Better Vascular Access Management : Key to prevent and control infections
The discovery of antibiotics was probably one of the most helpful and successful ones in the history of medicine. It is a well-established fact that antimicrobials have helped save many lives and played a significant role in controlling infections that contribute to the greatest number of complications and deaths in humans. However, the rapid increase in antibiotic resistance has been a matter of serious concern. WHO has declared Antimicrobial Resistance (AMR) to be amongst the top 10 global public threats1 to the human, animal, and environmental health, leading to exposure, spread, and persistence of multidrug-resistant (MDR) bacteria or "superbugs".
Researchers at the Center for Disease Dynamics, Economics & Policy (CDDEP) report that the number of hospital-acquired deaths is higher among patients infected with multi-drug resistant (MDR) or extensively drug-resistant (XDR) pathogens such as Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae2.
Results from this study reported that patients who had MDR bacterial infections were 1.57 times more likely to die, compared to patients with similar susceptible infections, while patients who contracted XDR infections were 2.65 times more likely to die when accounting for age, sex, site of infection, and the number of co-infections2.
In both the ICU and non-ICU, death rates were higher among patients with XDR infections; and this association was driven by Gram-negative infections (e.g., XDR K. pneumoniae). This fact emphasizes the importance of rapid detection of these infections among all patients2.
Patients can acquire MDR and XDR bacterial infections during their stay at a hospital, and effective antibiotic therapies for these infections are scarce. As antibiotic resistance shows no signs of decline, the focus is now on the prevention of infections.
Let's have a look at the most common healthcare-associated infection:
Hospital-acquired infections (Nosocomial infections)
Hospital-acquired infections (HAIs), also known as healthcare-associated infections (HCAI), are infections occurring in a patient in a hospital or other healthcare facility in whom the infection was not present at the time of admission3.
Amongst the hospital-acquired infections, those acquired in the ICU are very high.
HAIs are a major problem for patient safety and have a high impact on morbidity and mortality4,5.
Device associated infections
Hospitals and other healthcare facilities use various invasive devices to treat patients and help them recover. Commonly used devices include catheters or ventilators, and improper use of these devices may give rise to infections.
The 2014 fact sheet of WHO6 states that the low-and middle-income countries show up to 13 times more device-associated infections than the USA.
Therefore, it is critical to focus on preventive measures to help bring down the infection rate in hospitals and ICUs. This will also help reuce the financial burden on the patient and protect the hospital's reputation.
Vascular access devices are one of the primary origins of infections in a healthcare setting.
Hospitals and healthcare staff should make use of Care Bundles to provide safe and effective care to their patients, thereby reducing the risk of various infections. A 'Care bundle' is a set of interventions that can significantly and satisfactorily improve outcomes in patients. International guidelines recommend some key practices and 'care' to be taken during the use of vascular devices. Especially, when it comes to the usage of venous catheters, certain key practices to note include7,8:
• Scrub hands for minimum 20 seconds with an alcohol-based hand rub orantimicrobial soap and water before inserting the catheter
• Perform skin antisepsis using > 0.5% chlorhexidine in alcohol solution
• Use needle-free connectors (NFCs) that allow injection or infusion via gravity or pump
• Use split-septum needleless devices that reduce the risk of CRBSIs
• Change dressings at a frequency based on the type of dressing
• Perform normal saline flushing once daily to improve the patency of catheter
• Use pre-filled saline syringe to reduce the risk of catheter-related bloodstream infections (CRBSI) and to prevent syringe-induced blood reflux
• Use sterile normal saline for injection to flush and lock catheter lumens that are accessed frequently
• Train the relevant personnel in catheter insertion and care
International guidelines recommend use of pre-filled saline syringes for flushing vascular access devices and certain disinfection practices7-9.
Some of these recommendations include:
● Scrubbing the hub for 5 to 15 seconds based on the needle-free connector type
● Use of 70% isopropyl alcohol or alcoholic chlorhexidine to disinfect access surface of the needle-free connectors (NFCs)
● Flushing of vascular devices with sterile preservative-free 0.9% sodium chloride
● Flushing before every infusion to access catheter function and prevent complications
● Flushing post-infusion for clearance of the infused medication from the catheter lumen, to reduce the risk of contact between incompatible medications
● Use of pre-filled saline syringes to help save staff time for syringe preparation
● Locking of the device after completion of the final flush to prevent intraluminal occlusion and CRBSIs
Thus, appropriate use of the right kind of vascular access devices can certainly make a difference! Hospitals should not make any compromise on quality and type of device for the sake of saving costs because such cost-cutting may result in increased financial loss and even cost the patients' lives. Remember, the hospital and doctor reputation can be at stake if the infections are high. Hence, it is critical to follow strict infection control practices in all IPD settings.
Antibiotics are becoming increasingly ineffective as drug resistance spreads globally. This global threat is making it more difficult to treat infections and leading to deaths. To overcome this threat, healthcare facilities need to invest in all possible 'care', including staff training, setting up 'infection control committees', and using vascular access devices that can help prevent and control infections. It can help reduce the use of high antibiotics that are so precious and required to be preserved for future use in difficult-to-treat infections.
References:
1. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
2. https://cddep.org/wp-content/uploads/2018/11/November-16-2018-Drug-resistant-infections-associated-with-higher-in-hospital-mortality-rates-in-India.pdf
3. Benenson AS. Control of communicable diseases manual. 16th ed. Washington: American Public Health Association; 1995.
4. Burke JP. Infection control – A problem for patient safety. N Engl J Med. 2003;348:651–6.
5. Allegranzi B, BagheriNejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet. 2011;377:228–41.
6. https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
7. Infusion Nurses Society. Infusion Nursing Standards Practice. J InfusNurs. 2021
8. Infusion Nurses Society. Infusion Therapy Standards of Practice. J InfusNurs. 2021;39(1S):S65,33.II.D.
9. Satou, Kenichi &Kusanagi, Risa&Nishizawa, Aya& Hori, Satoshi. (2018). 'Scrubbing' technique for needleless connectors to minimize contamination risk. Journal of Hospital Infection. 100. 10.1016/j.jhin.2018.03.015.
