Bundle for reducing bloodstream infection

[Guest JMGomez]

Dear Colleagues,

I am interested in reducing bloodstream infection in the VLBW population in my NICU. Do any of you have bundles that have worked for you and willing to share? Thanks.

[Ricky]

We use a low dose Fluconazole protocol to reduce systemic fungal infection in VLBW babies less than 1000 gms. Low dose Fluconazole is given for a total of six weeks. The dose is adjusted according to weight q 2 wks. So the dose stays the same for the first 2 weeks, then it's adjusted on the 3rd week and again on the 5th week. We have significantly reduced systemic fungal infctions with this protocol. If the baby does become septic, the infection is treated with a full course of Fluconazole or Abelcet and the protocol is resume subtracting the weeks used for treatment. So if baby becomes infected the start of 3rd week of the protocol and you treat for 2 weeks, then you would resume the protocol at the 5th week. We trialed a type IVIG(Immunoglobulin) as a prophylaxis for bacterial infection but we found no difference in the amount of infections. So, presently we do not have a protocol for prevention bacteria sepsis.

[ernani miura]

We reduced fungus infection in VLBW using this protocol: premature baby less than 1.250 g with three of these situation, not doing well, prolonged parenteral nutrition with more than 3 g of fat, prolonged mechanical ventilation, cephalosporin of third generation, corticosteroid, B2 blocker, neutropenia and trombocytopenia, independent of blood culture we started amphotecyn IV infusion of 1 mg/kd/d. So we reduced from 5 cases/year to 1 case/year. Ernani Miura, Porto Alegre, Brazil.

[Guest Hortense Jones]

JM Gomez,

The March/April 2007, Vol.30, Journal of Infusion Nursing contains an article by Lisa Morgan. The article describes their 3 bundles for catheter used at Miami Childrens Hospital -Insertion bundle, dressing bundle and maintainance bundle.

[Guest bittybabygrower]

Go to IHI.org this is where we adapted our central line and handwashing bundles.

[Guest JMGomez]

Based on current evidence, what is the best skin preparation to use prior to setting PICCs and umbilical lines in extremely low birthweights (ELBW)? You could share with us preparation(s) that you have used without adverse effect on the ELBWs and have documented marked reduction in line-related infections. I am creating an infection control bundle and will value your input.

Thanks.

JM Gomez,

KK Hospital for Women and Children,

SINGAPORE

[JACK]

Based on current evidence, what is the best skin preparation to use prior to setting PICCs and umbilical lines in extremely low birthweights (ELBW)? You could share with us preparation(s) that you have used without adverse effect on the ELBWs and have documented marked reduction in line-related infections. I am creating an infection control bundle and will value your input.

Thanks.

JM Gomez,

KK Hospital for Women and Children,

SINGAPORE

I would like to refer you to the March 2008 edition of clinics in perinatalogy. You would find the answer to your querry here.

Also another very important article is

"Andersen C, Hart J, Vemgal P, Harrison C. Prospective evaluation of a multi-factorial prevention strategy on the impact of nosocomial infection in very-low-birthweight infants. J Hosp Infect. 2005;61:162–167"

I will quote from this study:

"Andersen et al showed a reduction in nosocomial bloodstream infections among VLBW infants following the introduction of a bundle of interventions that included: 1) replacement of a combination of povidone-iodine and isopropyl alcohol swabs by a 2% aqueous chlorhexidine solution for skin antisepsis prior to all central and peripheral catheter placements or invasive procedures in extremely low-birthweight infants until day 14 and by 1% chlorhexidine in ethanol for all other peripheral intravenous line placements, 2) introduction of a standardized sterile pack for line insertion, 3) removal of all peripheral lines after 48 hours, 4) removal of all intravascular lines when an infant achieved enteral feedings of 120 mL/kg per day, and 5) use of sterile technique when changing infusate solutions."

I think the short answer to your question is chlorhexidine solution. For details please see the journal.

Edited June 20, 2008 by JACK

[Guest JMGomez]

Precisely, this is the answer that I was looking for. Many have expressed caution about using 2% chlorhexidine solutions in the premature baby but do not state the alternatives. I have implemented use of 2% chlorhexidine aqueous preparation for the ELBW infants. Monitoring closely for any side-effects. Regards. JM Gomez, Singapore.

[JACK]

Precisely, this is the answer that I was looking for. Many have expressed caution about using 2% chlorhexidine solutions in the premature baby but do not state the alternatives. I have implemented use of 2% chlorhexidine aqueous preparation for the ELBW infants. Monitoring closely for any side-effects. Regards. JM Gomez, Singapore.

You may be interested in this article

Chlorhexidine Compared with Povidone-Iodine Solution for Vascular

Catheter–Site Care: A Meta-Analysis

Published in Ann Intern Med. 2002;136:792-801

You will find some side effects of chlorhexidine listed here.

Fortunately this article is free

Just click on the link below and you should be able to download the pdf format of article easily

http://www.annals.org/cgi/reprint/136/11/792

You might also want to check out this article (Review: chlorhexidine gluconate is more effective than povidone-iodine for preventing vascular catheter related bloodstream infection ) published in Evidence Based Nursing

http://ebn.bmj.com/cgi/reprint/6/1/18

(This pdf is also free to download)

Please do share with us your experiences with chlorhexidine.

[JACK]

Chlorhexidine plus alcohol ----burns!!!!!

READ

READ

(Moral : DO not forget the alcohol content in commercial products containing chlorhexidine)