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Findings point to factors affecting BSI frequency
As the trend to send patients home from the hospital earlier and sicker continues, a second recent trend gives home infusion providers plenty to think about. With the slowly growing momentum to require the use of needleless devices, providers will be faced with addressing how such devices affect outcomes and bloodstream infections (BSIs) in particular.
To address that concern, the Atlanta-based Centers for Disease Control and Prevention (CDC) recently published the results of a study, "Bloodstream Infection Associated with Needleless Device Use and the Importance of Infection-Control Practices in the Home Health Care Setting."1 The results point to a dizzying array of factors that, when combined, could have a huge impact on the outcomes of home infusion therapies.
In the study, conducted through Coram Healthcare in Denver, investigators looked at three needleless devices — the Clave from ICU Medical, Irvine, CA; the Safsite from Braun Medical, Bethlehem, PA; and the Interlink from Baxter, Deerfield, IL — and evaluated the BSI risk factors and rates associated with each.
For each of the needleless devices, endcaps were connected to the external end of the patient’s IV catheter. Patients were taught to wipe the endcap with alcohol before flushing or administering IV medications, with the endcap being changed at intervals ranging from once per week to every two days.
Keep those dressings dry
Patients with tunneled central venous catheters (CVCs) were allowed to take showers at home once the insertion site was well-healed as deemed appropriate by their physicians. The patients were not required to use a sterile technique to change their dressings and were allowed to remove the dressings while showering to wash around the insertion site with soap and water.
Those with other types of CVCs typically were told to bathe instead of showering. Such patients also were instructed to use sterile technique for dressing changes, including wearing sterile gloves and possibly a surgical mask during dressing changes. Dressings were to be kept in place while bathing. All patients from both groups were instructed to keep the dressings clean and dry.
According to the study, patients with a tunneled CVC and an external port were 13% more likely to have a BSI than patients with a midline catheter. The figure jumps to 14.1% for patients with a tunneled CVC who were allowed to shower, compared to 2.6% for the patients with a tunneled CVC instructed not to shower. Patients with other types of catheters did not have an increased risk for BSI.
When comparing the three needleless device endcaps with the Interlink as the reference, the Safsite was associated with a 4.5% increased risk of BSI. The Clave also had an increased risk (2.2%), but the risk was statistically insignificant, according to investigators.
When comparing all three brands and breaking down the BSI risk according to how often the endcap was changed, the BSI rate was highest for the Safsite when the endcap was changed weekly. The lowest BSI rate was with the Interlink when endcaps were changed every two days. The BSI rate decreased rapidly for all three devices as the endcaps were changed more frequently.
The study notes, "Our results suggested that the risk for BSI in Coram HHC patients was related to changing the endcaps of the needleless device on the IV catheter. . . . Although an increased BSI risk was seen with the Safsite device in the case-control study, this increased risk was probably associated more with how frequently the endcaps [were] changed than with the Safsite device itself."
It comes as no surprise that the study also points out that training of the caregiver is crucial in terms of practicing good infection-control technique. What did come as a surprise was that the pathogens causing BSI in hospitalized patients proved quite different from the patients in this study.
There was a high proportion of hydrophilic gram-negative bacteria (49%) and a low proportion of gram-positive cocci (17%) among BSI isolates from the home care patients in the study. This is in sharp contrast to data from the CDC’s National Nosocomial Infections Surveillance System, which showed a lower proportion of hydrophilic gram-negative bacteria (6%) and a higher proportion of gram-positive cocci (60%) among hospitalized patients. Researchers theorize that exposure to tap water in the home setting, such as during showering or swimming, could be the reason.
The study also found that the source of infection varies by IV catheter type but not needleless device type. Hydrophilic gram-negative bacteria were more prevalent in patients with a peripherally inserted central catheters or CVC with an external port. However, staphylococci were more prevalent in patients with a midline catheter or CVC with implanted port. Only the tunneled CVC was associated with an increased BSI risk, though.
1. Do A, Ray B, Banjeree S, et al. Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. J Infect Dis 1999; 179:442-448.