Better vascular access management for infection control

As vascular access devices are one of the major sources of infections in a hospital setting, Dr Prashant Borade, Head Critical Care Department, Global Hospital opines that to control antimicrobial resistance, healthcare facilities need to invest in all possible ‘care’, including staff training, establishing ‘infection control committees’, and using vascular access devices that can help control the acquisition of infection

The last century saw the immense worth of antibiotics in controlling infections, making humanity complacent. However, the rapid increase in antibiotic resistance has been a matter of serious concern. Antimicrobial resistance is now a global threat to human, animal, and environmental health, owing to the emergence, spread, and persistence of multidrug-resistant (MDR) bacteria or “superbugs.”

Results from studies indicate that patients who acquired MDR bacterial infections were 1.57 times more likely to die, compared to patients with similar susceptible infections, while patients who acquired XDR (extensively drug-resistant) infections were 2.65 times more likely to die when accounting for age, sex, site of infection, and the number of co-infections¹.

In India, MDR and XDR bacterial infections are frequent, and the availability of effective
antibiotic therapies are declining. As antibiotic resistance shows no signs of decline, the limelight is now on the prevention of infections.

One of the places where one may pick up an infection is during a hospital stay.

Hospital-acquired infections (nosocomial infections)

Studies from across the world show that in North America and Europe, 5 per cent–10per cent of all hospitalisations result in nosocomial infections. In contrast, Latin America, Sub-Saharan Africa and Asia show more than 40per cent hospitalisations with nosocomial infections. ²  Amongst the hospital-acquired infections, those acquired in the ICU are very high.

The ICU-acquired infection rate is at least 2 to 3-times higher in low – and middle-income countries than in high-income countries, where it’s about 30per cent.³

Device associated infections

In the 2014 fact sheet of WHO,³ it is stated that in the low- and middle-income countries, the device-associated infection densities are up to 13 times higher than in the USA.

In such situations, it is imperative to pay attention to preventive measures that can help bring down the infection rate in hospitals and ICUs, thereby reducing the economic burden on the patient and safeguarding the hospital’s reputation.

Vascular access devices (VADs) are one of the major sources of infections in a hospital setting.

Recently, with an advancement in medicine, some high-quality and reliable vascular access device products are available that include pre-filled saline syringes for flushing catheters. Pre-filled saline syringes are associated with a reduced risk of Catheter-Related Bloodstream Infections (CRBSIs)⁴.

Their salient features include⁵:

●        Unique syringe design – minimises syringe-induced reflux

●        Clear labelling – helps reduce the risk of medication errors

●        Standard 10mL syringe diameter – helps reduce the risk of catheter damage

●        Stubby syringes – help reduce environmental waste and hospital costs

 International guidelines recommend some key practices and ‘care’ to be taken during the use of vascular devices^6,7 which include:

●        avoiding catheterisation unless there is a medical indication

●        performing normal saline flushing once daily to improve the patency of catheter

●        using pre-filled saline syringe to reduce the risk of catheter-related bloodstream infections (CRBSI) and to prevent syringe-induced blood reflux 

●        using sterile normal saline for injection to flush and lock catheter lumens that are accessed frequently

●        using needle-free connectors (NFCs) that allow injection or infusion via gravity or pump

●        using split-septum needleless devices that reduce the risk of CRBSIs

●        training of personnel in catheter insertion and care

International guidelines recommend pre-filled saline syringes for flushing vascular access devices⁷.

Some specific recommendations while using VADs include⁸:

●        Using sterile preservative-free 0.9per cent sodium chloride for flushing vascular devices

●        Flushing prior to each infusion to access catheter function and prevent complications

●        Flushing after each infusion for clearance of the infused medication from the catheter lumen, reducing risk of contact between incompatible medications

●        Locking of the device after completion of the final flush to prevent intraluminal occlusion and CRBSIs

●        Using pre-filled syringes to help save staff time for syringe preparation

●        Using 70per cent isopropyl alcohol or alcoholic chlorhexidine to disinfect access surface of the needle-free connectors (NFCs)

●        Scrubbing the hub for 5 to 60 seconds in a straight line for effective disinfection

 

So, it is quite clear that the right kind of vascular access devices can make a difference. Hospitals and doctors should make no compromise on quality and type of devices used as otherwise it may increase morbidity, hospital stay and may not be cost-effective, hence strict infection control practices are crucial in all IPD settings.

 

In this era of antimicrobial resistance that threatens the world, healthcare facilities need to invest in all possible ‘care’, including staff training, establishing ‘infection control committees’, and using vascular access devices that can help control the acquisition of infection. It can help reduce the use of high antibiotics that are so precious and required to be preserved for future use in difficult-to-treat infections.

References:

1. https://cddep.org/wp-content/uploads/2018/11/November-16-2018-Drug-resistant-infections-associated-with-higher-in-hospital-mortality-rates-in-India.pdf
2. Khan, Hassan & Ahmad, Aftab & Mehboob, Riffat. (2015). Nosocomial infections and their control strategies. Asian Pacific Journal of Tropical Biomedicine. 5. 505-509.
3. https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
4. Saliba P, Cuervo G, Hornero A, De Carli G, Marani A, Puro V, Felisa López A, Iftimie S, Castro A, Diaz-Brito Fernandez V, Alvarez Moya MC, Jimenez De La Rosa C, Martínez-Sánchez J, Jimenez E, Carratalà J, Pujol M. The impact of flushing with pre-filled saline syringes on the incidence of peripheral venous catheter failure: A quasi-experimental study. J Vasc Access. 2020 Jul;21(4):490-496.
5. Gorski LA. The 2016 Infusion Therapy Standards of Practice. Home Healthc Now. 2017;35(1):10–18.
6. https://www.who.int/csr/resources/publications/whocdscsreph200212.pdf
7. Infusion Nurses Society. Infusion Nursing Standards Practice. J Infus Nurs. 2021
8. Satou, Kenichi & Kusanagi, Risa & Nishizawa, Aya & Hori, Satoshi. (2018). ‘Scrubbing’ technique for needleless connectors to minimize contamination risk. Journal of Hospital Infection. 100. 10.1016/j.jhin.2018.03.015.