It’s in the Blood

30 September 2008 (Last Updated September 30th, 2008 18:30)

Bruce Gingles of Cook Medical discusses the key elements to best-practice infection prevention. He focuses on the key issue of on catheter-related bloodstream infections.

It’s in the Blood

In today's health-conscious and litigious world, we are constantly bombarded by the media with horror stories about healthcare-associated infections (HCAIs), which are often blamed on negligence and incompetence.

The key to getting a grip on infection control lays across many different levels of treatment, from basic cleanliness, the oft-mentioned 'deep clean', and on to more technical approaches embracing the latest medical device technology. A critical element of HCAIs are catheter-related bloodstream infections (CRBSIs).

In the UK, increasing concern about HCAIs from NHS Trusts, politicians and the public means the need for a better way to treat patients has never been greater. According to the National Audit Office there are at least 100,000 hospital infections a year in the UK, and over 60% of these are blood infections introduced by intravenous feeding lines, catheters or similar devices.

The NHS provides a landscape for heated political discussion. The issue of reducing HCAIs has fuelled the passion with which the debate is being contested.

Recent policy proposals from opposition Conservative Party leader David Cameron, if accepted, would result in hospitals being fined for each patient that contracts an infection (or non-reimbursement if a patient does contract an infection) while receiving treatment.

"Catheter-related bloodstream infections (CRBSIs) account for a third of all bloodstream infections in England."

Health economics – prevention first

By preventing infection rather than trying to treat the condition once contracted, hospital trusts can achieve numerous benefits. The patient journey is dramatically quickened, resulting in less time spent in hospital and less likelihood of contracting an infection in situ.

This has a positive fiscal and human resource effect. Fewer bed days, particularly in high-dependency units, and reduced requirement for expensive treatment and aftercare all combine to reduce the economic impact.

The concept of total cost of ownership has long been recognised in the business world as a way of measuring the economic impact of a specific process, product or application. Perhaps it is time that health decision-makers (especially those responsible for reducing risk) accurately measure and recognise the importance of the total cost of treating a patient.

This encapsulates all aspects of a patient's treatment, or journey, from diagnostic tests through to nursing hours, medicine, outpatient costs and bed days. By being aware of the total impact of a single patient, decision-makers are better informed to make decisions about treatment options and start to identify the benefits associated with infection prevention.

Those responsible for procurement in hospitals are already aware that the cheapest option is not necessarily the best. A greater initial outlay in more effective or better-developed products and devices can combine to reduce costs in the long term. This is mirrored in the overarching procurement policy for the NHS as outlined by the NHS Purchasing and Supply Agency (PASA).

The policy sets out the legal framework within which all procurement in the NHS should be conducted. The document states that: 'NHS contracting authorities should therefore adopt the integrated procurement framework.

'A ministerial steering group will monitor its implementation across the NHS – in particular, to ensure that true value is achieved rather than simply lowest price (that is, when viewed on a whole-life cost basis) and its delivery across a broader set of benefits.'

Prevention first

The series of 'deep clean' campaigns currently underway are not enough to prevent the spread of infection as a stand-alone measure. Every infection prevention specialist will advise that a hospital should undergo a deep clean twice a year as a matter of course, while also ensuring that all members of staff are fully educated and compliant with basic hygiene standards.

"The series of 'deep clean' campaigns currently underway are not enough to prevent the spread of infection as a stand-alone measure."

Decades of data demonstrate that education without the elimination of barriers to this seemingly simple challenge rarely achieves sustainable compliance. The introduction of new sanitising hand products that can be dispensed easily at a variety of locations has significantly enhanced compliance from a basic hygiene perspective.

The UK's Department of Health requires that healthcare workers wash or sanitise their hands with an alcohol-based rub both before and after contact with each patient. Additionally, the use of gloves during patient care can also help to reduce transmission of infectious agents to patients.

Hospital personnel should remember that gloves should always be changed when moving from a contaminated site to a clean site on the same patient, and should never serve as a substitute for proper hand hygiene.

However, to truly address this issue, hospitals must start to look beyond the basic cleaning and hygiene measures to new innovations and unique technologies in medical devices to protect patients using preventative approaches.

Device technology and improved techniques

Such advanced devices may include catheters, urinary tract stents, wound dressings and chest tubes. Catheters are an ideal example for demonstrating how specific devices form vital keys in the battle against infection. Catheters are particularly important as they are commonly used in patients in high-dependency units often at particular risk of contracting an infection.

With such a high-risk patient group, catheter-related bloodstream infections (CRBSIs) account for a third of all bloodstream infections in England, according to the Department of Health. Additionally, they are associated with higher costs than the other most common infections and the frequency in which infections occur is on the increase.

When inserting intravenous devices such as catheters, healthcare workers are advised to implement full barrier sterile precautions. These precautions include wearing a cap, mask, sterile gown, sterile gloves, and a large area drape that extends well beyond the working field.

In order to reduce infection rates, hospitals should also consider the use of antimicrobial or antibiotic-coated catheters in patients. The synergistic combination of antimicrobial agents contained within the catheter material helps protect patients from the bacterial organisms that can cause infection.

"The latest generation of catheters are impregnated with the antibiotics minocycline and rifampin both internally and externally."

Catheter device innovation: from antiseptic to antibiotic

Initially, companies began producing catheters with an antiseptic surface coating in an attempt to fight infection. These coatings provide only limited anti-infective durability, however.

As a result manufacturers quickly began developing alternatives such as catheters coated on one side with chlorhexidine gluconate and silver sulfadiazine to form
an antibacterial agent. These devices provided some protection against HCAIs and their use did reduce a patient's risk of contracting an HCAI. But reduced risk is not enough. Everything possible must be done to prevent infection occurring.

The latest generation of catheters are impregnated with the antibiotics minocycline and rifampin both internally and externally. This uniquely synergistic antibiotic combination provides broad-spectrum activity against gram positive and gram negative infections.

Many studies over the past ten years have proven that using antimicrobial-impregnated catheters, rather than unimpregnated catheters, can drastically reduce the risk of CRBSI occurrence when used correctly.

A report in the New England Journal of Medicine stated that catheters impregnated with minocycline and rifampin, such as the Spectrum range from Cook Medical, were 12 times less likely to have a catheter-related bloodstream infection when compared with catheters coated with chlorhexidine gluconate and silver sulfadiazine¹.

This offers the patient a better defence against bacteria such as MRSA and associated HCAIs. Of course, antimicrobial and antibiotic-impregnated medical devices should be used in conjunction with best-placement practice to achieve the most effective outcome.

Antibiotic resistance

The evolutionary nature of infectious diseases has led to the current situation in which pharmaceutical companies must constantly search for new treatments to old infections due to the rise of antibiotic-resistant strains of bacteria.

In line with this, there are staph strains such as MRSA that have developed resistance to the antibiotics used to treat them. When questioning whether any resistance can be attributed to exposure to drug-coated catheters, the answer lies in the advanced technology of the devices being used.

"Those responsible for managing risk or with purchasing responsibility need to be sure that they are selecting catheters that reduce the risk of infection."

In a recent clinical study involving the Cook Spectrum catheters impregnated with minocycline and rifampin, the use of these catheters 'has been shown to decrease the use of systemic antibiotics such as Vancomycin, thus decreasing both cost and potential development of resistance'².

In addition to this, other studies have proven that this same combination is extremely effective and that 'no organisms resistant to these two agents were discovered'³.

This is partly due to the combination of two antibiotic agents, which makes it harder for the infection to adapt to resist the antibiotics as each works in a different way. In addition, unlike many antibiotics, minocycline and rifampin are not used as a primary treatment for bloodstream infections and do not leach or elute into the bloodstream from the catheter.

The use of this treatment has been shown to be successful because the infection has not had an opportunity to develop resistance to the antibiotic agents, especially when in combination. This increases the catheter's effectiveness at reducing the risk of infection.

Those responsible for managing risk or with purchasing responsibility need to be sure that they are selecting catheters that reduce the risk of infection; those that best protect patients from blood infections. This will ensure that patients can be treated safely, while reducing the possibility of contracting an infection – eliminating costly extended stays in the hospital for further treatment. Long term, this will dramatically improve patient well-being and reduce hospital expenditures.

References

1. Darouiche R, Raad I et al. 'A Comparison of Two Antimicrobial-Impregnated Central Venous Catheters'. New England Journal of Medicine 340. 1999; pp1–8.

2. Gilliam C, Yamauchi T, Robertson R, Meredith S, Schenaxayder S, Arkansas Children's Hospital. Little Rock, AR. 'Decrease In Bloodstream Infection Rates Using an Antibiotic Impregnated Catheter in Critical Care Units of a Pediatric Hospital,' Abstract of paper presented at the Infectious Diseases society of America Conference, September 2000, New Orleans, LA.

3. Raad I, Darouiche R, Hachem R et al. 'Antibiotics and Prevention of Microbial Colonization of Catheters'. Antimicrobial Agents and Chemotherapy. 1995: 39(11); pp2,397–2,400.