This 4-year observational experience with a bundled catheter care program demonstrated a low and declining CRBSI rate as reported per one thousand catheter days. The population of HPN patients was diverse with a multitude of clinicians providing the care for the HPN patient. Most of these physicians managed 1–2 HPN patients per year. It is likely that the bundled, standardized approach to catheter care contributed to this low incidence of CRBSI.
The incidence of CRBSI remains a topic of reporting from many clinicians and institutions. Table 7 provides a listing of reference articles for CRBSI infection in the HPN population and the reported CRBSI rates.(15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29) Only studies that included greater than 100 patients that were published since the year 2000 are listed in this table. These studies report a CRBSI rate between 0.35–3.20 per 1000 catheter days. These reports were also observational in nature. Some of the reports were based on surveys. No attempt was made to implement a specific CRBSI practice in these publications other than the practice that was ordered by the responsible clinician or was the standard of practice for the pharmacy compounding the PN or the nursing agency providing care for the HPN patient. The definition of CRBSI varied between the reported studies. There was no bundled approach to catheter care and maintenance. Many of these reports were single center reports and therefore do not represent a diverse patient population where multiple physicians are caring for patients at multiple unique sites. The majority of these studies reported out on only a small fraction of the patients included in this study.
Table 7
– CRBSI in HPN Patients in Published Reports of Greater than 100 Patients Since the Year 2000
Author | Patient Number | CRBSI Rate | Year |
Bozzetti et al (17) | 447 | .93/1000 catheter days | 2002 |
Colomb et al (18) | 302 | 1.20/1000 catheter days | 2007 |
Crispin et al (19) | 481 | 0.54/1000 catheter days | 2008 |
Elfassy et al (20) | 155 | 2.0/1000 catheter days | 2015 |
*Ireton-Jones et al (121 | 4540 | 0.66/1000 catheter days | 2005 |
Lloyd et al (22) | 188 | .85/1000 catheter days | 2006 |
Santarpia et al (23) | 222 | 3.20/1000 catheter days | 2002 |
Ugur et al (24) | 202 | 1.30/1000 catheter days | 2006 |
Violante et al (25) | 159 | 2.89/1000 catheter days | 2006 |
Cotogni et al (26) | 254 | .35/1000 catheter days | 2013 |
Vashi et al (27) | 241 | .54/1000 catheter days | 2017 |
Buchman et al (14) | 135 | .35/1000 catheter days | 2013 |
Dibb et al (28) | 588 | .38/1000 catheter days | 2016 |
*Report was on catheter-related infections (CRI) which included both CRBSI and CVC exit site infections. |
Understanding from the literature that HPN CRBSI rates were persistently higher than other home infusion therapies,, we developed a bundled approach to catheter maintenance appropriate for home care, utilizing a similar approach as in the Keystone Initiative in the hospital environment that was so effective. Our catheter care bundle (CCB) focuses on the post-CVC placement care and maintenance in the home setting within an HPN population. The interventions included the use of antimicrobial dressings, a protective device to be used when showering, a disinfecting cap, a PICC stabilization device and standardized patient education. In addition, patients were provided with a laminated mat to serve as their ‘clean space” for admixing components into their HPN. The mat contained instructions for maintaining CVC sterility
The use of antimicrobial dressings has been shown to have an impact on CVC infections. The AMD dressing® (Covidien, Minneapolis, MN) contains 0.2% polyhexamethylene biguanide (PHMB). PHMB is an antibacterial polymer and has been shown to inhibit bacterial growth. (30, 31)
Aquaguard® (Cenorin, Kent, WA) and Hydroseal® (2GMedical (Clearwater, FL) are moisture barriers which are placed over the CVC site and catheter during times of exposure to water, such as taking a shower. They replace hand-made devices such as a plastic bag placed over the CVC. The use of a protective cover from exposure to tap water contamination during showering and bathing has been shown to have an impact on CVC infections. (32, 33)
SwabCap® (ICU Medical, San Clemente, CA) and Curos™ (3M United States) are disinfecting caps for needle free intravascular connections. The cap itself contains 70% isopropyl alcohol on a sponge. A trauma intensive care unit (ICU) study demonstrated that the addition of a disinfecting cap to existing standard central line care bundles resulted in a 40% decrease in CRBSI.(34) Another study with a disinfecting cap was performed on adult patients with peripherally inserted central venous catheters (PICC) Compared to the baseline practice of catheter hub scrubbing alone, the use of a disinfecting cap reduced CRBSI.(35)
Peripherally inserted central venous catheters can cause vein damage, access site tissue inflammation and CRBSI if the PICC is not secured properly. A poorly secured PICC can “piston” in and out of a vascular access site, resulting in the delivery of skin-based microorganisms into the vein. StatLock® (BARD Medical, Covington, GA) and 3M® PICC Stabilization Device (3M® – Maplewood, MN) are vascular access stabilization devices. They have been shown to be an effective alternative to standard catheter fixation practices and avoids the use of sutures. Vascular access stabilization devices have been shown to reduce complications compared to unsecured CVCs, including CRBSI.(36)
Patient education is an important component of the care and management of CVC to prevent complications. The European Society of Parenteral and Enteral Nutrition Guidelines state that education should be provided to HPN patients. The teaching program should include catheter care, pump use, and preventing, recognizing and managing complications. Experienced nurses are usually best suited to take responsibility for the teaching program.(37) No time limits for training should be set; patients should be allowed to make progress at their individual pace.(38) It has been reported that patients who receive more detailed written and oral information on the aseptic management of catheters have a lower incidence of catheter sepsis.(39) It has also been reported in pediatric HPN patients that one of the factors improving the longevity of a CVC, including a reduction in associated infectious complications, was improved teaching of patients.(4) All of the patients in the study, irrespective of who was providing the nursing care, received the same education materials.
Central non-tunneled catheters had the lowest CRBSI rate; however, these catheters only represented 3% of the overall central venous catheters in the database. The highest level of reported CRBSI was with PICCs. PORTs had a significantly reduced CRBSI rate as compared to PICCs in 3 of the reported years. This finding was in contrast to previous published reports. A study in Japan in 68 HPN patients noted a CRBSI rate of 1.80/1000 catheter days with the use of a Port for HPN infusion as compared to .79/1000 catheter days for tunneled CVC. (40) Non-tunneled CVC and PICC were not used in this HPN population. Another report from Italy of 221 patients noted that the CRBSI rate was higher in patients with Port as opposed to patients with tunneled CVC. (23) They did not report out on non-tunneled CVC nor PICC. A Canadian report on HPN also noted that Port had an increased CRBSI rate as compared to PICC (2.4 vs 2.0/1000 catheter days respectively).(20) The difference in the results between previous publications and our current report may have been as a result of the number of patients reported on in our study which would have corrected for statistical errors that could be seen in smaller observational studies.
The type of nursing providing the CVC care and maintenance at home also impacted catheter outcome. The lowest CRBSI was noted with nursing employed or contracted by the specialty pharmacy home infusion provider or in patients who were “independent” and required no regular nursing visits (providing their own CVC maintenance and care). The highest CRBSI rate occurred in situations where the home infusion provider had no role in contracting with the assigned nursing agency, but rather that agency was assigned to the patient by the referral source or payer.
This study has its limitations. It is a retrospective, observational study. No attempt was made to equalize patient groups with regards to demographics or disease co-morbidities. No attempt was made to standardize the catheter care management interventions prior to the current CCB intervention bundle. Patient compliance with the CCB was not tracked. We did not collect data on a patient’s gastrointestinal anatomy, socioeconomic status, level of education or degree of family support. However, the number of patients reported in this study is the largest report of any HPN database; these large patient numbers can often mitigate result errors noted in retrospective clinical study designs.