Department of Acute Care Surgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
Surg Infect (Larchmt). 2011 Feb;12(1):27-32. doi: 10.1089/sur.2009.082. Epub 2010 Dec 20.
Central venous catheter (CVC)-related infections are a substantial problem in the intensive care unit (ICU). Our infection control team initiated the routine use of antiseptic-coated (chlorhexidine-silver sulfadiazine; Chx-SS) CVCs in our adult ICUs to reduce catheter-associated (CA) and catheter-related (CR) blood stream infection (BSI) as we implemented other educational and best practice standardization strategies. Prior randomized studies documented that the use of Chx-SS catheters reduces microbial colonization of the catheter compared with an uncoated standard (Std) CVC but does not reduce CR-BSI. We therefore implemented the routine use of uncoated Std CVCs in our surgical ICU (SICU) and examined the impact of this change.
The use of uncoated Std CVCs does not increase CR-BSI rate in an SICU.
Prospective evaluation of universal use of uncoated Std CVCs, implemented November 2007 in the SICU. The incidences of CA-BSI and CR-BSI were compared during November 2006-October 2007 (universal use of Chx-SS CVCs) and November 2007-October 2008 (universal use of Std CVCs) by t-test. The definitions of the U.S. Centers for Disease Control and Prevention were used for CA-BSI and CR-BSI. Patient data were collected via a dedicated Acute Physiology and Chronic Health Evaluation (APACHE) III coordinator for the SICU.
Annual use of CVCs increased significantly in the last six years, from 3,543 (2001) to 5,799 (2006) total days. The APACHE III scores on day 1 increased from a mean of 54.4 in 2004 to 55.6 in 2008 (p = 0.0010; 95% confidence interval [CI] 1.29-5.13). The mean age of the patients was unchanged over this period, ranging from 58.2 to 59.6 years. The Chx-SS catheters were implemented in the SICU in 2002. Data regarding the specific incidence of CR-BSI were collected beginning at the end of 2005, with mandatory catheter tip cultures when CVCs were removed. Little difference was identified in the incidence of BSI between the interval with universal Chx-SS use and that with Std CVC use. (Total BSI 0.7 vs. 0.8 per 1,000 catheter days; CA-BSI 0.5 vs. 0.8 per 1,000 catheter days; CR-BSI 0.2 vs. 0 per 1,000 catheter days.) No difference was seen in the causative pathogens of CA-BSI or CR-BSI.
Eliminating the universal use of Chx-SS-coated CVCs in an SICU with a low background incidence of CR-BSIs did not result in an increase in the rate of CR-BSIs. This study documents the greater importance of adherence to standardization of the processes of care related to CVC placement than of coated CVC use in the reduction of CR-BSI.
中心静脉导管（CVC）相关感染是重症监护病房（ICU）的一个重大问题。我们的感染控制小组在成人 ICU 中常规使用抗菌涂层（洗必泰-磺胺嘧啶银；Chx-SS）CVC，以减少导管相关性（CA）和导管相关（CR）血流感染（BSI），同时实施了其他教育和最佳实践标准化策略。先前的随机研究表明，与未涂层标准（Std）CVC 相比，Chx-SS 导管可减少导管的微生物定植，但不会降低 CR-BSI。因此，我们在外科 ICU（SICU）中常规使用未涂层的 Std CVC，并检查了这种变化的影响。
在 SICU 中使用未涂层的 Std CVC 不会增加 CR-BSI 发生率。
前瞻性评估 2007 年 11 月在 SICU 中普遍使用未涂层的 Std CVC。通过 t 检验比较 2006 年 11 月至 2007 年 10 月（普遍使用 Chx-SS CVC）和 2007 年 11 月至 2008 年 10 月（普遍使用 Std CVC）期间的 CA-BSI 和 CR-BSI 发生率。使用美国疾病控制与预防中心的定义来定义 CA-BSI 和 CR-BSI。通过专门的急性生理学和慢性健康评估（APACHE）III 协调员收集 SICU 患者的数据。
在过去六年中，CVC 的年使用率显著增加，从 2001 年的 3543 天增加到 2006 年的 5799 天。2004 年至 2008 年，第 1 天的 APACHE III 评分从 54.4 平均增加到 55.6（p=0.0010；95%置信区间[CI]为 1.29-5.13）。在此期间，患者的平均年龄保持不变，范围在 58.2 至 59.6 岁之间。Chx-SS 导管于 2002 年在 SICU 中实施。开始于 2005 年底收集有关特定 CR-BSI 发生率的数据，当移除 CVC 时，需要进行强制性导管尖端培养。在使用普遍的 Chx-SS 和 Std CVC 期间，BSI 的发生率差异不大。（总 BSI 为每 1000 个导管日 0.7 与 0.8；CA-BSI 为每 1000 个导管日 0.5 与 0.8；CR-BSI 为每 1000 个导管日 0.2 与 0）。未发现 CA-BSI 或 CR-BSI 的致病病原体有差异。
在 CR-BSI 背景发生率较低的 SICU 中消除普遍使用 Chx-SS 涂层 CVC 并未导致 CR-BSI 发生率增加。本研究证明，与涂层 CVC 使用相比，更重要的是要坚持与 CVC 放置相关的护理流程的标准化，以减少 CR-BSI。
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