Eliminating catheter-related bloodstream infections: Fairy tale or new reality?*

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Abstract
In this issue of Critical Care Medicine, Dr. Berenholtz and colleagues (1) from Johns Hopkins University School of Medicine describe their success using a stepwise, methodical, protocolized approach in decreasing catheter-related bloodstream infection (CRBSI) in the surgical intensive care unit. Results were impressive over the 5-yr study period, during which CRBSI was decreased from 11.3/1000 catheter days in the first quarter to 0/1000 catheter days in the 20th and last quarter. With deserved pride and some fanfare, they footnote no additional CRBSI for 9 months after the study was completed. Think about that! Zero incidence of CRBSI. CRBSI has been a bane of acute care medicine for half a century. What manner of pixie dust must these clinicians be scattering upon their patients to achieve zero CRBSIs? How was this feat achieved in a venerable, albeit resource-intensive and well-financed, academic medical center? Are we not in Camelot? Is this not a fairy tale? More about this to follow, but first, what has been the recent history of the science of preventing CRBSI? Early reports (2, 3) describing the extensive use of central venous catheters (CVC) to facilitate the treatment or resuscitation of patients first surfaced after World War II; but the insertion of CVC mainly escalated in the 1960s and 1970s with the evolution of intensive care medicine and the introduction of hyperalimentation (4, 5). More than 5 million CVCs are inserted in the United States each year, with the incidence of infectious complications ranging between 5% and 26% (6). Attributable mortality from CRBSI may be as low as 3%, but there is no disagreement as to the significance of morbidity, increased length of stay, and inflated cost (7). As a consequence, guidelines for the prevention of CRBSI have been issued (8) and the thrust of research in recent years has focused on strategies that enhance infection control methodology and practice. These measures have included standardized educational efforts directed toward CVC insertionists (9) and the preference of chlorhexidine antisepsis as a means of reducing CRBSI by nearly 50% compared with povidone-iodine (10). However, the greatest glitz has been reserved for antimicrobially coated CVC, which are effective at decreasing CRBSI and very costly (11, 12). For example, acquisition cost of a standard-issue triple-lumen catheter at Tufts-New England Medical Center is $22; the cost of an antimicrobially coated triple-lumen catheter is approximately $75. Because the CRBSI rate in our surgical intensive care unit is just 2.6/1000 central catheter days, which is one-half the national benchmark of 5.2/1000 central catheter days for surgical intensive care units (13), we have not been convinced of the cost effectiveness in implementing the high-technology solution of antimicrobially coated catheters. Interestingly, guidelines issued by the Centers for Disease Control and Prevention give a lukewarm recommendation for these catheters, which should be employed only after failure of a comprehensive approach at decreasing CRBSI (8). The investigators from Johns Hopkins significantly decreased CRBSI using a low-technology, stepwise, comprehensive strategy (1). This strategy included the following: a) standardized education of staff; b) essential grouping of necessary ingredients for a CVC into a single location by use of a vascular line cart; c) discontinuation of no longer necessary CVC by regularly inquiring as to the need through use of a daily goals sheet; d) implementing a catheter-insertion checklist for assurance of sterile technique; and e) empowering the bedside nurse to halt the CVC procedure when a sterile technique was observed to have been violated. This is no pixie dust. These clinicians used neither supernatural magic nor even glamorous high-technology solutions.