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Consistency between guidelines and reported practice for reducing the risk of catheter-related infection in British paediatric intensive care units

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Abstract

Purpose

Optimal strategies for reducing catheter-related blood stream infection (CR-BSI) differ for adults and children. National guidelines do not make child-specific recommendations. We determined whether evidence explained the inconsistencies between guidelines and reported practice in paediatric intensive care units (PICUs).

Methods

We conducted a survey of eight interventions for reducing CR-BSI in all 25 British PICUs in 2009. Interventions were categorised as requiring child-specific evidence, generalisable to adults and children, or organisational recommendations.

Results

Twenty-four of the 25 PICUs responded. For child-specific interventions, practice diverged from guidelines for “Insert into subclavian/jugular veins” (18 PICUs frequently used femoral veins, supported by observational evidence for increased safety in children). Practice reflected guidelines for “Use standard but consider antimicrobial-impregnated central venous catheters (CVCs) for high-risk patients” (14 used standard only, 3 used standard and antimicrobial-impregnated despite no randomised controlled trial (RCT) evidence for antimicrobial-impregnated CVCs in children, 7 used heparin-bonded for some or all children); “Use 2% chlorhexidine for skin preparation” (20 PICUs); “Avoid routine CVC replacement” (20 PICUs). For generalisable interventions, practice was consistent with guidelines for “Administration set replacement” (21 PICUs) but deviated for “Maintenance of CVC asepsis” (11 PICUs used alcohol due to inconclusive evidence for chlorhexidine). Practice diverged from guidelines for organisational interventions: “Train healthcare workers in CVC care” (9 PICUs); “Monitor blood stream infection (BSI) rates” (8 PICUs).

Conclusions

Guidelines should explicitly address paediatric practice and report the quality of evidence and strength of recommendations. Organisations should ensure doctors are trained in CVC insertion and invest in BSI monitoring, especially in PICUs. The type of CVC and insertion site are important gaps in evidence for children.

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References

  1. Hockenhull J, Dwan K, Boland A, Smith G, Bagust A, Dündar Y, Gamble C, McLeod C, Walley T, Dickson R (2008) The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream infections: a systematic review and economic evaluation. Health Technol Assess Rep 12:1–154

    Google Scholar 

  2. Yogaraj J, Elward A, Fraser V (2002) Rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics 110:481

    Article  PubMed  Google Scholar 

  3. Appelgren P, Hellström I, Weitzberg E, Söderlund V, Bindslev L, Ransjö U (2001) Risk factors for nosocomial intensive care infection: a long-term prospective analysis. Acta Anaesthesiol Scand 45:710–719

    Article  PubMed  CAS  Google Scholar 

  4. Urrea M, Pons M, Serra M, Latorre C, Palomeque A (2003) Prospective incidence study of nosocomial infections in a pediatric intensive care unit. Pediatr Infect Dis J 22:490

    PubMed  Google Scholar 

  5. Elward A, Hollenbeak C, Warren D, Fraser V (2005) Attributable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics 115:868

    Article  PubMed  Google Scholar 

  6. Brown R, Stechenberg B, Sands M, Hosmer D, Ryczak M (1987) Infections in a pediatric intensive care unit. Arch Pediatr Adolesc Med 141:267

    CAS  Google Scholar 

  7. Nosocomial Infection National Surveillance Service (2007) Surveillance of hospital-acquired bacteraemia in English hospitals, 1997–2002. Public Health Laboratory Service, London

  8. Bhutta A, Gilliam C, Honeycutt M, Schexnayder S, Green J, Moss M, Anand K (2007) Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ 334:362–365

    Article  PubMed  Google Scholar 

  9. Costello J, Morrow D, Graham D, Potter-Bynoe G, Sandora T, Laussen P (2008) Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics 121:915

    Article  PubMed  Google Scholar 

  10. Jeffries H, Mason W, Brewer M, Oakes K, Muñoz E, Gornick W, Flowers L, Mullen J, Gilliam C, Fustar S (2009) Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units: a performance improvement collaborative. Infect Control Hosp Epidemiol 30:645–651

    Article  PubMed  Google Scholar 

  11. McKee C, Berkowitz I, Cosgrove S, Bradley K, Beers C, Perl T, Winner L, Pronovost P, Miller M (2008) Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality. Pediatr Crit Care Med 9:40

    Article  PubMed  Google Scholar 

  12. Miller MR, Griswold M, Harris JM II, Yenokyan G, Huskins WC, Moss M, Rice TB, Ridling D, Campbell D, Margolis P, Muething S, Brilli RJ (2010) Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 125:206–213

    Article  PubMed  Google Scholar 

  13. Department of Health (2005) Saving lives: a delivery programme to reduce healthcare associated infections including MRSA. Department of Health, London

    Google Scholar 

  14. Pratt R, Pellowe C, Wilson J, Loveday H, Harper P, Jones S, McDougall C, Wilcox M (2007) epic2: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 65:S1–S59

    Article  PubMed  Google Scholar 

  15. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C (2006) An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355:2725–2732

    Article  PubMed  CAS  Google Scholar 

  16. Harris J (1997) Pediatric nosocomial infections: children are not little adults. Infect Control Hosp Epidemiol 18:739–742

    Article  PubMed  CAS  Google Scholar 

  17. O’Grady N, Alexander M, Dellinger E, Gerberding J, Heard S, Maki D, Masur H, McCormick R, Mermel L, Pearson M (2002) Guidelines for the prevention of intravascular catheter-related infections. Am Acad Pediatr Policy 110:e51–e74

    Google Scholar 

  18. Straus SE, Richardson WS, Glasziou P, Haynes RB (2005) Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone, Edinburgh

  19. Hamilton HC, Foxcroft D (2007) Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Syst Rev. doi:10.1002/14651858.CD004084.pub2

  20. Ruesch S, Walder B, Tramèr M (2002) Complications of central venous catheters: internal jugular versus subclavian access: a systematic review. Crit Care Med 30:454–460

    Article  PubMed  Google Scholar 

  21. Merrer J, De Jonghe B, Golliot F, Lefrant J, Raffy B, Barre E, Rigaud J, Casciani D, Misset B, Bosquet C (2001) Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 286:700–707

    Article  PubMed  CAS  Google Scholar 

  22. Casado-Flores J, Barja J, Martino R, Serrano A, Valdivielso A (2001) Complications of central venous catheterization in critically ill children. Pediatr Crit Care Med 2:57

    Article  PubMed  Google Scholar 

  23. Rey C, Álvarez F, De La Rua V, Medina A, Concha A, Díaz J, Menendez S, Arcos M, Mayordomo-Colunga J (2009) Mechanical complications during central venous cannulations in pediatric patients. Intensive Care Med 35:1438–1443

    Article  PubMed  Google Scholar 

  24. Venkataraman S, Thompson A, Orr R (1997) Femoral vascular catheterization in critically ill infants and children. Clin Pediatr 36:311–319

    Article  CAS  Google Scholar 

  25. Gilbert R, Harden M (2008) Effectiveness of impregnated central venous catheters for catheter related blood stream infection: a systematic review. Curr Opin Infect Dis 21:235–245

    Article  PubMed  Google Scholar 

  26. Wang H, Huang T, Jing J, Jin J, Wang P, Yang M, Cui W, Zheng Y, Shen H (2010) Effectiveness of different central venous catheters for catheter-related infections: a network meta-analysis. J Hosp Infect 76:1–11

    Article  PubMed  CAS  Google Scholar 

  27. Chaiyakunapruk N, Veenstra D, Lipsky B, Saint S (2002) Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care. Ann Intern Med 136:792–801

    PubMed  CAS  Google Scholar 

  28. Carson S (2004) Chlorhexidine versus povidone-iodine for central venous catheter site care in children. J Pediatr Nurs 19:74–80

    Article  PubMed  Google Scholar 

  29. Garland J, Alex C, Mueller C, Otten D, Shivpuri C, Harris M, Naples M, Pellegrini J, Buck R, McAuliffe T (2001) A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 107:1431

    Article  PubMed  CAS  Google Scholar 

  30. Onder A, Chandar J, Billings A, Diaz R, Francoeur D, Abitbol C, Zilleruelo G (2009) Chlorhexidine-based antiseptic solutions effectively reduce catheter-related bacteremia. Pediatr Nephrol 24:1741–1747

    Article  PubMed  Google Scholar 

  31. Tamma P, Aucott S, Milstone A (2010) Chlorhexidine use in the neonatal intensive care unit: results from a national survey. Infect Control Hosp Epidemiol 31:846–849

    Article  PubMed  Google Scholar 

  32. Mermel LA (2007) Prevention of central venous catheter-related infections: what works other than impregnated or coated catheters? J Hosp Infect 65:30–33

    Article  PubMed  Google Scholar 

  33. Mermel L (2000) Prevention of intravascular catheter-related infections. Ann Intern Med 132:391–402

    PubMed  CAS  Google Scholar 

  34. Cook D, Randolph A, Kernerman P, Cupido C, King D, Soukup C, Brun-Buisson C (1997) Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 25:1417–1424

    Article  PubMed  CAS  Google Scholar 

  35. Gillies D, Wallen Margaret M, Morrison Anne L, Rankin K, Nagy Sue A, O’Riordan E (2005) Optimal timing for intravenous administration set replacement. Cochrane Database Syst Rev. doi:10.1002/14651858.CD003588.pub2

  36. Casey A, Worthington T, Lambert P, Quinn D, Faroqui M, Elliott T (2003) A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow® needleless connector. J Hosp Infect 54:288–293

    Article  PubMed  CAS  Google Scholar 

  37. East D, Jacoby K (2005) The effect of a nursing staff education program on compliance with central line care policy in the cardiac intensive care unit. Pediatr Nurs 31:182–194

    PubMed  Google Scholar 

  38. Centers for Disease Control (2000) Monitoring hospital-acquired infections to promote patient safety—United States, 1990–1999. MMWR Morb Mortal Wkly Rep 49:149–153

    Google Scholar 

  39. Gaynes R, Richards C, Edwards J, Emori T, Horan T, Alonso-Echanove J, Fridkin S, Lawton R, Peavy G, Tolson J (2001) Feeding back surveillance data to prevent hospital-acquired infections. Emerg Infect Dis 7:295

    Article  PubMed  CAS  Google Scholar 

  40. Zuschneid I, Schwab F, Geffers C, Rüden H, Gastmeier P (2003) Reducing central venous catheter-associated primary bloodstream infections in intensive care units is possible: data from the German nosocomial infection surveillance system. Infect Control Hosp Epidemiol 24:501–505

    Article  PubMed  Google Scholar 

  41. Weber D, Sickbert-Bennett E, Brown V, Rutala W (2007) Comparison of hospitalwide surveillance and targeted intensive care unit surveillance of healthcare-associated infections. Infect Control Hosp Epidemiol 28:1361–1366

    Article  PubMed  Google Scholar 

  42. Niedner MF (2010) The harder you look, the more you find: catheter-associated bloodstream infection surveillance variability. Am J Infect Control 38:585–595

    Article  PubMed  Google Scholar 

  43. Lachman P, Yuen S (2009) Using care bundles to prevent infection in neonatal and paediatric ICUs. Curr Opin Infect Dis 22:224

    Article  PubMed  Google Scholar 

  44. Lee O, Johnston L (2005) A systematic review for effective management of central venous catheters and catheter sites in acute care paediatric patients. Worldviews Evid Based Nurs 2:4–13

    Article  PubMed  Google Scholar 

  45. Guyatt G, Oxman A, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann H (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336:924–926

    Article  PubMed  Google Scholar 

  46. Davies EG, Sharland M, Nicoll A (2003) Health protection and a new strategy for combating infection in children. Arch Dis Child 88:1–3

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors wish to thank Roger Parslow and other members of the PICANet team for their support and the following intensivists for completing the survey form: James Fraser, Helen Fardy, Akash Deep, Duncan Macrae, Samir Latiff, Oliver Bagshaw, Iain MacIntosh, Martin Gray, Julie Freeman, Raghu Ramaiah, Mehrengise Cooper, Iain Johnstone, Ann Karimova, Samantha Jukes, Shane Tibby, Robert Yates, Andrew Magnay, John Roche, Andrew McIntyre, Steve Kerr, Josep Panisello, Jane Cassidy.

Funding

This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number 08/13/47). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

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Correspondence to Quen Mok.

Additional information

Members of the CATCH team are given in the Appendix.

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Appendix 1: CATCH trial team

Appendix 1: CATCH trial team

Centre PIs: Quen Mok, John Roche, Ann Karimova, P Ramnarayan, Shane Tibby, Duncan Macrae, Mehrengise Cooper, Iain Macintosh, Michelle White, Steve Kerr, Oliver Bagshaw, N Moore, Raghu Ramaiah, Barbara Fulton, Jane Cassidy; Trial Steering Group: Robert Tasker, Jim Gray, Andy Vail, Derek Roebuck, Hazel Greig-Midline, Oliver Bagshaw, Shane Tibby, P Ramnarayan; Trial Management Group: Ruth Gilbert, Tracy Ball, Rachel Breen, Quen Mok, Mike Millar, Paula Williamson, Carrol Gamble, Kerry Dwan, Dyfrig Hughes, Elizabeth Draper; Statistical analyses: Carrol Gamble, Kerry Dwan, Katie Harron, Angie Wade; Independent Data Safety Monitoring Committee: Paul Ewing, Mike Sharland, Neena Modi.

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Harron, K., Ramachandra, G., Mok, Q. et al. Consistency between guidelines and reported practice for reducing the risk of catheter-related infection in British paediatric intensive care units. Intensive Care Med 37, 1641–1647 (2011). https://doi.org/10.1007/s00134-011-2343-9

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