Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis.

AIM: This paper is a report of a systematic review and meta-analysis of strategies, other than antimicrobial coated catheters, hypothesized to reduce risk of catheter-related bloodstream infections and catheter colonization in the intensive care unit setting. BACKGROUND: Catheter-related bloodstream infections occur at a rate of 5 per 1000 catheter days in the intensive care unit setting and cause substantial mortality and excess cost. Reducing risk of catheter-related bloodstream infections among intensive care unit patients will save costs, reduce length of stay, and improve outcomes. METHODS: A systematic review of studies published between January 1985 and February 2007 was carried out using the keywords 'catheterization - central venous' with combinations of infection*, prevention* and bloodstream*. All included studies were screened by two reviewers, a validated data extraction instrument was used and data collection was completed by two blinded independent reviewers. Risk ratios for catheter-related bloodstream infections and catheter colonization were estimated with 95% confidence intervals for each study. Results from studies of similar interventions were pooled using meta-analyses. RESULTS: Twenty-three studies were included in the review. The strategies that reduced catheter colonization included insertion of central venous catheters in the subclavian vein rather than other sites, use of alternate skin disinfection solutions before catheter insertion and use of Vitacuff in combination with polymyxin, neomycin and bacitracin ointment. Strategies to reduce catheter-related bloodstream infection included staff education multifaceted infection control programmes and performance feedback. CONCLUSION: A range of interventions may reduce risks of catheter-related bloodstream infection, in addition to antimicrobial catheters.

A systematic review comparing the relative effectiveness of antimicrobial-coated catheters in intensive care units.

BACKGROUND: Bloodstream infection related to a central venous catheter is a substantial clinical and economic problem. To develop policy for managing the risks of these infections, all available evidence for prevention strategies should be synthesized and understood. METHODS: We evaluate evidence (1985-2006) for short-term antimicrobial-coated central venous catheters in lowering rates of catheter-related bloodstream infection (CRBSI) in the adult intensive care unit. Evidence was appraised for inclusion against predefined criteria. Data extraction was by 2 independent reviewers. Thirty-four studies were included in the review. Antiseptic, antibiotic, and heparin-coated catheters were compared with uncoated catheters and one another. Metaanalysis was used to generate summary relative risks for CRBSI and catheter colonization by antimicrobial coating. RESULTS: Externally impregnated chlorhexidine/silver sulfadiazine catheters reduce risk of CRBSI relative to uncoated catheters (RR, 0.66; 95% CI: 0.47-0.93). Minocycline and rifampicin-coated catheters are significantly more effective relative to CHG/SSD catheters (RR, 0.12; 95% CI: 0.02-0.67). The new generation chlorhexidine/silver sulfadiazine catheters and silver, platinum, and carbon-coated catheters showed nonsignificant reductions in risk of CRBSI compared with uncoated catheters. CONCLUSION: Two decades of evidence describe the effectiveness of antimicrobial catheters in preventing CRBSI and provide useful information about which catheters are most effective. Questions surrounding their routine use will require supplementation of this trial evidence with information from more diverse sources.

Effect of healthcare-acquired infection on length of hospital stay and cost.

OBJECTIVE: To estimate the independent effect of a single lower respiratory tract infection, urinary tract infection, or other healthcare-acquired infection on length-of-stay and variable costs and to demonstrate the bias from omitted variables that is present in previous estimates. DESIGN: Prospective cohort study.Setting. A tertiary care referral hospital and regional district hospital in southeast Queensland, Australia. PATIENTS: Adults aged 18 years or older with a minimum inpatient stay of 1 night who were admitted to selected clinical specialities. RESULTS: Urinary tract infection was not associated with an increase in length of hospital stay or variable costs. Lower respiratory tract infection was associated with an increase of 2.58 days in the hospital and variable costs of AU $24, whereas other types of infection were associated with an increased length of stay of 2.61 days but not with variable costs. Many other factors were found to be associated with increased length of stay and variable costs alongside healthcare-acquired infection. The exclusion of these variables caused a positive bias in the estimates of the costs of healthcare-acquired infection. CONCLUSIONS: The existing literature may overstate the costs of healthcare-acquired infection because of bias, and the existing estimates of excess costs may not make intuitive sense to clinicians and policy makers. Accurate estimates of the costs of healthcare-acquired infection should be made and used in appropriately designed decision-analytic economic models (ie, cost-effectiveness models) that will make valid and believable predictions of the economic value of increased infection control.

Experiences of the generalist nurse caring for adolescents with mental health problems.

Mental healthcare for adolescents is currently provided in a range of settings, including general hospital wards and paediatric wards, although care of adolescents with mental health problems in general settings has not been evaluated. This descriptive study surveyed generalist nurses who provide care to adolescents with mental health problems in the general hospital setting to determine satisfaction with their abilities to provide care, challenges encountered in care provision and strategies to provide optimal care by these nurses. Participants included 30 generalist nurses (response rate of 73%) from two wards in a tertiary paediatric hospital in Queensland, Australia. The survey findings showed that 67 percent of the respondents felt inadequately prepared to care for this group and only 41 percent were satisfied with their ability to provide care. Strategies identified to improve nursing care included: enhancement of continuity of care and teamwork, provision of appropriate environmental facilities, greater support from specialist mental health nurses and further education on caring for adolescent mental health problems.