Impact of a program to prevent central line-associated bloodstream infection in the zero tolerance era.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) is one of the most important health care-associated infections in the critical care setting. METHODS: A quasiexperimental study involving multiple interventions to reduce the incidence of CLABSI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). From March 2005 to March 2007 (phase 1 [P1]), some Centers for Disease Control and Prevention evidence-based practices were implemented. From April 2007 to April 2009 (P2), we intervened in these processes at the same time that performance monitoring was occurring at the bedside, and we implemented the Institute for Healthcare Improvement central line bundle for all ICU and SDU patients requiring central venous lines. RESULTS: The mean incidence density of CLABSI per 1000 catheter-days in the ICU was 6.4 in phase 1 and 3.2 in phase 2, P < .001. The mean incidence density of CLABSI per 1000 catheter-days in the SDUs was 4.1 in phase 1 and 1.6 in phase 2, P = .005. CONCLUSION: These results suggest that reducing CLABSI rates in an ICU setting is a complex process that involves multiple performance measures and interventions that can also be applied to SDU settings.

Evaluation of interventions to reduce catheter-associated bloodstream infection: continuous tailored education versus one basic lecture.

BACKGROUND: This study evaluated the impact of 2 models of educational intervention on rates of central venous catheter-associated bloodstream infections (CVC-BSIs). METHODS: This was a prospective observational study conducted between January 2005 and June 2007 in 2 medical intensive care units (designated ICU A and ICU B) in a large teaching hospital. The study was divided into in 3 periods: baseline (only rates were evaluated), preintervention (questionnaire to evaluate knowledge of health care workers [HCWs] and observation of CVC care in both ICUs), and intervention (in ICU A, tailored, continuous intervention; in ICU B, a single lecture). The preintervention and intervention periods for each ICU were compared. RESULTS: During the preintervention period, 940 CVC-days were evaluated in ICU A and 843 CVC-days were evaluated in ICU B. During the intervention period, 2175 CVC-days were evaluated in ICU A and 1694 CVC-days were evaluated in ICU B. Questions regarding CVC insertion, disinfection during catheter manipulation, and use of an alcohol-based product during dressing application were answered correctly by 70%-100% HCWs. Nevertheless, HCWs' adherence to these practices in the preintervention period was low for CVC handling and dressing, hand hygiene (6%-35%), and catheter hub disinfection (45%-68%). During the intervention period, HCWs' adherence to hand hygiene was 48%-98%, and adherence to hub disinfection was 82%-97%. CVC-BSI rates declined in both units. In ICU A, this decrease was progressive and sustained, from 12 CVC-BSIs/1000 CVC-days at baseline to 0 after 9 months. In ICU B, the rate initially dropped from 16.2 to 0 CVC-BSIs/1000 CVC-days, but then increased to 13.7 CVC-BSIs/1000 CVC-days. CONCLUSION: Personal customized, continuous intervention seems to develop a "culture of prevention" and is more effective than single intervention, leading to a sustained reduction of infection rates.

Outbreak of Candida parapsilosis in a neonatal intensive care unit: a health care workers source.

Nosocomial neonatal candidiasis is a major problem in infants, which require intensive therapy. The subjects of the present study were three preterm infants admitted to the neonatal intensive care unit of the General Hospital "Dr. Manuel Gea Gonzalez". The infants developed Candida parapsilosis infection on the mean age of 13.6 day of life. Prior to fungemia, infants had received assisted ventilation and hyperalimentation through central venous catheter. Sequence analysis of the internal transcribed spacer gene ruled out other Candida species and revealed that the eight isolates were C. parapsilosis. The isolates were examined based on their molecular relation by random amplified polymorphic DNA analysis. The profiles allowed the identification of two main genotypes of C. parapsilosis as the outbreak cause and as a result of the cross-infection with health care workers' hands. We conclude that C. parapsilosis commonly colonize through horizontal transmission due to the staff's noncompliance of hand hygiene procedures.

Prevention of systemic mycoses in patients who are not neutropenic: should we do it? Can we do it?

It has been well documented that serious fungal infections may cause death in 5% to 10% of patients in certain high risk groups, such as those undergoing lung, pancreas, or liver transplantation. Patients in intensive care units, such as those with underlying severe disease, multi-organ fungal infection, those with catheters, those on broad spectrum antibacterial agents, and those in renal failure are also at risk and may be candidates for antifungal prophylaxis. However, recommendations regarding the use of antifungal drugs for prophylaxis in non-neutropenic patients are unclear. Several clinical trials in transplant recipients have supported the use of fluconazole for prophylaxis, particularly in liver transplantation, though the data are too few to permit generalized conclusions for all organ transplant recipients. There is also a trial in which antifungal prophylaxis has been successful after gut perforation. However, there are also reports in which high doses of fluconazole have not reduced fungal infection. The appropriate circumstances for prophylaxis are still undergoing definition. It is the author's opinion that effective prophylaxis will become more problematic in the future. In a year or two, once the drug becomes generic, the price of fluconazole will fall dramatically. A sharp increase in use is likely to occur, and is likely to be followed by increasing fluconazole resistance in both Candida albicans and non-albicans colonization and infections. The situation is similar to the consequences of widespread fluconazole use in AIDS patients. The best methods to delay resistance include strict handwashing, careful control of antibacterials, restricting fluconazole use to those situations where it has been most clearly shown to be beneficial, and carefully monitoring patients in intensive care units.

Nosocomial fungaemia: a 2-year prospective study.

Eighty-six consecutive patients with fungaemia were studied during a period of 2 years, 81% had two or more positive blood cultures. Gastrointestinal tract (28%) and haematological diseases (17%) were the most common underlying conditions. The majority of cases had received vancomycin and/or imipenem (87%) and a central venous catheter (78%). Candida albicans (50%) and Candida parapsilosis (17%) were the most frequent isolates. Overall mortality was 41%, and for patients with Candida tropicalis was 71%. There was not significant difference in survival with gender, age and days of treatment with antifungal drugs. Haematological diseases, neutropenia and a higher number of positive blood cultures were associated with poor outcome.

A double-blind, randomized, placebo-controlled trial of itraconazole capsules as antifungal prophylaxis for neutropenic patients.

To evaluate the efficacy of itraconazole capsules in prophylaxis for fungal infections in neutropenic patients, we conducted a prospective, double-blind, placebo-controlled, randomized trial. Patients with hematologic malignancies or those who received autologous bone marrow transplants were assigned either a regimen of itraconazole (100 mg orally twice daily; n=104) or of placebo (n=106). Overall, fungal infections (superficial or systemic) occurred more frequently in the placebo group (15% vs. 6%; P=.03). There were no differences in the empirical use of amphotericin B or systemic fungal infections. Among patients with neutropenia that was profound (<100 neutrophils/mm3) and prolonged (for at least 7 days), those receiving itraconazole used less empirical amphotericin B (22% vs. 61%; P=.0001) and developed fewer systemic fungal infections (6% vs. 19%; P=.04). For patients with profound and prolonged neutropenia, itraconazole capsules at the dosage of 100 mg every 12 h reduce the frequency of systemic fungal infections and the use of empirical amphotericin B.