Diagnosis dan Pencegahan

SSI

BSI
Agung Dwi Wahyu Widodo
Departemen Mikrobiologi Klinik
Fakultas Kedokteran Universitas Airlangga
Surabaya
 Introduction
• Intravenous (IV) infusions among the
commonest invasive procedures (peripheral or
central)
• IV central catheters are the main source of
bloodstream infection (CLABSI)
• Infections associated:
• Cellulitis, abscess, thrombophlebitis, bacteraemia,
endocarditis
• Principles to prevent infections similar for central
and peripheral catheters

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 Key points
• Strict asepsis for insertion and maintenance of
catheters
• Insertion site dry and protected with a sterile dressing
• No touch technique
• IV line secure without movements
• Closed system
• Inspection of the insertion site daily
• Remove the catheters as soon as possible
• No reuse of catheters intended for single use
• Healthcare personnel educated and their knowledge
assessed
• Alternative routes for hydration or parenteral therapy

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 Definition of BSI
• CDC (2011), Blood Stream Infection,
devide into:
– LC-BSI (Laboratory Confirm-BSI)
• LC-BSI Defined with 3 Criteria:
• Criteria 1: Any age
• Criteria 2: Any age
• Criteria 3: only patients < 1years
 LC-BSI Criteria 1

• Patient has a recognized pathogen

cultured from 1 or more blood cultures
• And
• Organism cultured from blood is not
related to an infection at another site.
 LC-BSI Criteria 2
• Patient has at least 1 of the following signs or symptoms:
fever (>38°C), chills, or hypotension
• and
• signs and symptoms and positive laboratory results are
not related to an infection at another site
• and
• common skin contaminant (ie, diphtheroids
[Corynebacterium spp], Bacillus [not B anthracis] spp,
Propionibacterium spp, coagulase-negative
staphylococci [including S epidermidis], viridans group
streptococci, Aerococcus spp, Micrococcus spp) is
cultured from 2 or more blood cultures drawn on
separate occasions.
 LC-BSI Criteria 3
• Patient <1 year of age has at least 1 of the following
signs or symptoms: fever (>38°C, rectal), hypothermia
(<37°C, rectal), apnea, or bradycardia
• and
• signs and symptoms and positive laboratory results are
not related to an infection at another site
• and
• common skin contaminant (ie, diphtheroids
[Corynebacterium spp], Bacillus [not B anthracis] spp,
Propionibacterium spp, coagulase-negative
staphylococci [including S epidermidis], viridans group
streptococci, Aerococcus spp, Micrococcus spp) is
cultured from 2 or more blood cultures drawn on
separate occasions
 Sites of possible contamination of
intravascular infusions

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Sources and Routes of Transmission
-1
• Sources of contamination intrinsic or extrinsic
• Most microorganisms from the patient’s skin
flora
• Contamination of device hub also a source of
infection
• S. aureus - 60 to 90% of infections

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 Sources and Routes of Transmission
-2
Hands of staff Flora del
paciente

Contamination of fluids Skin flora

Contamination of
insertion site

Injections ports

Contaminación de las
conexiones
December 1, 2013
Seed from 10
distant site
 Prevention of Infections - 1
Main source of Prevention
infection
Infusion fluids Monitor sterilisation
Ensure fluid is pyrogen free.
Avoid damage to containers
Inspect containers
Addition of Aseptic technique
medications Sterile medications
Carry out procedures in the pharmacy.
Sterile device for accessing the system.
Single-dose vials
If multi-dose vials have to be used:
Refrigerate after opening
Wipe diaphragm with 70% isopropanol
Warming- Ensure no contamination
container Dry warming systems are preferred.
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 Prevention of Infections - 2
Main source of Prevention
infection
Insertion of Thorough hand disinfection and sterile gloves
catheter Thoroughly disinfect the skin insertion site.
Catheter site Cover with sterile dressing
Remove catheter if signs of infection occur.
Inspect site every 24 hours.
Change dressing only when necessary.
Do not use antimicrobial ointments.
Injection ports Clean with 70% isopropanol and allow to dry
Close ports that are not needed with sterile stopcocks.
Changing of Replace no more frequently than 72 hours (blood and lipids
infusion set every 24 hours).
Thorough hand disinfection
Use good aseptic technique.

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 General Comments - 1
• Routine changes of peripheral IV catheters not
required
– In adults recommendation to change every
72-96 hours to reduce phlebitis
– In children should not be replaced routinely
• Routine replacement of central catheters not
necessary
• Central catheters used only when indicated
– Non-essential catheters removed
• Risk of infection increases with length of
catheterisation
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 General Comments - 2
• Teflon or polyurethane catheters associated with
fewer infections
• Steel needles same rate of infection as Teflon
catheters
– Steel needles complicated by infiltration of
IV fluids
• Well-trained staff to set up and maintain infusions
• Masks, caps, and gowns not necessary for insertion
of peripheral IV lines
• Use of non-sterile barriers will protect the operator if
blood exposure likely
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Protocol for peripheral infusions - 1
• Place arm on a clean sheet or towel
• Hand hygiene (alcohol hand rub or antiseptic soap)
• Dry hands on a paper or unused linen towel
• Hand hygiene (gloves does not replace it)
• Not remove hair (if necessary clip, avoid shaving)
– Disinfect skin site, apply for 30 seconds and allow drying
– 0.5% chlorhexidine-alcohol, 2% tincture of iodine,
10% alcoholic povidone-iodine, or isopropanol).
• Chlorhexidine products should not be used in children
younger than 2 months
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Protocol for peripheral infusions - 2
– Cannula preferably in an upper limb
– Secure sterile dressing
• Transparent dressings allow inspection of the site
– Secure cannula, label with insertion date
– Assess need for catheter every 24 hours
– Inspect catheter daily
– Avoid cut downs, especially in the leg
– Cannulae and sets must be sterile

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 Additional guidelines for central
catheters
• Selection of site
– Higher infections for jugular and femoral
• Maximum barriers
• Disinfect skin with 2% chlorhexidine/alcohol
• Change transparent dressings once a week or if soiled,
loose, or damp, gauze every two days
• Replace sets not for blood or lipids no more than 72 hours

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 Measures that should not be
considered as part of a general
prevention policy:

• Systemic antibiotic prophylaxis

• Topical use of antimicrobial ointments
• Routine replacement of central venous catheters
• Routine use of antibiotic locks for central venous
catheters
• Routine use of in-line filters

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Arigato-gozaimasu