular organisms. The acute phase response is the set of immediate inflammatory responses initiated by pattern recognition molecules. These germ cell-encoded proteins recognize microbial pathogens based on shared molecular structures and induce host responses that localize the spread of infection and enhance systemic resistance to infection. Innate immunity also influences the initiation and type of adaptive immune response by regulating T cell costimulatory activity and antigen presentation by antigen presenting cells and by influencing mediator production, which affects lymphocyte function and trafficking. Acute phase protein concentrations rapidly increase after infection, and their production is controlled primarily by IL-6- and IL-1-type cytokines. The acute phase proteins provide enhanced protection against microorganisms and modify inflammatory responses by effects on cell trafficking and mediator release. For example, serum amyloid A has potent leukocyte activating functions including induction of chemotaxis, enhancement of leukocyte adhesion to endothelial cells, and increased phagocytosis. The constellation of inflammatory responses seen after endotoxin administration to humans represents an in vivo model of the acute phase response. Studies with inflammatory modifying agents, such as soluble dimeric TNF receptor and IL-10, show that these responses are not dependent on a single mediator but result from multiple overlapping inflammatory pathways. Understanding the factors that initiate and alter the magnitude and duration of the acute phase response represents an important step in the development of new therapies for infectious and inflammatory diseases.

Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America

Objective:To update the practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit, for the purpose of guiding clinical practice. Participants:A task force of 11 experts in the disciplines related to critical care medicine and infectious diseases was convened from the membership of the Society of Critical Care Medicine and the Infectious Diseases Society of America. Specialties represented included critical care medicine, surgery, internal medicine, infectious diseases, neurology, and laboratory medicine/microbiology. Evidence:The task force members provided personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus was obtained. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. Consensus Process:The task force met twice in person, several times by teleconference, and held multiple e-mail discussions during a 2-yr period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the strength of the recommendation. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. Conclusions:The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the intensive care unit should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made.

Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections

These guidelines have been developed for healthcare personnel who insert intravascular catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home healthcare settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, healthcare infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine

Bundled care for septic shock: An analysis of clinical trials

Context: Sepsis bundles have been developed to improve patient outcomes by combining component therapies. Valid bundles require effective components with additive benefits. Proponents encourage evaluation of bundles, both as a whole and based on the performance of each component. Objective: Assess the association between outcome and the utilization of component therapies in studies of sepsis bundles. Data Source: Database searches (January 1980 to July 2008) of PubMed, Embase, and the Cochrane Library, using the terms sepsis, bundles, guidelines, and early goal directed therapy. Data Extraction: Inclusion required comparison of septic adults who received bundled care vs. nonprotocolized care. Survival and use rates for individual interventions were abstracted. Main Results: Eight unblinded trials, one randomized and seven with historical controls, were identified. Sepsis bundles were associated with a consistent (I2 = 0%, p = .87) and significant increase in survival (odds ratio, 1.91; 95% confidence interval, 1.49–2.45; p < .0001). For all studies reporting such data, there were consistent (I2 = 0%, p ≥ .64) decreases in time to antibiotics, and increases in the appropriateness of antibiotics (p ≤ .0002 for both). In contrast, significant heterogeneity was seen across trials for all other treatments (antibiotic use within a specified time period; administration of fluids, vasopressors, inotropes, and packed red blood cells titrated to hemodynamic goals; corticosteroids and human recombinant activated protein C use) (all I2 ≥ 67%, p < .002). Except for antibiotics, sepsis bundle components are still being investigated for efficacy in randomized controlled trials. Conclusion: Bundle use was associated with consistent and significant improvement in survival and antibiotic use. Use of other bundle components changed heterogeneously across studies, making their impact on survival uncertain. However, this analysis should be interpreted cautiously as these studies were unblinded, and only one was randomized.

Strategies to Prevent Central Line-Associated Bloodstream Infections 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 central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections 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.

Practice Parameters for Evaluating New Fever in Critically Ill Adult Patients. Task Force of the American College of Critical Care Medicine of the Society of Critical Care Medicine in Collaboration with the Infectious Disease Society of America.

Abstract Objective: To develop practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice. Participants: A task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine, and the Infectious Disease Society of America. Evidence: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four categories, according to study design and scientific value. Consensus Process: The task force met several times in person and twice monthly by teleconference over a 1‐yr period of time to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts’ opinions. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. Conclusions: The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost‐conscious approach to obtaining cultures and imaging studies should be undertaken if it is indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether or not infection is present, so additional testing can be avoided and therapeutic options can be made. (Crit Care Med 1998; 26:392‐408) In some intensive care units (ICUs), the measurement of a newly elevated temperature triggers an automatic order set which includes many tests that are time consuming, costly, and disruptive (Table 1). Moreover, the patient may experience discomfort, be exposed to unneeded radiation, or experience considerable blood loss due to this testing, which is often repeated several times within 24 hrs, and daily thereafter. In an era when utilization of hospital and patient resources is under intensive scrutiny, it is appropriate to assess how such fevers should be evaluated in a prudent and cost‐effective manner. Table 1. Typical costs associated with fever evaluation The American College of Critical Care Medicine of the Society of Critical Care Medicine and the Infectious Disease Society of America established a Task Force to provide practice parameters for the evaluation of a new fever in patients in an ICU with the goal of promoting the rational consumption of resources and promoting an efficient evaluation. These practice parameters presume that any unexplained temperature elevation merits a clinical assessment by a healthcare professional that includes a review of the patients history and a focused physical examination before any laboratory tests or imaging procedures are ordered. These practice parameters specifically address how to evaluate a new fever in an adult patient already in the ICU who has previously been afebrile and in whom the source of fever is not initially obvious. If the initial evaluation of history and physical examination reveals a consolidated lung, a purulent wound, or a phlebitic leg, then diagnosis and therapy of that infectious process should commence: such management is addressed by other practice parameters aimed specifically at pneumonia, catheter‐related infections, etc. Specific questions addressed in these practice parameters relate to the search for the underlying cause of fever and include: a) What temperature should elicit an evaluation? b) When are blood cultures warranted? c) When should intravascular catheters be cultured or removed? d) When are cultures of respiratory secretions, urine, stool, or cerebral spinal fluid warranted? e) When are radiographic studies warranted? These practice parameters do not address children, since children have different issues that merit discussion in a separate document. In addition, these practice parameters do not address an approach to persistent fever after the initial evaluation, or to localized infection once the anatomic source of fever has been identified. These issues are addressed in other monographs or practice parameters. The current document also does not address the desirability or selection of empiric vs. specific therapy since the need for therapy is so dependent on clinical evaluation and the underlying disease. It did not appear to this task force that useful therapeutic guidelines could easily be provided which took into account the acuity of illness, the underlying disease process, concurrent drugs (i.e., immunosuppressive agents, and antimicrobials), ability to tolerate toxicities, and geographic antibiotic susceptibility differences. Each ICU must establish its own policies for evaluating fever that take into account the type of ICU involved (e.g., medical ICU, surgical ICU, burn ICU, etc.), the specific patient population (e.g., immunosuppressed vs. immunocompetent, elderly vs. younger adults), recent epidemics (e.g., out‐breaks of Clostridium difficile diarrhea or vancomycin‐resistant Enterococcus), or endemic pathogens (e.g., methicillin‐resistant Staphylococcus aureus). It is hoped that these practice parameters will assist intensivists and consultants as a starting point for developing an effective and cost conscious approach appropriate for their patient populations. The specific recommendations are rated by the strength of evidence, using the published criteria of the Society of Critical Care Medicine (Table 2). Table 2. Society of Critical Care Medicines rating system for strength of recommendation and quality of evidence supporting the references