Device-related infections have been a big problem for a long time. Advances have been made and clinicians have worked tirelessly to remedy the problem, but it simply hasn't been enough. These infections are still occurring and some of the repercussions are staggering.

The three most common device-related infections are central line-associated bloodstream infection, ventilator-associated pneumonia (VAP), and foley catheter-associated urinary tract infection (UTI). Recent studies have also named several medical implants¹ to the list. This is because the problem-causing infectious agents are difficult to eradicate because the bacteria that cause these infections live in well-developed biofilms. Total parenteral nutrition and femoral catheter devices² also have been mentioned and both have been tied to catheterrelated vancomycin-resistant E. faecium bacteremia to boot. Even surgical sutures now play a role in the etiology of infections because they too can harbor both gram negative and gram positive bacteria.³ 

According to data from the Centers for Disease Control and Prevention (CDC), the majority of serious catheter-related infections are associated with central venous catheters (CVCs). CVCs have long been associated with bloodstream infections (BSIs). In fact, approximately 90 percent of all catheter-related bloodstream infections (BSIs) occur with CVCs.

CDC says that these infections occur most commonly in those that are placed in patients residing in the intensive care units (ICUs). This is due mainly to the higher incidence and need of central venous access, and the extended periods of time in the hospital that may be required for this patient group. Patients often are afflicted with hospital-acquired organisms because the catheter is manipulated multiple times per day for the administration of fluids, drugs, and blood products. Moreover, some catheters are inserted in emergent situations, during which optimal attention to aseptic technique may not have occurred.

The CDC's published data on the incidence of these infections reflects that in the United States, 15 million CVC days occur in ICUs each year. At the average rate of CVC-associated BSIs of 5.3 per 1,000 catheter days in the ICU, approximately 80,000 CVC-associated BSIs occur in ICUs each year. Moreover the cost per infection is an estimated $34,508 to $56,000, and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $2.3 billion — in the U.S. alone.

What's worse is mortality attributable to these infections, which rest at an estimated 12 to 25 percent for each infection. Studies of catheterrelated bloodstream infections that control for the underlying severity of illness suggest that attributable mortality for these infections is somewhere between 4 and 20 percent, and it is estimated that between 500 and 4,000 U.S. patients die annually due to these BSIs, according to CDC statistics.

Lynn Hadaway, MEd, RNC, CRNI, president of Lynn Hadaway Associates Inc., long-time member of the Infusion Nurses Association (INA), and executive director of the National Alliance for the Primary Prevention of Sharps Injuries (NAPPSI), says the CDC data is the best data currently available, however, she points out that it is just related to critical care patients in an ICU environment. She adds that CDC's document states that 80,000 BSIs occur annually in US ICUs, but she says, "If you look at the entire hospital, that number jumps to about 250,000, and when you look at the entire healthcare system, the number of catheter-related BSI is estimated to be as high as 500,000."

Hadaway explains that the biggest problems that stem from CVCs are BSIs and thrombosis. Infiltrations, extravasations, and nerve damage can occur from all kinds of catheters as well.

The percutaneously-placed CVCs U.S. the ones that go in directly through the jugular vein U.S. carry the greatest risk of infection, according to Hadaway. The risk comes from the skin because the skin in that area is oily and the density of the organisms of the skin in that area is greater. She also explains that there is increasing concern about the infection risk with peripherally inserted central catheters (PICCs) now too.

"Traditionally, we thought PICCs had a very low infection rate, but that data has primarily come from home care where the risk is going to be lower than a hospital situation. There is one article that shows that in hospital outpatients, the infection rate with PICCs is about equal to other CVCs," she declares.

Hadaway further explains that the arm, where the PICC is inserted, holds a lower risk than the other more organism-laden areas of the body. She says this is due to the dry skin on the extremities having a different profile of bacteria, and a different density of organisms compared to the neck and the chest where the other types of CVCs commonly are inserted.

"But that's still only looking at roughly half the picture," she notes, "because the other half of the risk comes from hub manipulation and catheters that have been in for long times (e.g. several weeks, months) have a greater risk of being infected from hub manipulation compared to skin. So it is what the caregiver is doing to the hub of the catheter that increases the risk of infection. You could have a very high infection rate with tunnel catheters or PICCs or implanted ports, due to hubs, not skin."

She offers that the remedy for this is a standardized approach that is research-based. For example, she points out what the 100K Lives Campaign, launched by the Institute for Healthcare Improvement, implemented in its program relating to lowering device-related infections.

"They are taking the most effective approach," Hadaway says, "because they have bundled a set of practices together. They really have good data that supports the number of lives they have saved", she adds, and, "that bundling approach, when you do all five steps, has been documented to decrease infection rates."

The Central Line Bundle used in the 100K Lives Campaign is a group of evidence-based interventions for patients with intravascular central catheters that, "when implemented together, result in better outcomes than when implemented individually," notes Hadaway.

The key components of the Central Line Bundle are: