I attended a Hospital Value Analysis Committee meeting yesterday and was informed that all PICCs placed in hospitals should be antimicrobial. Is this true? My understanding of the guidleines was to use antimicrobial catheters in the high risk areas when the rates of infection are high or when considering an exchange.
No this is not true for any anti-infective impregnated or coated CVAD based on guidelines from CDC and SHEA. But there are many available studies showing very good outcomes from their use. Frankly I was surprised to see that the CDC 2011 statements about these catheters did not change. So no organization or regulatory agency has made such a statement, but your infection prevention staff may think these should be used based on scientific evidence. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
CDC 2011 follows below:
Guidlines state to first try the following for catheters to remain in place > 5 days before choosing a coating or impregnated catheter.
1. Education of persons who insert and maintain catheters ( this is likely the best strategy out there for care and maintenance intraluminal and extraluminal infections from dressing change and access and is the least recognized)
2. Implementation of maximal sterile barrier precautions
3. >0.5% chlorhexidine preparation with alcohol for antisepsis during CVC insertion
A number of hospitals at or near zero have implemented the following strategies to obtain zero. Remember on a coating the peak day of efficacy is the day it is placed as it is a coating. Impregnated catheters differ by efficacy versus a coating. Know the difference between a coating and impregnation as they are not the same mechnism of action.
I also suggest reading studies before choosing a coating or impregnated catheter.
What is the coating/impregnated substance?
Is the coating / impregnation the same as the study being presented?
Is the coating / impregnation the same externally as internally?
Do studies show reduction of infection or reduction of colonization of bacteria?
What is the studied efficacy of the coating at day one, day 7, day 14, day 21, day 30 or over?
What hospitals currently use a coated / imprenated PICC or acute CVC and has it impacted their rates of CLA-BSI?
What hospitals currently use no coated / impregnated PICC or acute CVC and have gotten to almost zero or zero? How did they accomplish this?
Are there any contraindications to the coating / impregnated catheter?
Who currently does your dressing changes at the hospital and have you done a quality review for appearance and timeliness of dressing change. (anecdotally there seems to be a non intact, loose, dampened and soiled dressings)
What mechanism of education and quality check do we do for secondary and primary tubing sets?
What mechanism of education and quality check do we do for hub and needleless system access in every department?
How are nurses taught to flush after blood draws?
How is staff taught to obtain a catetheter culture or blood culture without contamnation?
Who rounds on central lines for necessity?
Who rounds on needleless systems to make sure they are changed in a timely interval according to policy?
Do you use a impregnated sponge at the insertion site and is it actually touching the site? Is it the right french size? Is the right side down? Is part of it touching the catheter and not the skin?
Getting to zero or near zero is not always easy and takes housewide education as almost every department interfaces with a central line. A central line is touched by every department in the house and not just ICU.
Kathy Kokotis RN BS MBA (previous Infection Preventionist)
Bard Access Systems
Antimicrobial/Antiseptic Impregnated Catheters and Cuffs
Recommendation
Use a chlorhexidine/silver sulfadiazine or minocycline/ rifampin -impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion [106–113]. Category IA
Background
Guidelines for the Prevention of Intravascular Catheter-Related Infections 37
Certain catheters and cuffs that are coated or impregnated with antimicrobial or antiseptic agents can decrease the risk for CRBSI and potentially decrease hospital costs associated with treating CRBSIs, despite the additional acquisition cost of an antimicrobial/antiseptic impregnated catheter [110]. Nearly all of the studies involving antimicrobial/antiseptic-impregnated catheters have been conducted using triple-lumen, uncuffed catheters in adult patients whose catheters remained in place <30 days. While most of the studies have been conducted in adults, these catheters have been approved by FDA for use in patients weighing >3 kg. Two non-randomized studies [112, 113] in pediatric ICU patients suggest that these catheters might reduce risk of catheter-associated infection. No antiseptic or antimicrobial impregnated catheters currently are available for use in infants weighing <3kg.
Chlorhexidine/Silver Sulfadiazine
Chlorhexidine/silver sulfadiazine catheters are more expensive than standard catheters. However, one analysis has suggested that the use of chlorhexidine/silver sulfadiazine catheters should lead to a cost savings of $68 to $391 per catheter [271] in settings in which the risk for CRBSI is high, despite adherence to other preventive strategies (e.g., maximal barrier precautions and aseptic techniques). Use of these catheters might be cost effective in ICU
Catheters coated with chlorhexidine/silver sulfadiazine only on the external luminal surface have been studied as a means to reduce CRBSI. Two meta-analyses of first-generation catheters [1, 263] demonstrated that such catheters reduced the risk for CRBSI compared with standard non-coated catheters. The duration of catheter placement in one study ranged from 5.1 to 11.2 days [264]. A second-generation catheter is now available with chlorhexidine coating the internal surface extending into the extension set and hubs while the external luminal surface is coated with chlorhexidine and silver sulfadiazine. The external surface has three times the amount of chlorhexidine and extended release of the surface bound antiseptics than that in the first generation catheters. All three prospective, randomized studies of second-generation catheters demonstrated a significant reduction in catheter colonization, but they were underpowered to show a difference in CRBSI [106–108]. Prolonged anti-infective activity provides improved efficacy in preventing infections [265]. Although rare, anaphylaxis with the use of these chlorhexidine/silver sulfadiazine catheters has been observed [266–270]. Guidelines for the Prevention of Intravascular Catheter-Related Infections 38patients, burn patients, neutropenic patients, and other patient populations in which the rate of infection exceeds 3.3 per 1,000 catheter days [264].
Minocycline/Rifampin
The decision to use chlorhexidine/silver sulfadiazine or minocycline/rifampin impregnated catheters should be based on the need to enhance prevention of CRBSI after bundled standard procedures have been implemented (e.g., educating personnel, using maximal sterile barrier precautions, and using >0.5% chlorhexidine preparation with alcohol for skin antisepsis) and then balanced against the concern for emergence of resistant pathogens and the cost of implementing this strategy.
In a multicenter randomized trial, CVCs impregnated on both the external and internal surfaces with minocycline/rifampin were associated with lower rates of CRBSI when compared with the first generation chlorhexidine/ silver sulfadiazine impregnated catheters [109]. The beneficial effect began after day 6 of catheterization. Silicone minocycline/ rifampin impregnated CVCs with an average dwell time of over 60 days have been shown to be effective in reducing CRBSI [111]. No minocycline/rifampin-resistant organisms were reported in these studies. Two trials demonstrated that use of these catheters significantly reduced CRBSI compared with uncoated catheters [110, 111]. No comparative studies have been published using the second-generation chlorhexidine/silver sulfadiazine catheter. Although there have been concerns related to the potential for development of resistance, several prospective clinical studies have shown that the risk is low [272, 273]. Further, no resistance to minocyline or rifampin related to the use of the catheter has been documented in the clinical setting. Two studies using decision model analysis revealed these catheters were associated with superior cost savings compared with first generation chlorhexidine/ silver sulfadiazine catheters [274, 275]. Such analysis needs to be done compared with the second-generation catheters. However, as baseline rates of infection decrease and the cost of catheters decrease, the cost-benefit ratio will likely change.Platinum/Silver
A combination platinum/silver impregnated catheter (i.e, a silver iontophoretic catheter) is available for use in the United States. Several prospective, randomized studies have been published comparing these catheters to uncoated catheters [276–279]. One study showed a reduction in the incidence density of catheter colonization and Guidelines for the Prevention of Intravascular Catheter-Related Infections 39CRBSI [278], but the other studies found no difference in catheter colonization or CRBSI between the impregnated catheter and a non-impregnated catheter [39, 276, 277]. In light of this, a firm recommendation for or against the use of these catheters cannot be made.
I wonder why the previous post by Kathy Kokotis was in Bold font and such large font?
I also wonder why people who have not experience with or expertise with an antimicrrobial PICC would be replying to such a post?
I would suggest you do some research and reach out to the two companies who make an antimicrobial PICC--Arrow and Cook. They are the companies that have the evidence to support the use of such a product. Ask to speak with a clinical speciialist for the product, they can refer you to studies that address your questions and concerns.
You may also do some research on your own about the two products, search under Google Scholar, PubMed and other journal search engines. I know Dr. Marcia Ryder has done some extensive research with antimicrobial PICCs and has seen good outcomes.
The companies can also give you some people to reach out to that are actually using the PICCs to get their feedback.
Good luck
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I am sorry about the bold. Did not mean to use large font.
To date there is only one study that is prospective, randomized and blinded on a PICC that is impregnated not coated. I suggest reading the study. It is always important to read studies.
Kathy
I am sorry about the bold. Did not mean to use large font.
To date there is only one study that is prospective, randomized and blinded on a PICC that is impregnated not coated. I suggest reading the study. It is always important to read studies.
Kathy
I am sorry about the bold. Did not mean to use large font.
To date there is only one study that is prospective, randomized and blinded on a PICC that is impregnated not coated. I suggest reading the study. It is always important to read studies.
Kathy