Prevention of Device-Related Healthcare-Associated Infections

Healthcare-associated infections (HAIs) are a leading cause of morbidity and mortality in hospitalized patients. Up to 15% of patients develop an infection while hospitalized in the United States, which accounts for approximately 1.7 million HAIs, 99,000 deaths annually and over 10 billion dollars in costs per year. A significant percentage of HAIs are preventable using evidenced-based strategies. In terms of device-related HAIs it is estimated that 65-70% of catheter-line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are preventable. To prevent CLABSIs a bundle which includes hand hygiene prior to insertion and catheter manipulation, use of chlorhexidene alcohol for site preparation and maintenance, use of maximum barrier for catheter insertion, site selection, removing nonessential lines, disinfect catheter hubs before assessing line, and dressing changes are essential elements of basic practices. To prevent CAUTIs a bundle that includes hand hygiene for insertion and catheter or bag manipulation, inserting catheters for appropriate indications, insert using aseptic technique, remove catheters when no longer needed, maintain a close system keeping bag and tubing below the bladder are the key components of basic practices.

Health care-associated infections (HAIs) are a leading cause of morbidity and mortality in hospitalized patients. Up to 15% of patients develop an infection while hospitalized. In the US, this accounts for approximately 1.7 million HAIs and 99,000 deaths annually. HAIs are now the fifth leading cause of death in US acute care hospitals 1 . A recent report estimated US health care system costs attributable to the five most common HAIs-central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia, surgical site infection, and Clostridium difficile infection-to be $9.8 billion, even without considering the sizable societal costs 2 . We now know a significant percentage of HAIs are preventable by using evidence-based strategies 3 . In terms of device-related HAIs, it is estimated that 65% to 70% of CLABSIs and CAUTIs are now preventable. There is now coordination of federal efforts aimed at HAI prevention, including public reporting of hospital-specific HAI rates and linking hospital-specific HAI performance to financial reimbursement as a strategy to motivate hospitals' HAI prevention efforts. Since 2011, hospitals have been required to report CLABSIs among patients in intensive care units (ICUs) to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) in order to qualify for annual payment updates. CAUTI reporting in ICUs was added in 2012. In addition, starting in 2015, CLABSIs and CAUTIs are reported in general medical surgical wards. Along with other quality metrics, these HAI data will be used to determine hospital-specific Centers for Medicare & Medicaid Services reimbursement levels as part of value-based purchasing, thereby shifting reimbursement from volume-driven to performance-driven.
Evidence-based recommendations provided through guidelines or guidance documents form the foundation for HAI prevention efforts. Translating knowledge into practice requires an integrated approach to address both technical and adaptive work, including a deep understanding of the health care delivery system and human behavior, fostering engagement and ownership of the improvement process by local interdisciplinary teams, creating centralized support for the technical work, encouraging local adaptation of the intervention bundle, and ensuring a collaborative culture within the facility 4 . The use of prevention bundles has been shown to reduce HAI rates. A bundle is best defined as a grouping of evidence-based practices that individually improve care. A number of studies have demonstrated the impact of catheter insertion and maintenance bundles on CLABSI rates and have shown that CLABSI prevention bundles are effective, sustainable, and cost-effective for both adults and children 5,6 . Bundles have also been used in successful multifaceted efforts to reduce CAUTI 7 . The purpose of this article is to review the strategies to prevent device-related infections, CLABSIs and CAUTIs.

Catheter line-associated bloodstream infection
An estimated 41,000 CLABSIs occurred in the US in 2009 8 . Although the primary focus over the last two decades has been the ICU, the majority of CLABSIs occur outside the ICU 9 . In 2013, Zimlichman et al. published a meta-analysis of costs and financial impact of HAIs on the US health care system 2 . On a per-case basis, CLABSIs were found to be the most costly HAIs at $45,814.
There are two major sources for contaminated catheters and subsequent CLABSI: (1) colonization at the insertion site with migration of organism(s) along the external surface of the catheter is the most common source of CLABSI in catheters within the first week of catheterization, and (2) direct contamination of connectors/hubs resulting in internal colonization and subsequent CLABSI is the major source in catheters in place for at least 1 week. Less commonly, catheters can be seeded hematogenously from another site of infection and rarely from contaminated intravenous (IV) fluids 10 .
CLABSI is a term used for surveillance purposes by the CDC's NHSN to identify bloodstream infections (BSIs) that occur in patients with a central venous line. A central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. A laboratory-confirmed CLABSI (LCBI) is where a central line was in place for more than 2 calendar days on the date of event, with day of device placement being day 1, and a central line was in place on the date of event or the day before. If a central line was in place for more than 2 calendar days and then removed, the date of event of the LCBI must be the day of discontinuation or the next day. There are two criteria: (1) the patient has a recognized pathogen cultured from one or more blood cultures, and the organism cultured from blood is not related to an infection at another site, or (2) the patient has at least one of the following signs or symptoms: fever (>38.0°C), chills, or hypotension and the organism cultured from blood is not related to an infection at another site, and the same common commensal-i.e. diphtheroids (Corynebacterium spp. not C. diphtheriae), Bacillus spp. (not B. anthracis), Propionibacterium spp., coagulase-negative staphylococci (including S. epidermidis), viridans group streptococci, Aerococcus spp., and Micrococcus spp.-is cultured from two or more blood cultures drawn on separate occasions 11 . Prevention strategies are divided into insertion and maintenance, as well as basic practices and special approaches. Basic practices should be implemented in all acute care hospitals, whereas special approaches should be considered only when CLABSIs are not controlled by use of basic practices 12 (Table 1).

Insertion
1. Have a process, such as a checklist, to ensure compliance with evidence-based infection prevention strategies to prevent CLABSIs. 11. Replace administration sets not used for blood, blood products, total parenteral nutrition (TPN), or lipids at intervals of no longer than 96 hours. Administration sets used for blood, blood products, TPN, or lipids should be changed every 24 hours.
13. Use a CHG-containing dressing for central venous catheters in patients over 2 months of age.
14. Use an antiseptic-containing cap to cover connectors.
15. Antimicrobial lock solutions in select populations. 6. Replace administration sets not used for blood, blood products, total parenteral nutrition (TPN), or lipids at intervals of no longer than 96 hours. Administration sets used for blood, blood products, TPN, or lipids should be changed every 24 hours 12 .
Special approaches 1. Antimicrobial-/antiseptic-impregnated catheters: Use of a chlorhexidine/silver sulfadiazine-or minocycline/ rifampin-impregnated CVC in adults whose catheter is expected to remain in place for more than 5 days has been shown to reduce the risk of CLABSIs 28,29 .
2. Use a CHG-containing dressing for CVPs in patients over 2 months of age: in a large multicenter randomized controlled trial, the investigators compared chlorhexidineimpregnated sponge dressing versus standard dressings in ICU patients. They found a significant reduction in CLABSIs (6/1953 catheters, 0.40 versus 17/1825 catheters, 1.3 per 1000 catheter-days; hazard ratio 0.24, 95% CI 0.09 to 0.65) 30 . In a follow-up study, the authors published a large randomized trial using a CHG-gel-impregnated transparent dressing and also found a significant decrease in CLABSIs 31 .
3. Use an antiseptic-containing cap to cover connectors: in an observational trial in a tertiary care unit, the practice of central line hub care was changed from cleaning with alcohol wipes to using alcohol-impregnated protectors.
The implementation of alcohol-impregnated protectors significantly reduced the rate of CLABSIs. Owing to concern over the development of antimicrobial resistance, there has been recent interest in non-antibiotic antimicrobial solutions such as ethanol 35 . The effectiveness of ethanol has been studied almost exclusively in hemodialysis patients, demonstrating a reduction of CLABSIs with long dwell times.

Catheter-associated urinary tract infection
Urinary tract infections (UTIs) are common hospital-acquired infections accounting for 15% of HAIs, and approximately 70% are associated with an indwelling urethral catheter. Up to 16% of inpatients have a urinary catheter at some point during their admission 1 . Although the primary focus over the last two decades has been the ICU, the majority of CAUTIs occur outside the ICU 36 .
In 2013, Zimlichman et al. published a meta-analysis of costs and financial impact of HAIs on the US health care system 2 . On a percase basis, CAUTIs cost at least at $896. The incidence rate was third highest among US adult inpatients. In addition, there are many non-infectious complications that are at least as common as urinary tract infections (UTIs). Urinary catheters can operate as physical restraints by reducing mobility, leading to increased falls, risk of venous thromboembolism, and pressure ulcers 37 . Leakage, urethral strictures, gross hematuria, and blockage have also been reported 38 .
The major contributing risk for developing CAUTI is the duration the urinary device is present. Other risk factors include meatal colonization with uropathogens, microbiological colonization of the draining bag, and gaps in catheter insertion and care.
CAUTI is a term used for surveillance purposes by the CDC's NHSN to identify UTIs that occur in patients with an indwelling Foley urinary catheter. A laboratory-confirmed CAUTI is where the indwelling urinary catheter is in place for more than 2 calendar days on the date of event, with day of device placement being day 1, and an indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for more than 2 calendar days and then removed, the date of event of the CAUTI must be the day of discontinuation or the next day. In 2015, two significant changes occurred in the surveillance definitions: (1) retirement of cultures with less than 100,000 colony-forming units (CFU)/ml and positive urinalysis diagnostic tests, and (2) removal of Candida species and yeast in the qualifying urinary pathogen list.
The 2015 surveillance criteria for symptomatic UTI in adults are the patient has a recognized pathogen cultured from urine of no more than two organism species, where at least one organism is a bacteria of more than 100,000 CFU/ml and the patient has at least one of the following signs or symptoms: fever (>38.0°C), suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency or dysuria, where symptoms except for fever have no other recognized cause within the infection window period 39 . Prevention strategies are divided into basic practices of insertion, maintenance, and removal and should be implemented in all acute care hospitals 40 (Table 2).
Insertion 1. Establish processes to assess for medical necessity for patient care and appropriateness of device in care areas such as emergency room, ICU, non-ICU ward, perioperative suites, and inserting urinary catheters. Table 3 includes suggested indication for urinary catheter insertion 40 . Consider alternative devices or intermittent catheterization when applicable. One statewide effort reduced catheter device utilization through education and monitoring compliance with appropriate indications 41 .
2. Perform hand hygiene before and after insertion.
3. Cleanse or perform pericare to remove gross material prior to applying antiseptic solution to maximize antiseptic bioactivity and minimize introduction of bacteria, fluids, and secretions into the bladder.
4. Use aseptic insertion technique and sterile supplies. Allinclusive prepackaged kits or having necessary supplies conveniently located support aseptic insertion and evidence-based practice.
5. Apply securement device to prevent movement and traction.

Insertion
• Assess for medical necessity and appropriateness of device.
• Hand hygiene • Cleanse or perform pericare to remove gross material prior to applying antiseptic solution.
• Use aseptic insertion technique and sterile supplies.
• Apply securement device to prevent movement and traction.

Maintenance
• Hand hygiene before and after catheter or bag manipulation.
• Regular pericare and incontinence care to keep catheter clean.
• Maintain a sterile, continuous closed system.
• Maintain unobstructed flow, minimizing dependent loops and kinks.
• Keep bag below bladder, including during transport.
• Collect urine from the port, not drain tubing.
• Empty drain bag regularly by using a patient-dedicated collection container.
• Assess daily for medical necessity and appropriateness of device.
• Replace devices when breaks or leaks occur with the catheter and collection system.

Removal
• Remove when no longer medically necessary.
• Implement approved device removal protocols (intensive care unit, wards, and post-anesthesia care unit).
• Support toileting and consider alternative urinary devices.
• Use bladder scanners to assess urinary retention.

Maintenance
1. Perform hand hygiene before and after catheter or bag manipulation.
2. Perform regular pericare and incontinence care to keep catheter clean.
3. Practice bundles to optimize unobstructed urine flow include the following: ○ Maintaining a sterile, continuous closed system.
○ Minimizing dependent loops and kinks.
○ Keeping bag below bladder, including during transport.
○ Emptying urine from the collecting bag regularly by using a patient-dedicated collection container.
4. Collect urine samples from the port, not drain tubing.
5. Replace devices when breaks or leaks occur with the catheter and collection system. 3. Do not change catheters routinely.

Summary
Effective sustainable reduction of CLABSIs and CAUTIs requires a multifaceted approach implementing evidence-based strategies plus an adaptive approach which aligns health care professional behaviors. We have made significant progress in the last 10 years, but more can be done in eliminating preventable CLABSIs and CAUTIs.
Competing interests ES and JM are currently conducting a trial in which participating hospitals are receiving products contributed by Mölnlycke Health Care (Gothenburg, Sweden) and Sage Products (Cary, IL, USA). However, the manufacturers had no part in the design or implementation of the trials.

Grant information
The author(s) declared that no grants were involved in supporting this work. • Perioperative use for selected surgical procedures, such as urologic surgery or surgery on contiguous structures of the genitourinary tract; prolonged surgery; large-volume infusions or diuretics during surgery; or intraoperative monitoring of urine output needed.
• Hourly assessment of urine output in patients in an intensive care unit.
• Management of acute urinary retention and urinary obstruction.
• Assistance in healing of open pressure ulcers or skin grafts for selected patients with urinary incontinence.
• As an exception, at patient request to improve comfort (e.g. end-of-life care) internal jugular venous catheters: a systematic review of the literature and 1 Open Peer Review Current Referee Status: Editorial Note on the Review Process are commissioned from members of the prestigious and are edited as a F1000 Faculty Reviews F1000 Faculty service to readers. In order to make these reviews as comprehensive and accessible as possible, the referees provide input before publication and only the final, revised version is published. The referees who approved the final version are listed with their names and affiliations but without their reports on earlier versions (any comments will already have been addressed in the published version).