Pamela A. Lipsett

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

Eliminating catheter-related bloodstream infections in the intensive care unit.

Objective:To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). Design:Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. Setting:The Johns Hopkins Hospital. Patients:All patients with a central venous catheter in the ICU. Intervention:To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. Measurement:The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. Main Results:Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

1,945,922 in additional costs per year in the study ICU. Conclusions:Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.

Pyogenic hepatic abscess. Changing trends over 42 years.

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

Double-Blind Placebo-Controlled Trial of Fluconazole to Prevent Candidal Infections in Critically Ill Surgical Patients

OBJECTIVE The authors document changes in the etiology, diagnosis, bacteriology, treatment, and outcome of patients with pyogenic hepatic abscesses over the past 4 decades. SUMMARY BACKGROUND DATA Pyogenic hepatic abscess is a highly lethal problem. Over the past 2 decades, new roentgenographic methods, such as ultrasound, computed tomographic scanning, direct cholangiography, guided aspiration, and percutaneous drainage, have altered both the diagnosis and treatment of these patients. A more aggressive approach to the management of hepatobiliary and pancreatic neoplasms also has resulted in an increased incidence of this problem METHODS The records of 233 patients with pyogenic liver abscesses managed over a 42-year period were reviewed. Patients treated from 1952 to 1972 (n = 80) were compared with those seen from 1973 to 1993 (n = 153). RESULTS From 1973 to 1993, the incidence increased from 13 to 20 per 100,000 hospital admissions (p < 0.01. Patients managed from 1973 to 1993 were more likely (p < 0.01) to have an underlying malignancy (52% vs. 28%) with most of these (81%) being a hepatobiliary or pancreatic cancer. The 1973 to 1993 patients were more likely (p < 0.05) to be infected with streptococcal (53% vs. 30%) or Pseudomonas (30% vs. 9%) species or to have mixed bacterial and fungal 26% vs. 1%) infections. The recent patients also were more likely (p < 0.05) to be managed by percutaneous abscess drainage (45% vs. 0%). Despite having more underlying problems, overall mortality decreased significantly (p < 0.01) from 65% (in 1952 to 1972 period) to 31% (in 1973 to 1993 period). The reduction was greatest for patients with multiple abscesses (88% vs. 44%; p < 0.05) with either a malignant or a benign biliary etiology (90% vs. 38%; p < 0.05). Mortality was increased (p < 0.02) in patients with mixed bacterial and fungal abscesses (50%). From 1973 to 1993, mortality was lower (p = 0.19) with open surgical as opposed to percutaneous abscess drainage (14% vs. 26%). CONCLUSIONS Significant changes have occurred in the etiology, diagnosis, bacteriology, treatment, and outcome patients with pyogenic hepatic abscesses over the past 4 decades. However, mortality remains high, and proper management continues to be a challenge. Appropriate systemic antibiotics and fungal agents as well as adequate surgical, percutaneous, or biliary drainage are required for the best results.

Choledochal cyst disease. A changing pattern of presentation.

ObjectiveTo evaluate the prophylactic use of enteral fluconazole to prevent invasive candidal infections in critically ill surgical patients. Summary Background DataInvasive fungal infections are increasingly common in the critically ill, especially in surgical patients. Although fungal prophylaxis has been proven effective in certain high-risk patients such as bone marrow transplant patients, few studies have focused on surgical patients and prevention of fungal infection. MethodsThe authors conducted a prospective, randomized, placebo-controlled trial in a single-center, tertiary care surgical intensive care unit (ICU). A total of 260 critically ill surgical patients with a length of ICU stay of at least 3 days were randomly assigned to receive either enteral fluconazole 400 mg or placebo per day during their stay in the surgical ICU at Johns Hopkins Hospital. ResultsThe primary end point was the time to occurrence of fungal infection during the surgical ICU stay, with planned secondary analysis of patients “on-therapy” and alternate definitions of fungal infections. In a time-to-event analysis, the risk of candidal infection in patients receiving fluconazole was significantly less than the risk in patients receiving placebo. After adjusting for potentially confounding effects of the Acute Physiology and Chronic Health Evaluation (APACHE) III score, days to first dose, and fungal colonization at enrollment, the risk of fungal infection was reduced by 55% in the fluconazole group. No difference in death rate was observed between patients receiving fluconazole and those receiving placebo. ConclusionsEnteral fluconazole safely and effectively decreased the incidence of fungal infections in high-risk, critically ill surgical patients.

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

ObjectiveThe authors compared the presentation, treatment, and long-term outcome of children and adults with choledochal cysts. Summary Background DataThe typical patient with choledochal cyst disease has been the female infant with the triad of jaundice, an abdominal mass, and pain. However, the recent experience of the authors suggested that the disease currently is recognized more commonly in adults. MethodsForty-two patients (11 children, 32 adults) with choledochal cyst disease were treated primarily at this institution between 1976 and 1993. Patient presentation, clinical evaluation, and operative treatment were obtained from existing records. Long-term follow-up was obtained by records, physician, or direct patient contact. ResultsOne child—but no adults—had the classic triad of jaundice, abdominal mass, and pain. Children were more likely to have two of the three signs or symptoms (82% vs. 25%; p = < 0.05). Adult patients most commonly had abdominal pain and were thought to have pancreatitis (23%) or acute biliary tract symptoms, prompting cholecystectomy (50%). The type of choledochal cyst seen in children and adults was similar; the fusiform extrahepatic (Type I) was most common (50%), and the combined intrahepatic and extrahepatic (Type IVA) was the next most prominent (33%). For both children and adults, treatment consisted of excision of the cyst and biliary reconstruction with a hepaticojejunostomy. There was no surgical mortality. Gallbladder or cholangiocarcinoma was identified in three adults (9.7%), two of which were manifest on presentation. Long-term follow-up revealed one patient with a biliary stricture and three patients with Type IVA cysts who had intrahepatic stones. ConclusionsChildren and adults differ in presentation of choledochal cysts, with adults commonly having acute biliary tract or pancreatic symptoms. Surgical treatment with cyst excision and biliary bypass is safe and effective in children and adults with excellent long-term results that minimize the development of malignancy.

Effect of a Second-Generation Venous Catheter Impregnated with Chlorhexidine and Silver Sulfadiazine on Central Catheter–Related Infections: A Randomized, Controlled Trial

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

Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection.

Context Bacterial colonization of central venous catheters is relatively common, and subsequent bacteremia is a serious iatrogenic complication of critical illness. Initial studies of antimicrobial-coated catheters have suggested that this approach might decrease catheter-associated infection. Contribution This randomized, double-blind, controlled study of a new antiseptic-coated catheter versus an uncoated catheter shows a substantial decrease in bacterial colonization in patients receiving the coated device. Caution The study was unable to show a substantial decrease in bloodstream infections, possibly because of the low infection rate as a result of meticulous aseptic techniques used during catheter insertion. The Editors Infections associated with central venous catheters are a substantial problem. Each year in the United States, at least 80 000 patients in intensive care units experience central venous catheterassociated bacteremia (1, 2). These infections are associated with an overall attributable mortality of approximately 3% (3), but estimates vary from 0% to greater than 30% depending on patient population, definitions, and pathogens (4). The attributable cost per infection ranges from

Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection

3240 to more than