Tag Archives: Infection Control

Are there systematic reviews of the evidence about the effect of chlorhexidine on rate of catheter associated urinary tract infections?

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Joanna Briggs Institute’s JBI+COnNECT, an evidence summary source, has published this evidence summary:  Urethral Catheter (Indwelling Short-Term):  Urinary Tract Infection Prevention

The Clinical Bottom Line section summarizes evidence on various care regimens, including daily cleaning.  Two relevant statements:
“Daily cleansing of the urethral meatus using soap and water or perineal cleanser has been shown to be effective to reduce CAUTI.3 (Level II)”
“The following interventions are not deemed effective for reducing CAUTI incidence: sterile technique for catheter insertion, use of antiseptic solutions or ointment during routine meatal care, 2-chambered urinary drainage bags, antiseptic filters incorporated into the drainage bag, bladder or catheter irrigation, frequent urinary drainage bag changes and placing an antiseptic solution into the urinary drainage bag.3 (Level I)”

References to other systematic reviews are available through this PubMed search: chlorhexidine AND urinary tract infection AND catheter AND (systematic review OR meta-analysis)

Does perineal cleaning with chlorhexidine prior to inserting a urinary catheter reduce the rate of catheter-acquired urinary tract infections (CAUTI)?

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Bottom line:  There is no evidence that cleaning the perineal area with chlorhexidine prior to catheter insertion reduces the rate of CAUTI.

Summary:  Identified documents using JBI+COnNECT (Joanna Briggs Institute)

Review of results led to CDC CAUTI guidelines, 2009.
Page 43 references two studies that found no difference between cleaning with chlorhexidine v. water prior to catheter insertion.  There are also studies referenced in that section that address intermittent care.

A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections
Page 702 – describes 1 RCT of 436 patients admitted to obstetrical unit who were randomized to periurethral cleaning with water v. chlorhexidine prior to insertion of catheter.  No significant difference in rates of CAUTI between the groups.

The RCT of 436 patients is also referenced in this best practice summary: Management of short-term indwelling urethral catheters to prevent urinary tract infections

Does frequency of providing stoma and inner canula care reduce rate of VAP in patients with tracheostomy?

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Bottom line:  There is not much evidence available on this question.  Most recommendations are based on expert opinion.

A search of PubMed and CINAHL for these concepts–tracheotomy, tracheostomy, ventilator-associated pneumonia, prevention–revealed one study specifically examining care of the tracheostomy–Eid RC, et al.  Successful prevention of tracheostomy associated pneumonia in step-down units.  Am J Infect Control. 2011 Aug;39(6):500-5.
Intervention included “drainage and discarding of condensate” in the tubing at least 3 times per day, but this doesn’t say specifically changing the tubing. No additional studies identified that evaluated care of the tracheostomy in preventing outcome of ventilator-associated pneumonia.

Tracheostomy: Stoma Care.  Joanna Briggs Institute, 2010.  States that evidence regarding tracheostomy is mostly based on expert opinion as there are not many published studies on tracheostomy procedures and care.

Tracheostomy:  Management – references guideline that relies on expert opinion in recommendation

Cites this small study that found no statistically significant difference in bacterial colonization between patients who had canula changed daily versus those who did not.

Burns SM, et al.  Are frequent inner cannula changes necessary?: A pilot study.  Heart Lung. 1998 Jan-Feb;27(1):58-62.
This small study that found no statistically significant difference in bacterial colonization between patients who had canula changed daily versus those who did not.  Did not look at ventilator-associated pneumonia rates.

Can a MRSA bundle prevent healthcare-associated MRSA infections in the ICU?

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Bottom line:  Use of a bundle decreased infection rates of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) at Veterans Affairs (VA) hospitals.

Summary: Jain R, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.  N Engl J Med. 2011 Apr 14;364(15):1419-30.

The study compared rates of healthcare-acquired MRSA infections at VA units before (October 2005 – March 2007) and after (October 2007 – June 2010) implementation of a care bundle that included universal nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, promotion of hand hygiene, and a change in the workplace culture that made infection control the responsibility of every staff member who had contact with patients. During the period there was a total of  8,318,675 patient days. Rates of MRSA infections in ICU units were reduced by 62% while the rates at units other than ICUs were reduced by 45% during the same period.

Huskins WC, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011 Apr 14;364(15):1407-18.

This study of 18 ICU units looked at infection rates of MRSA and vancomycin-resistant enterococcus (VRE) in adult ICUs. Units were randomized to receive an intervention (n=10)  of increased surveillance and expanded barriers or to remain the same as a control (n=8). Intervention group patients were assigned to contact precautions based on history of MRSA or VRE in the past 12 months or results of nasal and perianal swabs. Patients in control units had swabs, but contact precautions were instituted based on hospital procedures and were blinded to the swab results. As Figure 3 summarizes, there was no significant difference in change of infection rates between the two groups. Authors concluded that the intervention was unable to reduce the transmission of MRSA and VRE. The surveillance cultures identified a significant subgroup of colonized patients who would not have been recognized otherwise, but the healthcare providers who participated in the study failed to use clean gowns and gloves and perform hand hygiene as often as was required by the intervention.

Two studies of antibiotic care bundles for MRSA in ICUs can be found here.

Reviewed and updated 4/11/2014 ldt

For inpatients, is daily bathing with chlorhexidine gluconate (CHG) more effective than daily bathing with soap and water to reduce methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enteroccocus (VRE) hospital-acquired infections (HAIs)?

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Bottom line: Use of CHG results in significant reductions in risks of central-line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), and colonizations with VRE or MRSA but not reductions in infections.

Summary: Karki S, Cheng AC. “Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review.” J Hosp Infect. 2012;82(2):71-84.
This systematic review included sixteen published studies and four conference abstracts. Studies compared the use of CHG in washcloths with at least one of the following: soap and water bathing, routine advice, or no intervention.

Reviewed and updated 4/11/2014 ldt

 

What are defined best practices in the literature to perform a central line dressing change?

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Marschall J, et al.  Strategies to prevent central line-associated bloodstream infections in acute care hospitals.  Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S22-S30.

For nontunneled CVCs in adults

Transparent dressings:  change and disinfect site with chlorhexidine‐based antiseptic every 5‐7 days or more frequently for soiled, loose, or damp dressing

Gauze dressings:  Change every 2 days or more frequently for soiled, loose, or damp dressing

Evidence for this practice came from ≥ 1 properly randomized, controlled trial and evidence considered to be good to support a recommendation for use from the Society for Healthcare Epidemiology of America.

Detailed instructions for changing a dressing are found within the following review article.

Macklin D. Catheter management. Semin Oncol Nurs. 2010;26(2):113-120.

Reviewed and updated 4/11/2014 ldt

AHRQ-sponsored intervention reduces rates of ventilator-associated pneumonia (VAP) in intensive care units (ICUs)

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Matar, Dany S, et al. “Achieving and sustaining ventilator-associated pneumonia-free time among intensive care units (ICUs): evidence from the Keystone ICU Quality Improvement Collaborative.” Infection control and hospital epidemiology 34.7 (2013):740-743.
This retrospective analysis of the Michigan Keystone intensive care unit (ICU) collaborative showed that a zero rate of VAP could be attained and sustained for a considerable period of time in adult ICUs.

Berenholtz SM, et al. “Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infection control and hospital epidemiology 32.4 (2011):305-314.
Study of an intervention consisting of the Comprehensive Unit-Based Safety Program (CUSP) and a ventilator care bundle of five evidence-based practices from the Centers for Disease Control and Prevention. Reduced rates of VAP by up to 71% at 112 Michigan intensive care units (ICUs).

Reviewed and updated 4/24/2014 ldt