p - CCLIN Est

Prévention des infections liées
aux CVC en réanimation
Journée scientifique du CClin-Est
Dijon, 14 mars 2013
Dr Rémi BRUYERE
Chef de clinique - Assistant
Service de Réanimation Médicale - CHU de Dijon
SAD
13,1%
Figure 2
Répartition des patients selon l’l’exposition aux dispositifs invasifs
SAD + CVC
10,5%
SAD + INT
11,9%
SAD + CVC + INT
49,2%
CVC + INT
2,4%
Les cathéters,
c’est fréquent ?
Aucun
10,3%
INT
1,1%
Aucun
INT
CVC
veineu
10,3% = cathéter
1,1%
INT = intubation
SAD = sonde urinaire à demeure
INT = intubation
CVC = cathéter veineux central
Tableau 17
Exposition des patients aux dispositifs invasifs
Exposition des patients aux dispositifs
Dispositifinvasifs
invasif
Patients exposés
n
n’
Intubation
25 648
16 548
Cathéter veineux central
25 562
16 181
Sonde urinaire
24 931
21 690
n : nombre de patients dont on sait s’ils sont exposés ou non
n’ : nombre de patients exposés au risque
Patients exposés
n
n’
Intubation
25 648
16 548
Cathéter veineux central
25 562
16 181
Tableau 18
Sonde urinaire
24 931
21 690
Exposition aux dispositifs invasifs
n : nombre de patients dont on saitExposition
s’ils sont
en joursexposés ou non
n
moy.
(± ds)
Durée de séjour
25 685
11,6
(14,1)
n’ : nombre de patients exposés au risque
Durée d’intubation
16 548
10,9
(15,1)
Dispositif invasif
CVC
1,6%
SAD + CVC + INT
49,2%
SAD = sonde urinaire à demeure
Tableau 17
SAD
13,1%
CVC
1,6%
Durée de cathétérisme
Durée de sondage
16 180
21 690
12,2
11,3
(13,1)
(13,4)
%
64,5
63,3
87,0
%
64,5
63,3
87,0
min.
3
1
1
1
P25
4
3
5
4
méd.
7
6
8
7
P75
13
13
15
13
Données REA-Raisin 2010
max
3
3
2
2
 Réintubations
Epidémiologie
Parmi les 16 424 patients (sur les 16 548 patients intubés) pour lesquels l’information a été recueillie :
- 14 230 (86,7 %) n’ont jamais subi de réintubation,
- 2 192 (13,3 %) ont subi 1 ou plusieurs réintubations.
Le délai moyen
de 1ère réintubation est de 10,9 jours +/- 10 (médiane à 8 j).
ème
- ILC = 3
cause d’IN en réanimation
 Cathétérisme veineux central
- ILC
concerne
à 10
% des
veineux centraux
Un patient
peut être porteur5
de plus
d’un cathéter
lors de cathéters
son séjour.
On observe 19 773 CVC parmi les 16 181 patients avec un cathétérisme soit un ratio de 1,22 CVC / patient :
- patients avec 1 CVC :
84,3 %,
- patients avec 2 CVC :
11,4 %,
- patients avec 3 CVC et + :
4,3 %.
- Variable selon le germe concerné
Tableau
Tableau 20
Répartition et durée de maintien des CVC selon le site de pose
Site de pose
Sous-clavier
Jugulaire interne
Fémoral
Autre
Total
Tableau 21
Devenir du cathéter veineux central
Répartition des CVC
%
n
9 185
47,1
6 441
33,1
3 801
19,5
61
0,3
19 488
100,0
n
9 184
6 441
3 801
61
19 772
Durée de maintien du CVC
moy.
(± ds)
11,5
(9,3)
9,3
(7,8)
8,8
(6,9)
8,7
(7,7)
10,2
(8,5)
méd.
9
7
7
6
8
Données REA-Raisin 2010
PREVENTION
Facteurs de risque - Prévention
Liés au cathéter
Liés aux patients et aux soins
• Matériau
• Site de pose
• Technique de pose
• Expérience de l’opérateur
• Nombre de voies
• Durée de cathétérisme
• Asepsie lors de la pose et des
soins
• Pansements
• Echange sur guide
• Personnel
• Protocoles
• Surveillance
Asepsie lors de la pose du cathéter
En Urgence vs Asepsie Chirurgicale
Pose en urgence
(n=167)
Asepsie chirurgicale
(n=178)
p
67 (2-100)
70 (2-100)
0,3
41
34
0,24
123 (74)
135 (76)
0,5
Colonisation, %
7,2
2,3
0,04
Bactériémie, n
67 (2-100)
1
0,5
0,08
Durée de cathétérisme, j
(extr)
Multi-lumière (%)
Voie sous-clavière, n (%)
Densité d’incidence / 1000 j
de CVC
0,02
Raad et al, ICHE 1994;15:231-36
Solution antiseptique
Groupe Chlorhexidine
Colonisation
Groupe Povidone Iodine
ILC
BLC
Mimoz et al. CCM 1996
hexidine gluconate in preventing catheter-related
is likely to be clinically important.
bloodstream infection in patients who are catheterized
Two additional issues should be considered regardfor an average of longer than 10 days or the potential
ing the use of chlorhexidine gluconate for catheter-site
additional benefit of chlorhexidine gluconate when an
care. Hypersensitivity reactions have been reported with
antimicrobial catheter is used (40, 41).
use of central venous catheters impregnated by chlorNathorn
Chaiyakunapruk,
PharmD,and
PhD;with
Daviduse
L. Veenstra,
PharmD, PhD; Benjamin
A. Lipsky,
MD;
and Sanjayaccumulation
Saint, MD, MPHof studies
Considering
the
progressive
hexidine-silver
sulfadiazine
of chlorhexiover the past decade supporting the efficacy of chlordine gluconate for bathing (34 –38). No hypersensitivity
Purpose: Bloodstream infections related to use of catheters, parData Synthesis: Eight studies involving a total of 4143 cath
hexidine
gluconate in reducing catheter colonization,
reactions
were
reported
by
the
studies
in
our
meta-analticularly central-line catheters, are an important cause of patient
ters met the inclusion criteria. All studies were conducted in
Chlorhexidine Compared with Povidone-Iodine Solution for Vascular
Catheter–Site Care: A Meta-Analysis
morbidity, mortality, and increased health care costs. This study
evaluated the efficacy of skin disinfection with chlorhexidine gluFigure compared
2. Analysis
of catheter-related
bloodstream
infection in
conate
with
povidone-iodine solution
in preventing
povidone-iodine
solutionsinfection.
for care of vascular catheter sites.
catheter-related
bloodstream
Data Sources: Multiple computerized databases (1966 to 2001),
reference lists of identified articles, and queries of principal investigators and antiseptic manufacturers.
Study Selection: Randomized, controlled trials comparing chlorhexidine gluconate with povidone-iodine solutions for cathetersite care.
Data Extraction:
Using a standardized form, two reviewers
abstracted data on study design, patient population, intervention,
and incidence of catheter-related bloodstream infection from all
included studies.
I
ntravascular catheters are commonly used in caring for
hospitalized patients but can lead to serious infectious
complications (1). Catheter-related bloodstream infection is associated with increased morbidity, mortality,
length of hospitalization, and medical costs (2– 6). Use
hospital setting, and various catheter types were used. The sum
mary risk ratio for catheter-related bloodstream infection was 0.4
studies
comparing
chlorhexidine
gluconate
and
(95% CI,
0.28 to 0.88)
in patients
whose catheter
sites we
disinfected with chlorhexidine gluconate instead of povidon
iodine. Among patients with a central vascular catheter, chlorhex
dine gluconate reduced the risk for catheter-related bloodstrea
infection by 49% (risk ratio, 0.51 [CI, 0.27 to 0.97]).
Conclusions:
These results suggest that incidence of bloo
stream infections is significantly reduced in patients with centr
vascular lines who receive chlorhexidine gluconate versus pov
done-iodine for insertion-site skin disinfection. Use of chlorhex
dine gluconate is a simple and effective means of reducing va
cular catheter–related infections.
Ann Intern Med. 2002;136:792-801.
For author affiliations, see end of text.
www.annals.
We sought to aid clinical decision making by eva
uating the effectiveness of chlorhexidine gluconate ve
sus povidone-iodine as a skin disinfectant for cathete
site care. We performed
a meta-analysis of all availab
Ann Intern Med 2002;136:792-801
published and unpublished studies comparing chlo
The diamond indicates the summary risk ratio and 95% CI. Studies are ordered chronologically. The size of squares is proportional to the reciprocal of
Alcoholic povidone-iodine to prevent central venous catheter
colonization: A randomized unit-crossover study*
Jean-Jacques Parienti, MD, DTM&H; Damien du Cheyron, MD; Michel Ramakers, MD;
Brigitte Malbruny, MD; Roland Leclercq, MD; Xavier Le Coutour, MD; Pierre Charbonneau, MD; for
Members of the NACRE Study Group
considered for the main analys
parison
of the 57 pairs of CVCs
Objective: To compare effectiveness in preventing central ve- significantly lower in the alcoholic povidone-iodine solution
protocol
Aqueous
Alcoholic
tients risk,
in both protocols is pres
nous catheter colonization and infection of two protocols of than in the aqueous povidone-iodine solution protocol (relative
Povidone-Iodine
Povidone-Iodine
cutaneous antisepsis using povidone-iodine solution in combina- 0.38; 95% confidence interval, 0.22– 0.65, p < .001), and Table
so was3.the
Characteristics
(n ! 117)
(n ! 106)
tion with ethanol or water.
incidence of catheter-related infection (relative risk, 0.34; 95%
conThirty-one
pairs and one pair
Design: Randomized trial.
fidence
interval,
0.13–
0.91,
p
<
.04).
Catheter-related
bacteremia
respectively,
to
negative and posi
No. of days catheter in place, mean (SD)
9.0 (4.4)
8.7 (4.8)
Setting: Medical intensive Internal
care department
in
a
university
hospital.
were
similar
in
both
protocols.
After
adjusting
for
other
risk
factors,
jugular vein
9.2 (3.3)
7.6 (3.6)
colonization. Twenty-one and fo
Patients: Consecutive patients
requiring
Subclavian
veincentral venous catheter in time to central venous
8.7 (4.6)catheter colonization
9.3 was
(5.1)significantly
werelonger
only positive in the aqueo
two similar 11-bed units fromFemoral
Januaryvein
1, 2001, to January 1, 2002.
in the alcoholic solution
ratio,
0.3; 95% confidence
9.5 (4.7) (adjusted hazards8.3
(5.2)
and alcoholic PVP-I protocols,
Site
of central venous
catheter
Interventions: Alcoholic
povidone-iodine
solution
protocol was interval, 0.2– 0.6, p < .001). Based on a subgroup of 114 patients (57
The number of conflicti
vein the study began. in each protocol),
24 analysis
(20.5) of 57 pairs of
28 central
(26.4) venoustively.
randomly assigned to one Internal
of two jugular
units when
catheters
was
statistically
significant (chi-s
Subclavian
vein
58
(49.6)
59
(55.7)
Every 3 months the alcoholic protocol was switched from one unit matched for age, duration, and site of insertion found similar results
Femoral vein
35 (29.9)
19 (17.9)
p"
to the other. Depending on the unit and the time the patient was regarding the superiority of alcoholic povidone-iodine 11.5,
solution
in .002), and the use of a
Number of lumina
PVP-I
was
associated with a redu
admitted, catheters were inserted
and cared for with 10% aque- preventing central
1
10 venous
(8.5) catheter colonization
7 (6.6)and infection.
for
CVC
colonization
in alcoho
ous povidone-iodine solution
Conclusions:37The(31.6)
use of alcoholic povidone-iodine
2 or 5% povidone-iodine solution 70%
34 (32.1) for skin disinfecparedinfecwith aqueous PVP-I (od
ethanol-based combination.3
tion reduced the
42incidence
(35.9) of catheter colonization
42 (39.6) and related
23 (21.7) disinfection
Measurements and Main4Results: Rates of catheter colonization, tion compared28with(24)
aqueous 10% povidone-iodine
0.2; 95%inCI, 0.1– 0.6).
Use of
catheter
for administration
of antibiotics
catheter-related bacteremia,
and
catheter-related
infection
were an adult intensive care unit. (Crit Care Med 2004; 32:708–713) Fifty-five pairs and no pair y
Yes 223 catheters were included in an
(59.8)
55 central
(51.9) venous catheter;
alcohol-based
antiseptic;
compared in the two protocols;
KEY WORDS: 70
negative and positive CVC-relate
47 (40.2)
51 (48.1)
prevention
intent-to-treat analysis. TheNo
incidence of catheter colonization was nosocomial infection;
tion, respectively. Ten and two pa
Location of insertion and care
Unit A
57 (48.7)
63 (59.4)
positive in the aqueous PVP-I a
Unit B
60 (51.3)
43 (40.6)
holic PVP-I protocols, respectivel
PVP-I
in a
osocomial infection remains a causes of central venous catheter (CVC)- Viatris, Merignac, France) with 5%the
number
of conflicting pairs
No catheter
characteristic
between
protocolscutaneous
(p # .05). Results
expressed inaqueous
numbersolution (Beta70% are
ethanol-based
frequent complication
in critrelated differed
infection
(3). Efficient
tistically
significant
(chi-square
(percent).
ically ill patients,
representing antisepsis before CVC insertion and follow- dine alcoolique, Viatris) for the prevention of
"
.05),
and
the
use
of
alcoholic P
a major source of morbidity, ing hubline manipulations is therefore es- catheter colonization and catheter-related infection. Alcoholic PVP-I, a recentlyassociated
developed with a reduced risk f
Table
223 (4).
catheters
inserted
during the study
mortality, and medical costs
(1,2.2).Outcome
Cutane- of the
sential
Aqueous
2% chlorhexidine
so-period
disinfectant, was approved for clinical
use infection
in
related
compared with
ous microorganisms are predominant lution has significantly reduced nosocomial
this
setting.
The
study
was
approved
by
the
PVP-I (odds ratio, 0.2; 95% CI, 0
Aqueous
catheter-related Alcoholic
infections (5) compared
local ethics
committee
andp was conducted in
Povidone-Iodine
Povidone-Iodine
Relative
Risk
CVCs were removed more fr
with 10% aqueous polyvidone iodine (PVP- two similar 11-bed adult medical
Parienti
intensiveet al. CCM 2004
(n ! 106)
(n ! 117)
(95% CI)
Valuea
because they were not needed wh
Table 1. Characteristics of the 223 catheters inserted during the study period
N
Characteristics
(n ! 117)
(n ! 106)
Thirty-one pairs and one pair yielded,
respectively, to negative and positive CVC
colonization. Twenty-one and four pairs
were only positive in the aqueous PVP-I
and alcoholic PVP-I protocols, respectively. The number of conflicting pairs
was statistically significant (chi-square !
11.5, p " .002), and the use of alcoholic
PVP-I was associated with a reduced risk
for CVC colonization in alcoholic compared with aqueous PVP-I (odds ratio,
0.2; 95% CI, 0.1– 0.6).
Fifty-five pairs and no pair yielded to
negative and positive CVC-related infection, respectively. Ten and two pairs were
positive in the aqueous PVP-I and alcoholic PVP-I protocols, respectively. Again,
the number of conflicting pairs was stasignificantly lower in the alcoholic povidone-iodine solution protocol
tistically significant (chi-square ! 4.1, p
in the
aqueous
povidone-iodine
solution protocol (relative risk,
"than
.05), and
the use
of alcoholic
PVP-I was
associated
with
a reduced risk
for CVC0.38; 95%
confidence
interval,
0.22– 0.65, p < .001), and so was the
related
infection
compared with aqueous
incidence
of catheter-related
infection (relative risk, 0.34; 95% conPVP-I (odds ratio, 0.2; 95% CI, 0.0 – 0.9).
fidence
interval,
p < .04). Catheter-related bacteremia
CVCs were
removed0.13–
more0.91,
frequently
because
they wereinnot
needed
when alcowere similar
both
protocols.
After adjusting for other risk factors,
holic
was used
(chi-square
! 5.0,colonization was significantly longer
timePVP-I
to central
venous
catheter
p " .05).
Alcoholic povidone-iodine to prevent central venous catheter
colonization: A randomized unit-crossover study*
No. of days catheter in place, mean (SD)
Internal jugular vein
Subclavian vein
Femoral vein
Site of central venous catheter
Internal jugular vein
Subclavian vein
Femoral vein
Number of lumina
1
2
3
4
Use of catheter for administration of antibiotics
Yes
No
Location of insertion and care
Unit A
Unit B
9.0 (4.4)
9.2 (3.3)
8.7 (4.6)
9.5 (4.7)
8.7 (4.8)
7.6 (3.6)
9.3 (5.1)
8.3 (5.2)
24 (20.5)
58 (49.6)
35 (29.9)
28 (26.4)
59 (55.7)
19 (17.9)
10 (8.5)
7 (6.6)
Jean-Jacques Parienti, MD, DTM&H;
du
Cheyron, MD; Michel Ramakers, MD;
37 (31.6) Damien 34
(32.1)
42 (35.9)
42 (39.6)
Brigitte Malbruny, MD; Roland Leclercq,
MD; 23Xavier
28 (24)
(21.7) Le Coutour, MD; Pierre Charbonneau, MD; for
Members of the NACRE Study Group
70 (59.8)
55 (51.9)
47 (40.2)
51 (48.1)
57 (48.7)
60 (51.3)
63 (59.4)
43 (40.6)
No catheter
characteristic
differed between
protocols (p # .05).
Results are expressed
in number
Objective:
To compare
effectiveness
in preventing
central
ve(percent).
nous catheter colonization and infection of two protocols of
cutaneous
using
povidone-iodine
solution in combinaTable
2. Outcome antisepsis
of the 223 catheters
inserted
during the study period
tion with ethanol or water.
Alcoholic
Aqueous
Design: RandomizedPovidone-Iodine
trial.
Povidone-Iodine
Relative Risk
p
(n !care
106) department
(n ! 117)in a university
(95% CI) hospital.
Valuea
Setting: Medical intensive
Patients:
Consecutive patients
central venous
catheter
in
Catheter-tip
colonization
14 (13.2) requiring
41 (35.0)
0.38 (0.22–0.65)
".001
Gram
5 (4.7)
(18.8) to January 1, 2002. .002
two positive
similar 11-bed units from
January 1,222001,
in the alcoholic solution (adjusted hazards ratio, 0.3; 95% confidence
Staphylococcus epidermidis
5 (4.7)
15 (12.8)
.04
Interventions:
interval, 0.2– 0.6, p < .001). Based on a subgroup of 114 patients (57
Staphylococcus
aureus Alcoholic0 povidone-iodine
3 (2.6) solution protocol was
DISCUSSION
Enterococcus
0
3 (2.6)
randomly
assigned
to
one
of
two
units
when
the
study
began.
in each protocol), analysis of 57 pairs of central venous catheters
Corynebacterium
0
1 (0.9)
Gram
negative
9 (7.7)
(16) switched from one unit
.11
Every
3 months the alcoholic
protocol 19
was
matched
foralcoholic
age, duration,
and ofsite of insertion found similar results
The use of
PVP-I instead
Escherichia coli
0
7 (6.0)
.02
aqueous
PVP-I
for
insertion
site
disinfectoKlebsiella
the other.
Depending on4 (3.4)
the unit and
the time the patient was regarding the superiority of alcoholic povidone-iodine solution in
pneumoniae
5 (4.3)
tion and catheter care procedures markProteus mirabilis
(3.4)
(2.6)
admitted,
catheters were 4inserted
and3 cared
for with 10% aque- edly
preventing
central
colonization and infection.
reduced the
risk of venous
catheter catheter
coloniPseudomonas aeruginosa
1 (0.9)
3 (2.6)
ous
povidone-iodine
solution
or 5% povidone-iodine
solution 70% zationConclusions:
use of in
alcoholic
povidone-iodine for skin disinfecEnterobacter
cloacae
0
1 (0.9)
and related The
infections
this
Catheter-related infection
5 (4.7)
16 (13.7)
0.34 (0.13–0.91)
.04
study.
The benefitthe
wasincidence
most apparent
as
ethanol-based
combination.
tion
reduced
of
catheter
colonization and related infecBacteremia
1 (0.9)
4 (3.4)
regards Gram-positive bacteria. The use
S. Measurements
epidermidis
0 Results: Rates
2 (1.7)of catheter colonization,
and Main
tion
compared
with
aqueous
10%
povidone-iodine
disinfection in
of alcoholic PVP-I also appeared to be
S. aureus
0
1 (0.9)
catheter-related
bacteremia,
and
catheter-related
infection
were
an
adult
intensive
care
unit.
(Crit
Care
Med
2004;
32:708–713)
independently associated with longer colK. pneumoniae
1 (0.9)
1 (0.9)
Clinical
infectionin the two protocols;
4 (3.8) 223 catheters
12 (10.3) were included in .09
catheter
survival. To our
: alcohol-based
antiseptic; central venous catheter;
compared
an onization-free
KEY WORDS
knowledge,
only infection;
one
previous
study (10)
Figure
1.
Kaplan-Meier
estimates
of time to catheter-tip colonization according to alcoholic povidonenosocomial
prevention
intent-to-treat
analysis.
The
incidence
of
catheter
colonization
was
CI, confidence interval.
reported a significant
CVC
iodinereduction
or aqueousofpovidone-iodine
protocols. Time to catheter-tip colonization was significantly
colonization associated
with
use ofpovidone-iodine protocol (p ! .005 by the log-rank test). The time to
longer in
thethe
alcoholic
iodine-based disinfectant
alcoholcolonization in
remained
statistically longer in the alcoholic povidone-iodine protocol (adjusted hazards
iodine)
water-based
0.3;vs.
95%
confidence interval, 0.2– 0.6; p ! .001) in the Cox model after adjusting for site of
onization-free catheter survival was sig- burning sensation in one conscious pa- based (tincture of ratio,
Viatris,
Merignac,
France)
with 5% PVP-I
a
infection remains
a causes
of central
venous
insertion
vs. subclavian
and femoral
vs. subclavian),
age, andin
immunodepression
status.
(PVP-I)catheter
solutions (CVC)(9% vs.(jugular
14%
respecnificantly higher osocomial
during the alcoholic
tient, but ablation
of the catheter
because
70%
aqueous solution (Betafrequentlog-rank
complication
crit- problems
related never
infection
(3). tively,
Efficient
cutaneous
p " .001),
but this study
wasethanol-based
obPVP-I protocol (chi-square
test, of in
tolerance
occurred
effect of the
disinfecdine
alcoolique, Viatris) for the prevention of
7.8; p ! .005). ically ill patients, representing
during the study.
In the aqueous
antisepsis
beforePVP-I
CVC servational
insertion and
andthefollowin the
In the Cox multivariable analysis, al- protocol, one death was a consequence of tant’s choice disappeared
It
is
noteworthy
that
alcoholic PVP-I
tained release ofiniodine and reduces skin
catheter
colonization
and catheter-related
a major source of morbidity, ing hubline manipulations is therefore escoholic PVP-I significantly and indepen- bloodstream CVC-related bacteremia multivariate analysis.
reduced thefection.
risk of catheter
colonization
irritationdeveloped
(17).
Alcoholic
PVP-I,
a
recently
mortality,
and
costscol(1, 2).(methicillin-resistant
Cutane- sentialStaphylococcus
(4). Aqueous 2%The
chlorhexidine
so-of catheterpathogens,
overall incidence
coldently
prolonged
the medical
time to catheter
by Gram-positive
which
is an for Although
not in
statistically significant,
disinfectant,
was
approved
clinical use
our increasing
study (29.0cause
per 1000
onization
(adjusted hazards ratio,
aureus endocarditis).
ous microorganisms
are 0.3;
predominant
lution has significantlyonization
reducedinnosocomial
of CVC-related blood- duration of catheter insertion was shorter
this setting.
The study
was approved by the
very similar
that prevalence
95% CI, 0.2– 0.6; p " .001) compared
Matched Case-Control Subgroup catheter-days) wasstream
infectionto(12):
rates of and number of subclavian sites higher in
catheter-related infections (5) compared
For
example,
a
rate
local
ethics
committee
and
conducted
in protocol than in the
with assignment to aqueous PVP-I.
Analysis. Matching was possible for 114 previously reported.
28%
during 1986 –1989 and 36% during was
the alcoholic
PVP-I
with 10%
aqueousin-polyvidone
iodine
(PVPof 31 per 1000
catheter-days
with
PVP-I
Adverse Events and Mortality Rate. CVCs in the alcoholic
PVP-I protocol
two been
similar
11-bed
adult medical
1992–1997 have
reported
for Staphaqueous intensive
PVP-I protocol. Moreover, paa
Fisher’s exact test. Only p values " .20 are reported. Results are expressed in number (percent).
N
T
tio
cat
lat
wit
iod
adu
p " .0
provid
adequ
trolled
Third,
and ab
formed
both p
manip
and th
opmen
Howev
cathet
extralu
Parienti et al. CCM 2004
Mimoz O. et al. Arch Intern Med 2007;167:2066-2072
Mimoz O. et al. Arch Intern Med 2007;167:2066-2072
Site de pose
Sous-Clavière >
Jugulaire
Richet et al. J Clin Microbiol 1990;28:2520-2525
Medical
99 (68)
108 (75)
93 (69)
101 (74)
78 (67)
81 (77)
Complications of Femoral and
Subclavian Venous Catheterization
in Critically Ill Patients
41 (31)
35 (26)
38 (33)were
26
(23)
complication
in bivariate
analysis
COMMENT
101 (75)
105 (77) site and
84 (72)
insertion
at the femoral
center 82In(78)
this prospective, randomized, con2.0 (1.2)
2.0 (1.2)
1.8 (1.2)
2.0 (1.2)
and 2 in the subclavian group (1.5%; (1 center had a lower risk and 1 center cealed multicenter study in critically ill
Time between intensive care unit admission
1 (0-3)
1 (0-3)
1 (0-3)
1 (0-3)
1 (0-3)
1 (0-3)
P = .07
by log-rank
test). The inci- had a higher risk). In a multivariate lo- patients, we found that catheterizaand insertion, median
(interquartile
range), d
unlessinfectious
otherwise specified.
SAPS II indicates
Acute Physiologic
Score II ;(HosmerODIN, Organ Dysfunction
and/or
*P..20 for femoral vs subclavian
gisticSimplified
regression
model
tion
of the femoral vein was associdence catheterization
densities groups,
of major
comInfection.
2
†P = .03.
Lemeshow
x
ated
with
a significantly higher risk of
=
noncalculable;
likeliplications
were
4.5
per
1000
femoral
‡P = .13.
Merrer
et al. JAMA 2001
A
Randomized
Controlled
Trial
2
catheter-days and 1.2 per 1000 subcla- hood ratio test x 1 =23.8), the only risk overall complications compared with
factorContext
for thrombotic
complications was catheterization of the subclavian vein.
vian catheter-days.
Significant
Jacques
Merrer, MD factors
Whether venous catheterization at the femoral site is associated with an
Table 2. Characteristics Associated With Central Venous Catheter Insertion*
at the
femoral
sitecompared
(OR, 14.42;
catheterization
increased the
associated with Bernard
occurrence
of anMDinfec- insertion
De Jonghe,
increased
risk of
complications
with that atFemoral
the subclavian
site is debated.
Patients With
To compare
mechanical, infectious,
and thrombotic
of fem- infection and
Patients
With
Catheter
Ultrasonographic
All Patients
CI,
3.33-62.57;
P,.001).
risk of complications
catheter-related
tious complication
inGolliot,
bivariate
analy- 95% Objective
Franck
MS
Culture
(n = 270)
Examination (n = 223)
(n = 289)
oral and
subclavian
venous catheterization.
Overall
Reduction
in Complicathrombosis, whereas the rate of mesis included 3 risk
factors:
insertion
at
Jean-Yves
Lefrant,
MD
Design
and Setting
Concealed,Femoral
randomized controlled
clinical trial conducted beFemoral
Subclaviantions.
Femoral
Subclavian
Subclavian
Brigitte
Raffy,
MD
The
estimated
absolute
risk
rechanical
complications
did not differ befemoral site, high
Organ
Dysfunction
tween
at 8 intensiveGroup
care units (ICUs)
in France.
Group
Group
GroupDecember 1997
Groupand July 2000
Group
Eric
Barre,
MD
Characteristics
= 145)
(n
= 144) duction
(n = 134)
(n = 136)
(n = adult
116) patients
(ntween
= 107)
associated
with
subclavian
groups.
and/or Infection score at(nadmission,
and
Patients
Two hundred
eighty-nine
receiving
athe
first 2
central
venous To our knowlLumens, No. of patients
catheter.
Jean-Philippe
Rigaud,
MD
catheterization
rather
than
femoral
edge,
this
is
the
first
randomized study
insertion
at
2
centers;
and
2
protective
1
26
28
24
28
22
25
Interventions
Patients
were
randomly
assigned
to
undergo
central
venous
cathDominique
Casciani,
MD
catheterization
was
(95%
providing direct comparison of 3 types
factors: use of the catheter
for sys2
69
66
65
60 33%site
57CI,or23%eterization
at the femoral
(n = 145)
subclavian45site (n = 144).
Benoı̂t Misset,
MD
43%)Main
for
complications
and
6%
(95%
of complications associated with subtemic administration
of 50
antibiotics
and
3
50
45 all
48
37
37
Outcome Measures Rate and severity of mechanical, infectious, and thrombotic
Christophe
Bosquet,
MD
Catheter inserted by insertion
a senior physician,
No.
(%)
77
(53)
84
(58)
68
(51)†
83
(61)†
59
(51)‡
64
(60)‡
complications, compared
by catheterization
site in 289, 270,
and 223and
patients,
respectively.
for major
complicaclavian
femoral
catheterization.
at 2 centers. In a Cox model CI, 0.2%-12%)
2 (86)
Use of povidone-iodine antisepsis, No. (%) Hervé Outin,
125
122 (85)
115
(86)
115
(85)
101
(87)
89
(83)
MD
Femoral catheterization
was associated
incidence
rate of catheter–related
overall
Consequently,
3 patients
(95%with a higher
Central
venous
com(likelihood ratio test x 2 = 22.1), inser- tions.Results
Use of catheter for administration of, No. (%)Christian Brun-Buisson, MD
infectious complications (19.8% vs 4.5%; P,.001; incidence density of 20 vs 3.7 per 1000
tion at the femoral site (HR,
wouldand
need
be treated
plications
ill patients are usuAntibiotics
89 (61) 4.83; 95%
92 (64) CI, 2-4)
80 (62)
87
(64)toinfectious
65complications
(56) us- (clinical
69
(64)sepsis within
catheter-days)
of major
orcritically
without bloodGérard Nitenberg,
MD
stream
4.4%
vs
1.5%;femoral
P=.07;
incidence
of 4.5
vs 1.2 per 1000
catheterBlood products CI, 1.96-11.93; P,.001)
30increased
(21)
26 (18) ing subclavian
28 (21)infection,
24 (18)
23 (20)
18
(17)
the
rather
than
cath-density
ally
classified
as mechanical,
infectious,
days),
as well as of overall
thrombotic
complications
(21.5%
vs 1.9%; P,.001) and comfor the French
Catheter Study
Group
Parenteral nutrition
88
(61)
91
(63)
83
(62)
89
(65)
71
(61)
70
(65)
risk of infection,
whereas
eterization
to prevent
1 (6%
complication
thrombotic.
In our study, the 4 maplete thrombosis
of the vessel
vs 0%; P=.01); ratesand
of overall
and major mechanical
in Intensive
Careuse of the
Prophylactic anticoagulation, No. (%)
123 (85)
123 (85)
116 (87)
120
(88) between101
97 (91)
complications
were
similar
the(87)
2 groups
18.8 %; P=.74 and
1.4% vs
catheter for systemic antibiotic
therapy
of catheterization,
and
16 patients
(95%(17.3%
jorvsmechanical
complications
(2.8%) obDuration of catheter placement, mean (SD), d
9.3 (6.2)§
11.0 (6.3)§
9.4 (6.2)\
11.1 (6.3)\ Risk factors
9.6 (6.3)¶
11.3
(6.4)¶
2.8%;
P=.44, respectively).
for mechanical
complications
were duration of in(HR, 0.41; 95% CI, 0.18-0.93;
P = .03)
CI,- 8-411)
to prevent
1 major
compli- 2.8served
with
the subclavian
approach
ENTRAL VENOUS
CATHETER
sertion
1.03-1.08
per additional
minute;
Time between catheter removal and
NA
NA
NA (odds ratio [OR],
NA1.05; 95% confidence
2.6 (1.5) interval [CI],
(1.7)
ization is often
necessarycation.
to P,.001); insertion in 2 of the centers (OR, 4.52; 95% were
CI, 1.81-11.23;
P=.001); and inultrasonographic decreased
study, mean (SD),
d risk of infectious
the
compneumothoraces
necessitating chest
sertion during the night (OR, 2.06; 95% CI, 1.04-4.08; P=.03). The only factor associated
critically
patients
otherwise
noted.ill
NA
indicateshosnot applicable.
*P..20 for femoral vs subclavian catheterization groups, unlesstreat
plications. Microorganisms
recovered
†P = .09.
pitalized
in intensive care with infectious complications was femoral catheterization (hazard ratio [HR], 4.83; 95%
‡P = .18.
(ICUs).are
However,
this proce- CI, 1.96-11.93; P,.001); antibiotic administration via the catheter decreased risk of infecfrom catheter units
cultures
summa§P = .01.
complications (HR, 0.41; 95% CI, 0.18-0.93; P=.03). Femoral catheterization was
dure can lead to serious and some\P = .009.
Tabletious
3. Catheter-Related
Infectious Complications
rized in TABLE 4.
¶P = .02.
times life-threatening complications, the only risk factor for thrombotic complications (OR, 14.42; 95% CI, 3.33-62.57; P,.001).
Femoral
Subclavian
Thrombotic Complications.
the
whether mechanical,Of
infectious,
or Conclusion Femoral venous catheterization is associated with a greater risk of inGroup,
No.
Group, No.
fectious and thrombotic complications than subclavian catheterization in ICU patients.
choice of insertion
223
patients
who The
underwent
ul- site
704 JAMA, August 8,
2001—Vol
286, (77.2%)
No. 6thrombotic.
(Reprinted)
©2001
American Medical
Association. All rights reserved. (n = 134)
*
Code
Classification
(n = 136)
P Value†
JAMA.
2001;286:700-707
www.jama.com
can influence the incidence and type of
trasonographic examination
for
detecNA Sterile
100
127
NA
such complications.
3,4
subclavian cath-3
Reported(,1000
rates ofcolony-forming
catheter- from 10% to 50% with 7
tion of a catheter-related
thrombosis,
116 he- 1 of cases.
Major femoral
or retroperitoneal
Contamination
NA
thrombosis
range
from 6.6%
to eterization.8,9 These differences may be
matoma
is theand
most107
frequent
major me- related units/mL
and
no clinical
sepsis)
were in the femoral
group
were
5-7
and related to use of various diagnostic ap25% with
catheterization
chanical complication
of femoral ve-by
Downloaded
from
jama.ama-assn.org
onfemoral
April 6,
2012 colony-forming
2 guest
Colonization
($1000
units/mL
19
3
in the subclavian
group.
Among
the
66
nous catheterization, occurring in up
and
no
clinical
sepsis)
Author
Affiliations
and
Study
Group
Members
are
(e-mail:
jmerrer@chi-poissy-st-germain.fr).
patients in whom
ultrasonography
was
pneumo- listed at the end of this article.
to 1.3%
of cases,1,2 whereas
for the Critically Ill Patient Section Editor:
Clinical sepsis
without bloodstream Caring
infection
4
1
Author and Reprints: Jacques
Deborah J. Cook, MD, Consulting Editor, JAMA.
is the most
frequent
major com- 3 Corresponding
.07 ,.001
not performed, thorax
41 (65%)
died
before
Merrer, MD, Service de Réanimation Médicale,
Advisory Board: David Bihari, MD; Christian BrunClinical
sepsis
with
bloodstream
infection
2
1
plication of subclavian venous cath- 4 Hôpital
de
Poissy/St
Germain-en-Laye,
10
Rue
Buisson,
MD;
Timothy
Evans,
MD;
John
Heffner,
MD;
catheter removaleterization,
or ultrasonographic
ex-to 2.3% d u C h a m p - G a i l l a r d , 7 8 3 0 3 P o i s s y , F r a n c e Norman Paradis, MD.
occurring in 1.5%
5
Unable to discriminate between codes 2 and 3
2
1
amination, 10 were discharged from the
Codes 2, 3, 4, and 5 were collectively
considered
infectious
complications.
700 JAMA, August 8, 2001—Vol 286, No. 6*(Reprinted)
©2001
Americancatheter-related
Medical Association.
All rights
reserved. Codes 3 and 4 were
hospital before examination was perconsidered major catheter-related infectious complications. NA indicates not applicable.
Surgical
46 (34)
36 (25)
major catheter-related infectious
comMechanical ventilation,
No. (%)
112group
(77)
109 (76)
plications
in the femoral
(4.4%)
ODIN score, mean (SD)
2.0 (1.3)
2.0 (1.2)
19
20
C
Site de pose
« En raison du risque accru d’ILC en
territoire cave inférieur, il est
recommandé d’insérer les cathéters
en territoire cave supérieur. »
5ème conférence de consensus – Prévention des infections
nosocomiales en réanimation – SFAR - SRLF
O’Grady NP et al. Guidelines for the prevention of intravascular
catheter-related infections. Clin Infect Dis 2011
Durée de
cathétérisme
Richet et al. J Clin Microbiol 1990;28:2520-2525
Mode de pose
« A l’aveugle » ?
Echographie ?
Research
Results
OpenaAccess
longitudinal axis provided
clear image of both walls of the
vessel
(theinternal
actual vein puncture
using either the longitudinal or
Baselineultrasound-guided
characteristics of the study population
are presented
eal-time
catheterisation
of
the
jugular
the transverse axis of the 2D image was left to the discretion
1. There were no significant differences between the
vein:intwo
aTable
prospective
comparison
with
the
landmark
technique in
of the operator). Also, using this approach, a single-wall puncgroups of patients in gender ratio, age, BMI, or side of
critical
care patients
ture can be made by observing the point at which the needle
catheterisation
or in the presence of risk factors for difficult
1
2
3
first indents
the anterior4,wall of the IJV. A short stabbing
venous
cannulation
such as Labropoulos
prior catheterisation,
limited
sites, Alexandros
Dimitrios
Karakitsos
, Nicolaos
, Eric De
Groot
P Patrianakos
5, Johnprevious
1, George
6, Dimosthenis
7, at this point will tend to puncture the
motionA of
the needle
for access
attempts,
difficulties
during
catheterisaGregorios
Kouraklis
Poularas
Samonis
Tsoutsos
anterior
wall
without
opposing it to the posterior wall, thereby
tion,
previous
mechanical
complication,
known
vascular
abnorManousos M Konstadoulakis8 and Andreas Karabinis1
avoiding a double-wall puncture (Figure 2). Single-wall puncmality, untreated coagulopathy, skeletal deformity, and
tures were achieved in all cases using ultrasound guidance.
cannulation during cardiac arrest (Table 1).
1Department
of Intensive Care, General State Hospital of Athens, 154 Mesogeion Avenue, 11527 Athens, Greece
of Vascular Surgery, University of Medicine and Dentistry of New Jersey, The University Hospital-150 Bergen Street Newark, NJ 07103 USA
3Academic Medical Center, Department of Vascular Medicine, University of Amsterdam Tafelbergweg 51 .1105 BD Amsterdam, The Netherlands
4Department of Cardiology, University Hospital of Heraklion, PO Box 1352 Stavrakia, Heraklion, Crete, Greece
Table 1
52nd Department of Propedeutic Surgery, University of Athens School of Medicine, Laiko General Hospital, 17 Agiou Thoma street-11527 Athens,
Greece
Characteristics
of the
total study
population
6Department
of Internal Medicine
and Infectious
Diseases,
University of Crete, P. O. Box 2203, 71003 Heraklion, Greece
7'J. Ioannovic' Burn Center, General State Hospital of Athens, 154 Mesogeion Avenue, 11527 Athens, Greece
81st Department
Characteristics
Ultrasound
group
(n = Hospital,114
450)
Landmark
of Propedeutic Surgery, University of Athens School of Medicine,
Hipokrateion
University
Vasilis Sofias Avenue
11527 group (n = 450)
Athens, Greece
2Division
Age (years)a
58.3 ± 10.3
59 ± 9.5
Gender (male/female ratio)a
0.56 ± 0.4
0.6 ± 0.4
Side of catheterisation (left/right)
222/228
218/232
Limited sites for access attempts
51 (11.3%)
55 (12.2%)
44 (9.7%)
40 (8.8%)
18 (4%)
20 (4.4%)
Corresponding author: Dimitrios Karakitsos, echolabicu@gmail.com
Received: 23 May 2006 Revisions requested: 15 Jun 2006 Revisions received: 8 Sep 2006 Accepted: 10 Nov 2006 Published: 17 Nov 2006
Critical Care 2006, 10:R162 (doi:10.1186/cc5101)
mass
index (kg/m2)a
24.1 ± 5.3
23.7 ± 5.9
This article Body
is online
at: http://ccforum.com/content/10/6/R162
© 2006 Karakitsos et al.; licensee BioMed Central Ltd.
Prior
catheterisation
85 (18.8%)
76 (16.8%)
This is an open
access
article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
See relatedPrevious
commentary
by Bodenham,
http://ccforum.com/content/10/6/175
difficulties
during
catheterisation
Previous mechanical complication
Abstract
Known vascular abnormality
Introduction Central venous cannulation is crucial in the
Untreated coagulopathy
management of the critical care patient. This study was
designed Skeletal
to evaluate
whether real-time ultrasound-guided
deformity
cannulation of the internal jugular vein is superior to the standard
Cannulation during cardiac arrest
landmark method.
Values
are presented
as mean
± standard
Methods In
this randomised
study,
450 critical
care deviation.
patients
who underwent real-time ultrasound-guided cannulation of the
internal jugular vein were prospectively compared with 450
critical care
patients
Page
4 of 8in whom the landmark technique was used.
Randomisation
was performed by means of a computer(page number not for citation purposes)
a
4 (0.8%)
3 (0.6%)
coagulopathy, skeletal deformity, and cannulation during cardiac
25 (5.5%)
24 (5.3%)
arrest between the two groups of patients. Furthermore, the
physicians 15
who
performed the procedures had comparable
(3.3%)
13 (2.8%)
experience in the placement of central venous catheters (p =
31 (6.8%)
35 (7.7%)
non-significant).
Cannulation of the internal jugular vein was
achieved in all patients by using ultrasound and in 425 of the
patients (94.4%) by using the landmark technique (p < 0.001).
Average access time (skin to vein) and number of attempts were
significantly reduced in the ultrasound group of patients
compared with the landmark group (p < 0.001). In the landmark Crit Care
group, puncture of the carotid artery occurred in 10.6% of
2006:10;R162
Research
Open Access
medial to theultrasound-guided
common carotid artery in 53catheterisation
(12.6%) cases and of the internal jugular
eal-time
directly medial to the artery in 17 (3.7%) cases.
Discussion
vein: a prospective comparison with the landmark
technique in
The use of CVCs may be associated with adverse effects that
critical
care
Results using
thepatients
landmark technique are in sharp contrast to
are both hazardous to patients and expensive to treat [18].
1, Nicolaos Labropoulos2, Eric De Groot3, Alexandros P Patrianakos4,
Dimitrios
Karakitsos
those obtained
by the
ultrasound method and are presented in
Mechanical complications are reported to occur in 5% to 19%
5, John Poularas1, George Samonis6, Dimosthenis A Tsoutsos7,
Gregorios
Kouraklis
Table 2. Average access time and number of attempts were
of patients, infectious complications in 5% to 26%, and throm8
1
Manousos
M Konstadoulakis
and
Andreas compared
Karabinis with the
both significantly
reduced using
ultrasound
botic complications in 2% to 26% [19,20]. These complicalandmark technique (p < 0.001) (Table 2). The success rate
tions increase in association with several characteristics,
1Department
of Intensive Care,
General
State
Hospital
154 Mesogeion
Avenue, 11527 Athens,
Greece patient anatomy (for example, morbid obesity,
was significantly
lower
and
the
rateofofAthens,
mechanical
complicaincluding
2Division
of Vascular Surgery, University of Medicine and Dentistry of New Jersey, The University Hospital-150 Bergen Street Newark, NJ 07103 USA
Medical Center, Department of Vascular Medicine, University of Amsterdam Tafelbergweg 51 .1105 BD Amsterdam, The Netherlands
4Department of Cardiology, University Hospital of Heraklion, PO Box 1352 Stavrakia, Heraklion, Crete, Greece
Table
2
52nd
Department of Propedeutic Surgery, University of Athens School of Medicine, Laiko General Hospital, 17 Agiou Thoma street-11527 Athens,
Greece
6Department
of Internal
Medicine
Diseases,
University
of Crete,
P. landmark
O. Box 2203, group
71003 Heraklion,
Greece
Outcome
measures
inand
theInfectious
ultrasound
group
versus
the
of patients
7'J. Ioannovic' Burn Center, General State Hospital of Athens, 154 Mesogeion Avenue, 11527 Athens, Greece
81st Department of Propedeutic Surgery, University of Athens School of Medicine, Hipokrateion University Hospital,114 Vasilis Sofias Avenue 11527
Outcome measures
Ultrasound group (n = 450)
Landmark
Athens, Greece
3Academic
Access time
(seconds)
Corresponding
author:
Dimitrios Karakitsos, echolabicu@gmail.com
17.1 ± 16.5 (11.5 to 41.4)a
44 ± 95.4 (33.2 to 77.5)
a 10 Nov 2006 Published: 17 Nov 2006
Received:
23 May
2006 Revisions requested: 15 Jun 2006 Revisions received: 8 Sep450
2006(100%)
Accepted:
Success
rate
Critical
Care 2006,
10:R162 (doi:10.1186/cc5101)
Carotid
puncture
5 (1.1%)a
This article is online at: http://ccforum.com/content/10/6/R162
© 2006
Karakitsos et al.; licensee BioMed Central Ltd.
Haematoma
2 (0.4%)a
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
a
which
permits unrestricted use, distribution, and reproduction in any medium, provided the original
is properly cited.
Haemothorax
0 (0%)work
SeePneumothorax
related commentary by Bodenham, http://ccforum.com/content/10/6/175
Average number of attempts
Abstract
CVC-BSI
group (n = 450)
425 (94.4%)
48 (10.6%)
38 (8.4%)
8 (1.7%)
0 (0%)a
11 (2.4%)
1.1 ± 0.6 (1.1 to 1.9)a
2.6 ± 2.9 (1.5 to 6.3)
47 (10.4%)a
72 (16%)
Introduction Central venous cannulation is crucial in the
coagulopathy, skeletal deformity, and cannulation during cardiac
aComparison
management
of the
critical
care measures
patient. This
study the
wasultrasound
arrest between
the the
twolandmark
groups ofgroup
patients.
Furthermore,
of the
outcome
between
group and
of patients
(p <the
0.001). Access time and average
designed
real-timeasultrasound-guided
physicians
who confidence
performed the
procedures
had rate,
comparable
numbertoofevaluate
attemptswhether
are expressed
mean ± standard deviation
(95%
interval).
Success
carotid puncture, haematoma,
cannulation
of the internal
jugular veinand
is superior
to theare
standard
in the placement
central venous
catheters (pof=their group. CVC-BSI, central
haemothorax,
pneumothorax,
CVC-BSI
expressedexperience
as the absolute
number ofofpatients
and percentage
landmark
method.
non-significant). Cannulation of the internal jugular vein was
venous
catheter-associated blood stream infection.
achieved in all patients by using ultrasound and in 425 of the
Methods In this randomised study, 450 critical care patients
patients (94.4%) by using the landmark technique (p < 0.001).
who underwent real-time ultrasound-guided cannulation of the
Average access time (skin to vein) and number of attempts were
Page 5 of 8
internal jugular vein were prospectively compared with 450
significantly reduced in the ultrasound group of patients
critical care patients in whom the landmark technique was used.
compared with the landmark group (p < 0.001). In the landmark
(page
number
not
for
citation
purposes)
Crit Care 2006:10;R162
Randomisation was performed by means of a computergroup, puncture of the carotid artery occurred in 10.6% of
p < 0,001
Pansements
Quel type de pansement ?
Pansements transparents semi-perméables
Car permettent un examen quotidien du site d’insertion
Randomized Controlled Trial of Chlorhexidine Dressing
and Highly Adhesive Dressing for Preventing
Catheter-related Infections in Critically Ill Adults
Jean-François Timsit1,2, Olivier Mimoz3, Bruno Mourvillier4, Bertrand Souweine5, Maı̈té Garrouste-Orgeas6,
Serge Alfandari7, Gaétan Plantefeve8, Régis Bronchard9, Gilles Troche10, Remy Gauzit11, Marion Antona12,
Emmanuel Canet13, Julien Bohe14, Alain Lepape14, Aurélien Vesin1, Xavier Arrault15, Carole Schwebel2,
17, Stéphane Ruckly1, Caroline Tournegros2, and Jean-Christophe Lucet18
Christophe Adrie16, Jean-RalphTimsit,
Zahar
Mimoz,
Mourvillier, et al.: CHG-Gel Dressing for Catheter-related Infection Prevention
1
12
2
Université Grenoble 1 (Joseph Fourier), U823 “Outcome of Cancers and Critical Illness,” Albert Bonniot Institute, La Tronche, France; Université
Grenoble 1, Medical ICU, Albert Michallon Hospital, Grenoble, France; 3Service d’Anesthésie Réanimation, Centre Hospitalier Universitaire,
Université de Poitiers et Inserm U1070, Poitiers, France; 4Medical ICU, 9Surgical ICU, and 15Drug Delivery Department, Bichat-Claude Bernard
University Hospital, Paris, France; 5Université Clermont-Ferrand, Medical ICU, Gabriel Montpied Hospital, Clermont-Ferrand, France; 6MedicalSurgical ICU, Saint Joseph Hospital Network, Paris, France; 7Intensive Care and Infectious Diseases Unit, General Hospital, Tourcoing, France;
8
Medical Surgical ICU, General Hospital, Argenteuil, France; 10Medical Surgical Intensive Care Unit, General Hospital, Versailles, France;
11
Surgical Intensive Care Unit, Hotel-Dieu University Hospital, Paris, France; 12General ICU, Raymond Poincaré Hospital, University of Versailles
SQY, Garches, France; 13Université Paris VII, Medical ICU, Saint Louis Hospital, Paris, France; 14Université Claude-Bernard Lyon 1, Medical-Surgical ICU,
Centre Hospitalier Lyon Sud, Lyon, France; 16Physiology Department, Cochin Hospital, Paris, France; 17Micro-Biology and Hygiene, Necker Hospital, Paris,
France; and 18Infection Control Unit, Bichat-Claude Bernard University Hospital, Assistance-Publique Hôpitaux de Paris, and Université Paris Diderot,
Sorbonne Paris Cité, France
Rationale: Most vascular catheter-related infections (CRIs) occur extraluminally in patients in the intensive care unit (ICU). Chlorhexidineimpregnated and strongly adherent dressings may decrease catheter
colonization and CRI rates.
Objectives: To determine if chlorhexidine-impregnated and strongly
adherent dressings decrease catheter colonization and CRI rates.
Methods: In a 2:1:1 assessor-masked randomized trial in patients with
vascular catheters inserted for an expected duration of 48 hours or
more in 12 French ICUs, we compared chlorhexidine dressings, highly
adhesive dressings, and standard dressings from May 2010 to July
2011. Coprimary endpoints were major CRI with or without catheterrelated bloodstream infection (CR-BSI) with chlorhexidine versus
nonchlorhexidine dressings and catheter colonization rate with highly
adhesive nonchlorhexidine versus standard nonchlorhexidine dressings. Catheter-colonization, CR-BSIs, and skin reactions were secondary endpoints.
Measurements and Main Results: A total of 1,879 patients (4,163 catheters and 34,339 catheter-days) were evaluated. With chlorhexidine
dressings, the major-CRI rate was 67% lower (0.7 per 1,000 vs. 2.1 per
1,000 catheter-days; hazard ratio [HR], 0.328; 95% confidence interval
AT A GLANCE COMMENTARY
Figure 1. Flow chart of the study. C
BSI ¼ catheter-related bloodstream
Scientific Knowledge on the Subject
fection; CRI ¼ catheter-related infectio
Chlorhexidine-impregnated sponges decrease catheter-related
ITT ¼ intention to treat.
infections (CRI) in the intensive care unit (ICU) but make
impossible the continuous inspection of insertion site. Dressing
disruption is frequent in the ICU and a major risk factor
of CRI.
What This Study Adds to the Field
Chlorhexidine-impregnated gel dressings decrease by 60%
the risk of CRI in the ICU. This second large, multicenter
randomized control trial confirmed the benefits of chlorhexidine dressings. A highly adhesive nonchlorhexidine transparent dressing decreased dressing disruption but increased
cutaneous and positive catheter tip culture.
different between these two groups (Table 3; see Figure E
changes per catheter-days was significantly lower in the highly
J Respir
Crit Care
Meddifferent
2012;186:1272-8
Also,
CLA-BSI
was
between groups (H
per
catheter-day;
,0.0006)
0.0001;Am
[CI],
0.174–0.619;PP ¼
and the
CR-BSI
rate 60%rate
lower
(0.5not
per
adhesive
(0.33 [0.20–0.50]
(Received in original form June 9, 2012; accepted
in final group
form September
17, 2012)
Transport to operating room with catheter in place, n (%)
No
Once
Twice
More than twice
Transport out of ICU with catheter in place, n (%)
No
Once
Twice
More than twice
Number of dressing changes per catheter, median (IQR)
1,2Catheter removal for suspected
3 infection, n (%)
Data for arterial catheters only
7
8
9
Arterial catheter, n (%)
13
14
14
Femoral
3,436
587
94
46
(82.5)
(14.1)
(2.3)
(1.1)
877
148
24
18
(82.2)
(13.9)
(2.2)
(1.7)
812
140
25
11
(82.2)
(14.2)
(2.5)
(1.1)
1,747
299
45
17
(82.9)
(14.2)
(2.1)
(0.8)
2,638
1,109
294
122
2
563
(63.4)
(26.6)
(7.1)
(2.9)
(1–4)
(13.5)
675
272
86
34
3
155
(63.3)
(25.5)
(8.1)
(3.2)
(1–5)
5
(14.5)
632
284
45
27
2
130
(64)
(28.7)
(4.6)
(2.7)
(1–4)
(13.2)
1,331 (63.1)
553 (26.2)
163 (7.7)
61 (2.9)
2 (1–4)
6 278 (13.2)
12
1,128 (53.5)
393 (34.8)
73518(65.2)
473 (47.9)
980 (46.5)
Randomized Controlled Trial of Chlorhexidine Dressing
and Highly Adhesive Dressing for Preventing
Catheter-related Infections in Critically Ill Adults
Jean-François Timsit , Olivier Mimoz , Bruno Mourvillier4, Bertrand Souweine , Maı̈té Garrouste-Orgeas ,
Serge Alfandari , Gaétan Plantefeve , Régis Bronchard , Gilles
Troche10, Remy
Gauzit11, Marion
Antona ,
2,201 (52.9)
558 (52.3)
515 (52.1)
1, Xavier Arrault
2,
773 (35.1)
207 (37.1) 15, Carole
173Schwebel
(33.6)
Emmanuel Canet , Julien Bohe , Alain Lepape , Aurélien Vesin
Radial
1,428 (64.9)
351 (62.9)
342 (66.4)
17, Stéphane Ruckly1, Caroline
2, and Jean-Christophe
Christophe Adrie16, Jean-Ralph
Zahar
Tournegros
Lucet
Data for CVCs only
1
All CVCs, n (%)
1,962 (47.1)
509 (47.7)
Jugular
CVCs
728 (37.1)
180Bonniot
(35.4)
3732Université
(38.1)
Université Grenoble 1 (Joseph
Fourier),
U823 “Outcome of Cancers and Critical
Illness,” Albert
Institute,175La(37)
Tronche, France;
Subclavian
CVCs
567
(28.9)
152
(29.9)
140
(29.6)
275 (28.1)
3
Timsit,
Mourvillier, Hospital,
et al.: CHG-Gel
Dressing
for Catheter-related
Infection Réanimation,
Prevention
1277
Grenoble 1, Medical
ICU, Mimoz,
Albert
Michallon
Grenoble,
France;
Service
d’Anesthésie
Centre
Hospitalier
Universitaire,
Femoral CVCs
667 (34)
177 (34.8)
158 (33.4)
332 (33.9)
4
9
Guidewire
exchange,
n (%) France; Medical ICU, Surgical
76 (3.9)
23 (4.5)
20 (4.2) Bichat-Claude33Bernard
(3.4)
Université de Poitiers et Inserm
U1070,
Poitiers,
ICU, and 15Drug
Delivery Department,
5 catheters,
n (%)
5 (0.3)
(0.2)
2 (0.4)
2 (0.2)
3. Tunneled
HAZARD
RATIOS
IN THE INTENTION-TO-TREAT
ANALYSIS
University Hospital,TABLE
Paris, France;
Université
Clermont-Ferrand,
Medical ICU,
Gabriel
Montpied 1Hospital,
Clermont-Ferrand,
France; 6MedicalVenous catheter lumens, n (%)
7
Surgical ICU, Saint Joseph Hospital
Network, Paris, France; Intensive
Care and17Infectious
Diseases
Unit, General Hospital,
Tourcoing,
One
(0.9)
6 (1.2)
3 (0.6)Standard
8Adhesive
(0.8)
Nonchlorhexidine
vs. Chlorhexidine
Dressings
vs. HighlyFrance;
Dressings
8
Two Hospital, Argenteuil, France; 10Medical Surgical
201 (10.2)
(9.8) General Hospital,
42 (8.9) Versailles, France;
109 (11.1)
Medical Surgical ICU, General
Intensive
Care
Unit,
(941 patients/2,055
catheters
vs.50938
(476 patients/1,067
catheters vs. 465
Three
1,458
375 (73.7)
358 (75.7)
725 (74)
11
12 (74.3)
patients/2,108
catheters)
patients/988
Surgical IntensiveVariable
Care Unit,
Hotel-Dieu
ICU, Raymond
University
of catheters)
Versailles
Greater
than three University Hospital, Paris, France; 286General
(14.6)
78 (15.3) Poincaré Hospital,
70 (14.8)
138
(14.1)
13
14
Use of lipids,Paris
n (%) VII, Medical ICU, Saint Louis Hospital, 938
(47.8)
247 (48.5) Claude-Bernard
219 (46.3)
472 (48.2) ICU,
SQY, Garches, France;
Université
Paris,
France;
Université
Lyon
1,
Medical-Surgical
Catheter colonization
of heparin, n (%)
615 (31.3)
159
146 (30.9)
310 (31.6)
16
17 (31.2)
Centre Hospitalier Lyon
Sud,Use
Lyon,
Physiology Department, Cochin Hospital,
Paris, France;201
Micro-Biology
and
Hygiene, Necker
Paris,
Incidence
(n perFrance;
1,000
9.6Hospital,
vs. 12.5
Red-blood-cell
packcatheter-days)
transfused, n (%)
766 10.9
(39) vs. 4.3
(39.5)
182 (38.5)
383
(39.1)
18
Hazard
ratio
0.412
(0.306–0.556),
P
,
0.0001
1.651
(1.208–2.256),
P ¼ 0.0016
France; and Infection Control Unit, Bichat-Claude Bernard University Hospital, Assistance-Publique Hôpitaux de Paris, and Université Paris Diderot,
of abbreviations:
CVC ¼ central venous catheter; ICU ¼ intensive care unit; IQR ¼ interquartile range.
bloodstream
infection
Sorbonne Paris Cité,Catheter-related
France Definition
Incidence (n per 1,000 catheter-days)
1.3 vs. 0.5
1.3 vs. 1.3
Hazard ratio
0.402 (0.186–0.868), P ¼ 0.02
1.215 (0.470–3.142), P ¼ 0.689
Skin Colonization
catheters (67.5%; P , 0.001). Median (IQR) rate of Count-Tact
Major catheter-related
infections
was significantly lower in the chlorhexidine
Incidence
(n per 1,000
catheter-days)
0.7
2.3 versus
vs. 1.9 the
Rationale: Most vascular
catheter-related
infections
(CRIs) occur
extra-of 2,965 cathe-2.1 vs.positivity
Count-Tact
cultures
were performed
at removal
nonchlorhexidine
group
and
significantly
higher
in
the
highly
adHazard
ratio
0.328
(0.174–0.619),
P
¼
0.0006
1.052
(0.517–2.142),
P ¼ 0.888
ters
and
were
negative
in
918
(31%)
cases.
Bacterial
growth
was
luminally in patients in the intensive care unit (ICU). Chlorhexidine-
AT A GLANCE COMMENTARY
hesive nonchlorhexidine versus the standard group (23 [1–101] vs.
common
in patients
with
colonization
(89%), major-CRI
impregnated and stronglymore
adherent
dressings
may
decrease
catheter
10 [0–100];
P ¼ 0.010)
Table
E3).
(87.5%), or CR-BSI (87.5%) than in patients with noncolonized
Scientific
Knowledge
on (see
theand
Subject
colonization and CRI
rates.
Adverse Events
decreased
major-CRI
CR-BSI rates in our study similarly to
Objectives: To determine
if chlorhexidine-impregnated
and strongly
the sponge (13). The sponges
rate of severe
contact
dermatitis was comChlorhexidine-impregnated
decrease
catheter-related
No systemic
adverse reaction to chlorhexidine
occurred. Severe
parable
with
that
reported
with
chlorhexidine
adherent dressingscontact
decrease
catheter
colonization
and
CRI
rates.
(CRI) in the intensive care unit (ICU) sponges.
but make
dermatitis requiring permanent discontinuation ofinfections
the
In our
previous study
(13), we
standard
Methods: In a 2:1:1 assessor-masked
randomized
trial
in
patients
with
study dressing occurred in 22 chlorhexidine-group patients impossible
(1.1
the
continuous
inspection
of used
insertion
site.transparent
Dressing Tegaderm dressings, of which two-thirds were replaced earlier than
vascular catheters per
inserted
for an expected
duration
of 48 hours
or
100 catheters),
four highly
adhesive-group
patients
(0.5disruption
per
is frequent in the ICU and a major risk factor
scheduled, because of soiling or detachment. Spontaneous dressmore in 12 French ICUs,
we compared
chlorhexidine
dressings,
100 catheters),
and one
standard-group
patienthighly
(0.1 per 100 cathof CRI. ing detachment was associated with catheter colonization and inadhesive dressings,
and (P
standard
from May
2010
Julygroups, P ,
eters)
¼ 0.0005dressings
for comparison
among
theto
three
fection (28), suggesting that a highly adhesive transparent dressing
0.0001 forwere
comparison
between
chlorhexidine
and nonchlorhex2011. Coprimary endpoints
major CRI
with or
without catheter(Tegaderm HP Transparent Film Dressing) might decrease cathidine
dressings,
P ¼ 0.17with
for chlorhexidine
comparison between
and This
related bloodstream
infection
(CR-BSI)
versusstandardWhat
Adds and
to the
Field rates. However, skin and catheter
eterStudy
colonization
major-CRI
highly
adhesive
nonchlorhexidine
dressings).
nonchlorhexidine dressings and catheter colonization rate with highly
colonization rates at catheter
removal
were higher
with TegaChlorhexidine-impregnated
gel dressings
decrease
by 60%
Contact
dermatitis
usually
occurred for a single
adhesive nonchlorhexidine
versus
standard
nonchlorhexidine
dress-catheter per
derm
HP,
despite
a
significant
decrease
in
early
dressing
changes.
the
risk
of
CRI
in
the
ICU.
This
second
large,
multicenter
patient andCR-BSIs,
selectively
patients
withsecondmultiple organ failings. Catheter-colonization,
andaffected
skin reactions
were
The control
hydrophilic
acrylate
component
in Tegaderm
HP may have
randomized
trial
confirmed
the
benefits
of
chlorhexiure,
subcutaneous
edema,
and
fragile
skin.
No
systemic
adverse
ary endpoints.
resulted in skin toxicity or dermabrasion during dressing changes,
reactions
to chlorhexidine
occurred.
dine dressings.
A highly adhesive nonchlorhexidine transMeasurements and Main
Results:
A total of 1,879
patients (4,163 cathincreasing the risk of colonization from the pilosebaceous units.
The rate of abnormal International Contact Dermatitis Research
parent
dressing
decreased dressing disruption but increased
eters and 34,339 catheter-days) were evaluated. With chlorhexidine
Our study is the first to evaluate chlorhexidine-gel dressings
Group scores was significantly higher with chlorhexidine (2.3%)
cutaneous
and
positive
catheterand
tipthe
culture.
dressings, the major-CRI rate was 67% lower (0.7 per 1,000 vs. 2.1 per
for major-CRI prevention
second large randomized conthan without chlorhexidine (1%; P , 0.0001). Abnormal scores
1,000 catheter-days;
hazard
ratio
[HR],
0.328;
95%
confidence
interval
trolled
trial
(after
[13])
showing
that
chlorhexidine dressings dewere significantly more common with the highly adhesive dresscrease major-CRI
CR-BSI
rates in ICUs.
Nine
out
Figure
2. Cumulative
of (A) major
catheter-related
(CRI) with chlorhexidine-gel
(CHG) and
dressings
and nonantiseptic
dressings,
and
(B) of the 12
ing (1.4%)
than
with the risk
standard
dressing
(0.7%; Pinfections
¼ 0.0039).
J Respir
Crit
Care
Med
2012;186:1272-8
never
usedAm
chlorhexidine
dressings.
In
addition,
we obcatheter colonization with highly adhesive nonchlorhexidine dressings versusICUs
standard
dressings.
Pansements
Rôle primordial pour la prévention des ILC
Périodicité de réfection des pansements reste discutée…
Recommandations françaises : tous les 3 jours
Recommandations américaines : tous les 7 jours sauf si souillure
5ème conférence de consensus – Prévention des infections
nosocomiales en réanimation – SFAR - SRLF
O’Grady NP et al. Guidelines for the prevention of intravascular
catheter-related infections. Clin Infect Dis 2011
Maki et al. Am J Med 1981;70,739-744
3 groupes :
- Groupe contrôle : rien
- PI2 : Iodophore
- PNB : Polymyxine, Néomycine et
Bacitracine
Place des pommades
antibiotiques
Pas moins d’infections …
… et au contraire : + d’infections à Levures !
Nombre de lumières
Nombre de lumières : méta-analyse
Cathéter et héparine
Si CVC imprégnés d’héparine : moindre risque de
thrombose ?
Hoar PF. Heparin bonding reduces thrombogenicity of pulmonary-artery catheters. N Engl
J Med 1981;305:993-995
Daniel HW. Heparin in the prevention of infusion phlebitis. A double-blind controlled study.
JAMA 1973;226:1317-21
Prévention de l’infection de cathéter par l’héparine
Randolph AG. Benefit of heparin in central venous and pulmonary artery
catheters. A meta-analysis of randomized controlled trials.
Chest 1998;113:165-171
Cathéters imprégnés …
Cathéter imprégnés d’antiseptiques
Imprégnés
(n=227)
Non
imprégnés
(n=215)
Nb jours-cathéters
6 +/- 3,4
6 +/- 2,8
Colonisation, n (%)
28 (13,5)
47 (24)
Taux/1000 j
22,5
40
Bactériémie, n (%)
2 (1)
9 (4,6)
Taux/1000 j
1,6
7,6
Nouveau site
1,4
4,6
Après échange/
guide
2
6
p
0,005
0,03
Maki et al. Ann Intern Med 1997;127:257-266
Méta-analyse
Colonisations
Bactériémies
Veenstra et al. JAMA 1999;281:261-267
VOLUME 340
J A N U A R Y 7, 1999
NUMBER 1
A C O M PA R I S O N O F T WO A N T I M I C R O B I A L - I M P R EG N AT E D C E N T R A L V E N O U S C AT H ET E R S
A COMPARISON OF TWO ANTIMICROBIAL-IMPREGNATED
CENTRAL VENOUS CATHETERS
an independent effect. The limit for entering or removRABIH O. DAROUICHE, M.D., ISSAM I. RAAD, M.D., STEPHEN O. HEARD, M.D., JOHN I. THORNBY, PH.D.,
bles in the logistic-regression models was a P value of
TABLE 1. CHARACTERISTICS OF THE PATIENTS
O
C.
WENKER
, M.D.,
ANDREA GABRIELLIAND
, M.D.,
JOHANNES BERG, M.D., NANCY KHARDORI, M.D., HEND HANNA, M.D.,
LIVIER
ess. All computations were performed
with
SAS/STAT
ANTIMICROBIAL-IMPREGNATED CATHETERS.*
12 An independent monitoring
RAY board
HACHEM
, M.D., of
RICHARD
L. HARRIS, M.D., AND GLEN MAYHALL, M.D., FOR THE CATHETER STUDY GROUP*
composed
exinfectious diseases reviewed and helped interpret the
MINOCYCLINE– CHLORHEXIDINE–SILVER
of the study. An interim analysis of the data was not per-
ABSTRACT
I
RIFAMPIN
SULFADIAZINE
associated
with the use of central
CNFECTION
ATHETERS
CATHETERS
(N=356)
(N=382)
venous catheters can result in serious medical
Background The use of centralCHARACTERISTIC
venous catheters
RESULTS
complications
and
expensive care.1 In prospecimpregnated with either minocycline
and rifampin
No. of patients
350
370
eristics of Patients and
Catheters
or chlorhexidine and silver sulfadiazine
reduces the
tive,
clinical trials, the use of cenMale sex (%)
59 randomized63
rates
of
catheter
colonization
and
catheter-related
tral
venous
catheters
impregnated
with either mital of 865 study catheters (414 impregnated
Median age (yr)
56
56
bloodstream infection as compared with the use of
2 or chlorhexidine and silver
nocycline
and
rifampin
inocycline and rifampin
and 451 impregnatUnderlying disease (%)
unimpregnated catheters. We compared
the rates
Cancer
28 3 was associated
26
sulfadiazine
with reduced rates of
h chlorhexidine and
silver
sulfadiazine)
were
of catheter colonization and catheter-related
bloodCardiopulmonary
disease
32 colonization 34and catheter-related bloodcatheter
d into 817 patients.
Complete
data
could bewith these
stream
infection
associated
two disorder
kinds of
Neurologic
16
19
stream 24
infection, as compared
with unimpregnated
Other
21
ed for 738 catheters
(85 percent):
356 imantiinfective
catheters.
4 and studies in animals5
catheters.
In
vitro
studies
Patients
in
intensive
care
unit
(%)
66
67
We conducted
Methods
ted with minocycline
and rifampin
and 382a prospective, randomRisk factors for
infection (%) have suggested that catheters impregnated with miized clinical
in 12
university-affiliated
hospitals.
nated with chlorhexidine
andtrial
silver
sulfadiaHyperalimentation
16 and rifampin
16 can resist infection more efnocycline
High-riskThe
adult
patients127
in whom central venous
nserted in 698 patients.
remaining
Immunosuppressive therapy fectively22than catheters
20impregnated with chlorhexicatheters were expected to remain Bone
in place
for
three
marrow
transplantation
6
4
rs (58 impregnated
with minocycline and ridine and5 silver sulfadiazine,
but the clinical efficacy
or more days were randomly assigned
to undergo
Neutropenia
3
and 69 impregnated
with
chlorhexidine
and
insertion of polyurethane, triple-lumen
catheters
imMechanical
ventilation
60
65
of these two types of antiinfective catheters has not
ulfadiazine, with similar
patient
catheter
catheter been compared
53
54 We compared catheters impregnated
with and
either
minocycline Other
and intravascular
rifampin (on
directly.
Urinaryor
catheter
85
86
eristics) were not both
cultured
(84 were
removed
the luminal
and
external surfaces)
chlorhexpregnated
with minocycline
and rifampin with those
Receiving
systemic
antibiotics
(%)
89
90
idine coordinators,
and silver sulfadiazine
t notification of study
19 were (on only the external
impregnated
with
chlorhexidine
and silver sulfadiaInsertion
(%)
surface).
After their
andsite
subcutanecontaminated during
removal,
and removal,
24 were the tips
zine in terms
of the rates
Subclavian vein
54
53 of colonization of catheters
ous segments
of the were
catheters
cultured
by both
ilable for other reasons)
and therefore
ex- wereJugular
vein
38
36
and bloodstream
infection.
the roll-plate and the sonication methods.
Peripheral11
Femoral
vein
8
from further analysis.
The
two
groups
of
blood cultures were obtained if clinically
indicated.
Duration
of
placement
(days)
METHODS
rs that could be evaluated
with
Results were
Of 865similar
catheters
inserted,
738 (85 percent)
Mean
8.4
8.2
to characteristicsproduced
of patients
and
catheters
Patients 6
7
culture results that could Median
be evaluated. The
Range
1–55
1–36
1).
clinical characteristics of the patients
and the risk facThe trial was conducted between December 1995 and July
Reason
removal
(%)
tors for infection were similar in
the for
two
groups.
1997 in 12 university-affiliated hospitals. The study was approved
Catheter no longer needed by the appropriate
67
69 review boards. Hospitalized adults
ation of Catheters Catheters impregnated with minocycline
institutional
and rifamSuspected catheter infection
14
13
pin were 1/3
as likely to be
colonized
as catheters
ty-seven of 382 catheters
impregnated
with
Occluded
catheter im3
1
with
chlorhexidine
Other sulfadiazine
16
17
xidine and silver pregnated
sulfadiazine
(22.8
percent) and silver
(28 of 356 catheters [7.9 percent] vs. 87 of 382 [22.8
Antiseptiques
ou
Antibiotiques ?
Minocycline Rifampicine
Chlorhexidine Sulfadiazine
(n=356)
(n=382)
Durée séjour en réa
(jours)
8,4
8,2
Colonisation, n (%)
28 (7,9)
87 (22,8
RR=2,9
Bactériémie, n (%)
1 (0,3)
13 (3,4)
RR=12,5
1 (0,3)
11 (6,4)
p=0,01
survenue > 7 j
Incidence BLC/1000
0,3
The jNe w E n g l a nd Jo
u r n a l o f Me d ic i ne 4,1
Minocycline–rifampin catheters
1.0
Proportion of Catheters!
without Infection
p<0,001
0.9
0.8
0.7
Chlorhexidine–silver sulfadiazine catheters
0.6
0.5
0.4
p=0,001
0.3
0.2
0.1
0.0
0
5
10
15
20
25
30
Duration of Catheterization (Days)
NO. AT RISK
Darouiche et al. NEJM 1999
Cathéters imprégnés …
L’utilisation de cathéters imprégnés d’agents antiinfectieux diminue l’incidence des ILC.
En raison de leur coût et du risque potentiel de sélection
de BMR ou de levures, il n’est pas recommandé de les
utiliser en 1ère intention.
Ils peuvent trouver leur indication dans les unités où
l’incidence des ILC reste élevée malgré la mise en
place de mesures préventives.
5ème conférence de consensus – Prévention des infections
nosocomiales en réanimation – SFAR - SRLF
O’Grady NP et al. Guidelines for the prevention of intravascular
catheter-related infections. Clin Infect Dis 2011
Entretien des lignes veineuses
Le changement des lignes de perfusion peut
n’être effectué que tous les 3 à 4 jours. En
revanche, les tubulures doivent être
changées après chaque transfusion sanguine
ou quotidiennement lors de perfusions
d’émulsions lipidiques.
5ème conférence de consensus – Prévention des infections
nosocomiales en réanimation – SFAR - SRLF
O’Grady NP et al. Guidelines for the prevention of intravascular
catheter-related infections. Clin Infect Dis 2011
Autres mesures préventives...
En l’absence d’efficacité, certaines mesures ne
sont pas recommandées : antibioprophylaxie à
l’insertion, pommade antibiotique, filtres
antibactériens, boîtiers protecteurs, changement
systématique du cathéter à intervalle régulier.
5ème conférence de consensus – Prévention des infections
nosocomiales en réanimation – SFAR - SRLF
O’Grady NP et al. Guidelines for the prevention of intravascular
catheter-related infections. Clin Infect Dis 2011
Education
ACADEMIA AND CLINIC
Education of Physicians-in-Training Can Decrease the Risk for
Vascular Catheter Infection
Robert J. Sherertz, MD; E. Wesley Ely, MD, MPH; Debi M. Westbrook, RN; Kate S. Gledhill, RN;
Stephen A. Streed, MS; Betty Kiger, RN; Lenora Flynn, MT; Stewart Hayes, RRT; Sallie Strong, RN;
Julia Cruz, MD; David L. Bowton, MD; Todd Hulgan, MD; and Edward F. Haponik, MD
V
s. The second
year’s supBackground:
Procedure instruction for physicians-inascular catheter infection is a substantial cause
training
is
usually
nonstandardized.
The
authors
observed
$12 000. Almost all physiof morbidity and death in hospitalized patients.
that
during
insertion
of
central
venous
catheters
(CVCs),
It has been estimated that 50 000 to 100 000 bloodwere fellows; most other
few physicians used full-size sterile drapes (an intervention
stream infections related to vascular devices occur
ad salaries
equivalent to
proven to reduce the risk for CVC-related infection).
yearly in the United States; 90% of these infections
yearly salary plus benefits
Objective: To improve standardization of infection conoriginate from central venous catheters (CVCs) (1).
cost for trol
thepractices
participating
and techniques during invasive procedures.
The attributable mortality rate for CVC-related
each day of faculty time
Design: Nonrandomized pre–post observational trial.
bloodstream infections ranges from 14% to 28%
For the purposes of this
(2– 6). The attributable cost of such infections has
Setting: Six intensive care units and one step-down unit
ider costsatof
faculty
prepbeen estimated to be as high as $29 000 per episode
Wake Forest University Baptist Medical Center, Winrtunity. Assuming
(4). Various interventions, including skin preparaston-Salem,that
Norththe
Carolina.
tions withParticipants:
two facultyThird-year
per
tion with chlorhexidine (7), use of vascular catheters
medical students and physicians
Figure.
Effect
of
a
procedure
course
on
the risk
for primary bloodwith
anti-infective
coatings (8, 9), and use of maxirse days, completing
the total cost
for postgraduate
their first
year.
stream infection (white bars) and catheter-related infection (striped
barrier
during catheter insertion,
ately $9600
for 1 year A
and
bars) inon
sixinfection
intensivecontrol
care units
and onemum
step-down
unit.precautions
The course
Intervention:
1-day course
pracAnn to
Intern
Med
offered twice; participants were medicalhave
students
andshown
physicians
combeen
reduce
risk2000;132:641-48
for catheter-related
e full-size
drapes givenwas
ticessterile
and procedures
in June 1996 and June 1997.
Programme multi-facette
process, yielding an “exact” zero that our inter- balances (22–24).
an 81% reduction in unadjusted CLABSI
The appropriateness of the distribution rates at 19-month postimplementation
vention would not affect. In other units, zeroes
might be occasional, could be brought about by was confirmed using a Vuong test and visual and the control group, after undertaking
our intervention (along with smaller and small- inspection of the data. Models were compared the intervention, achieved a 69% reducer positive rates of infection), and are thus not using the Akaike information criterion and
tion 12-month postimplementation. Both
considered structurally produced (21). The zero- Bayesian information criterion goodness-of-fit
groups reduced CLABSIs to approximately
inflated Poisson model uses two parts: it specifies statistics. All analyses used Stata 10.0 (Stata
0.8 per 1,000 line days by the end of the
the conditional probability of an exact zero using Corp., College Station, TX).
study. A trend of increasing numbers of
a logit model to predict exact zeros and uses a
Jill A. Marsteller,
PhD,
MPP;
J.
Bryan
Sexton,
PhD;
Yea-Jen
Hsu,
PhD,
MHA;
Chun-Ju
Hsiao,
PhD,
MHS;
consistently
performed infection prevenPoisson model to specify the other zeroes and the
Christinecontinuous
G. Holzmueller,
BLA;
Peter
J.
Pronovost,
MD,
PhD,
FCCM;
David
A.
Thompson,
DNSc,
MS,
RN
tion behaviors over time was also found in
positive portion of the distribution. RESULTS
We included ICU structural variables of system,
both intervention groups (Fig. 2).
Ninety-five percent (35/37) of ICUs
bed size, and number of CLABSIs in year 2006
In multivariate
Objectives: To determine the causal effects of an intervention the intervention and control groups (p = .28), respectively.
By October analysis, model 1 demto predict exact zeros. The intervention effect from the
Adventist
Health
System
(East)
a significantly lower adjusted
Lavage
mains
proven effective in pre-post studies in reducing central line-asso- to December
2007,des
the infection
rate declined toonstrates
1.33 in the intervenwas assessed
in the nonexact
zero part
where
and
59% (10/17)
Adven-groupincidence
ciated bloodstream
infections
in the intensive
care
unit. we participated
tion group
compared
to 2.16 from
in the control
(adjusted incidence
rate ratio for CLABSI in the
Asepsie
chirurgicale
infections
in the postimplementation
tist-Health
not interval
Design:regressed
We conducted
a multicenter,
phased, cluster-randomrate ratio(West)
0.19; p (Fig.
= .003;1).
95%Those
confidence
0.06–0.57). group
The
intervention
postimplementation
periodtrial
(with
an offset
for linewere
days)randomized
on baselineinto two intervention group sustained rates <1/1,000 central line days at 19
ized controlled
in which
hospitals
Chlorhexidine
participating
in the East system were compared to the control group (adjusted
infections
and group
groupstarted
assignment.
The2007
offset
forthe con- months (an 81% reduction). The control group also reduced infection
groups. The
intervention
in March
and
extremely
small orsite
recently
opened; rea- incidence rate ratio 0.19; p = .003, 95%
-rates
Eviter
fémoral
number
of central
for theSeptemtrol group the
started
in October
2007;line
the days
studyadjusted
period ended
to <1/1,000
central
line days (a 69% reduction) at 12 months.
sons for nonparticipation were not col- confidence interval 0.06–0.57; Table 3).
risk of infection
facedgroups
by each
ber 2008. Baseline
data for both
areICU.
fromBecause
2006. a - Retrait
Conclusions:
This study demonstrated
a causal relationship
cathéters
inutiles
lectedbetween
from the
system.intervention
The
overalland the
Thisreduced
corresponds
regression
offset
the in two
Setting:Poisson
Forty-five
intensivewith
carethe
units
fromconverts
35 hospitals
theWest
multifaceted
central to a reduction of 81%
into the
log of the count divided by the log participation
rate was
83% (45/54).
CLABSI
rates in the intervention group
Adventist count
healthcare
systems.
line-associated
bloodstream
infections. Bothingroups
decreased
Interventions: A multifaceted intervention involving evidence- infection rates after implementation and sustained these results
based practices to prevent central line-associated bloodstream over time, replicating the results found in previous, pre-post stud2. Comprehensive
Central line-associated
bloodstream
infectiontorateies
group
comparisons
infectionsTable
and the
Unit–based
Safety Program
of this
multifaceted intervention and providing further evidence
improve safety, teamwork, and communication.
that most central line-associated bloodstream infections are preIntervention
Group (Crit
(n = Care
23) Med 2012; 40:2933–2939)
Control Group (n = 22)
Measurements and Results: We measured central line-associventable.
KEY WORDS: catheter-related infections; evidence-based pracated bloodstream infections per 1,000 central line days and reported
CLABSI Rate
CLABSI rate
quarterly rates. Baseline average central line-associated blood- tice; intensive care units; prevention and control; quality improvestream infections per 1,000 central line days was 4.48 and 2.71, for ment; randomized controlled trial
Median
Incidence
A multicenter, phased, cluster-randomized controlled trial to
reduce central line-associated bloodstream infections in intensive
care units*
N
Median (Interquartile
Incidence
% of
(Interquartile
Rate
% of
Range)
Mean (SD)
Rate Ratio
Reductiona
Range)
Mean (SD)
Ratio
Reductiona
early 250,000 healthcare- life-saving medical care (1). Furthermore, known as the Comprehensive Unit–based
associated
infections
25%
of patients 4.48
contracting
a central
Safety Program
(CUSP)
(13). Together
Baseline
(Jan-Dec
2006) occur 2.56
(0.74–5.87)
(7.03)
1.00
1.78
(0.00–3.80)
2.71 (3.01)
1.00
b
annually
in
patients
with 0.00
line-associated
bloodstream
these 5interventions reduced
the overall
(0.00–1.79)
4.71 (17.31) infection
1.05
——
Mar 2007
central
lines placed
First
Q (Apr-Jun
2007) to deliver 0.00
(0.00–2.02)
1.12 (2.34)
−80 rate by 66% in
— a cohort of ICUs
—
(CLABSI)
in the intensive
care unit0.25
(ICU) CLABSI
Second Q (Jul-Sep 2007)
0.00
(0.00–2.59)
(4.25)
16
—
die,
totaling 31,0001.83
deaths
annually 0.41
in the (7). Nevertheless,
this—
cohort study, with
0.00
(0.00–1.50)
1.33
(2.77) review0.30
−11
0.00 (0.00–2.89)
2.16
(3.93)
0.79
−21
Third Q (Oct-Dec 2007)c
United
States
(2).
A
recent
estino
concurrent
control
group,
was
not
able
*See also p. 3083.
Fourth Q (Jan-Mar 2008)
0.00
(0.00–0.00)
0.96 (2.78)
0.21
−8
0.00 (0.00–0.00)
0.56 (1.35)
0.21
−59
mated
an added annual
cost of $9 billion
to establish
a causal
relationship between
From the Department of Health Policy and
Fifth
Q
(Apr-Jun
2008)
0.00
(0.00–0.00)
0.88
(2.19)
0.20
−2
0.00
(0.00–0.00)
0.52
(1.46)
0.19
−2
Management (JAM, JBS, Y-JH, C-JH, PJP), Johns
to the U.S. healthcare system (3).
the intervention and the reduced CLABSI
Sixth Q
(Jul-Sep
2008)
0.85 (1.39)
0.19
−1
0.00 (0.00–0.00) 0.83 (2.30)
0.31
12
Hopkins Bloomberg
School
of Public
Health, Baltimore, 0.00 (0.00–1.94)
Previous quality improvement studies rate.−81
The rational next scientific step was
CLABSI rate
reduction from
−69
MD; and Department
of Anesthesiology
and Critical
suggest that these infections are largely to test a causal relationship between this
Care Medicine baseline
(JAM, JBS,
CGH, PJP,
DAT), Johns
to sixth
quarter
preventable (4–8). However, these studies multifaceted intervention and reduced
Hopkins School of Medicine, Baltimore, MD.
The work was performed at Adventist Health and
were based infection;
on nonrandomized
withnot collected.
CLABSI rates in a randomized controlled
CLABSI, central line-associated bloodstream
Q, quarter;trials
—, data
the Adventist Health System.
Crit Care
Med reductions
2012;40:2933-39
historical
or
contemporaneous
controls.
trial (RCT)
to evaluate
theto magnitude
of (percentage
a
Calculated as differences of CLABSI rate or incidence rate ratio between two consecutive
quarters
relative
baseline values
are
Supported by a grant from the Robert Wood
Au total : quelle méthode de prévention ?
• Lavage des mains
• Asepsie : chirurgicale
• Antisepsie cutanée : chlorhexidine ou PVI-alcool
• Site : Sous-clavier > Jugulaire interne > Fémoral
• Nombre de voie : multi-lumière = mono-lumière
• Matériau : Polyuréthane ou élastomères de silicone
• Cathéters imprégnés : pas en 1ère intention
• Pansement : tous les 3 jours
• Entretien des lignes : tous les 3-4 jours
• Retrait des cathéters inutiles
• Education
5ème conférence de consensus – Prévention des infections nosocomiales en
réanimation – SFAR - SRLF
O’Grady NP et al. Guidelines for the prevention of intravascular catheter-related
infections. Clin Infect Dis 2011