BLOODSTREAM INFECTIONS AMONG PATIENTS USING CENTRAL VENOUS CATHETERS IN INTENSIVE CARE UNITS

Os cateteres venosos centrais (CVC), utilizados, principalmente em unidades de terapia intensivaUTIs, são importantes fontes de infecção da corrente sangüínea (ICS). Este estudo epidemiológico analítico, tipo coorte prospectiva, enfoca a incidência de ICS, fatores de risco associados e ações assistenciais relacionadas ao uso desses cateteres em 7 UTIs no Distrito Federal. Dos 630 pacientes com CVC, 6,4% apresentaram ICS (1,5% relacionadas ao cateter e 4,9% ICS-Clínica). A permanência de internação foi 3,5 vezes maior para esse grupo de pacientes. Observou-se condutas diversificadas com relação à inserção dos cateteres e o uso de antiséptico. O tempo de permanência do CVC mostrou-se associado à infecção (p<1x10), assim como à punção em veia subclávia direita e a cateter de duplo-lúmen. Pacientes neurológicos e os traqueostomizados foram os mais acometidos. Sugere-se a formação de um grupo de cateter, para padronizar rotinas relacionadas ao uso dos cateteres no intuito de reduzir o período de internação e os custos hospitalares.


INTRODUCTION
Intravascular catheters are essential in modern medicine, particularly at intensive care units (ICUs).However, they constitute an important source of primary blood stream infection.Approximately 150 million catheters are punctured every year at hospitals and clinics in the United States, more than 5 million of which are central venous catheters (1) .As a result of technological advances, venous access is maintained longer and used more frequently, hence entailing an increased number of infections related to this procedure.The hospitals from the National Nosocomial Infection Surveillance System (NNISS) of the Centers for Disease Control and Prevention (CDC) in the United States have published blood stream infection (BSI) rates at intensive care units, which range from 4.9 at cardiothoracic intensive care units and 11.9 at trauma units, per 1,000 central catheters-day, for the period from 2002-2004 (2) .
Before, the NNISS had already published a rate of 3.48 per 1,000 discharges.Argentinean data register 2.92% of these infections (3) .
Infection risk related to vascular access is associated with the access location, the inserted solution, the experience of the professional who performs the procedure, dwelling time, type and catheter handling, among others (4) .These factors constitute important strategic points for actions to prevent these infections.
Although the incidence of blood stream infection is lower than of other hospital infections (HI) like lung, urinary tract and surgical site infections, blood stream infections are important because they are a cause of substantial morbidity, mortality and increased hospital costs (3)(4) .North American data register an extended hospitalization period, ranging from 6.5 to 22 days (5) .A study in Argentina found a cost surplus of $4888 and an extension of the hospitalization period by 11.9 days per blood stream infection episode .
This study aims to calculate the incidence and risk factors associated with blood stream infections caused by Central Venous Catheters (CVC) at intensive care units from hospitals in the Single Health System (SUS) hospital network of the Federal District, Brazil.In addition, this research intends to contribute to the elaboration of actions to prevent and control blood stream infections in patients using central venous catheters, as well as to achieve the rational use of this procedure.

PATIENTS AND METHODS
We were registered.The catheter insertion technique and the professional who carried out the procedure were not assessed, as a large majority of the patients were catheterized at the emergency units.
Peripheral blood cultures were carried out in all patients with a fever or other signs of infection.
The catheters were removed when their use had become unnecessary, in case of obstruction or accidental loss, and submitted to cultures (semiq u a n t i t a t i v e i n f i v e i n t e n s i v e c a r e u n i t s a n d quantitative in the rest).To obtain the diagnosis of blood stream infection, a technique was used with the catheter in place, without the need to remove it.
This article reports initial results of a larger project, aimed at assessing the incidence of infections in patients at the mentioned intensive care units, and was approved by the Institutional Review Board from the Federal District Health Secretary (SES-DF).
The criteria recommended by the CDC (6) were used for the diagnosis.Catheters with negative results of microorganism cultures were considered sterile.

RESULTS
During the study period, 1,165 patients were hospitalized at the 7 intensive care units, 1,006 of whom (49.4% female and 50.6% male) remained hospitalized at these units for more than 24 hours.
The mean age was 48 ± 20.Definitely, this increase in the duration of hospitalization is directly related with the severity of the patient's case, and not only with the presence of infection.
No catheter inserted in another unit was changed when the patient was admitted at the intensive care unit, except on one occasion, when the catheter was changed using the guide wire.None of the ICUs had an established Catheter Commission.
As these hospitals had a medical residence program, usually, the procedure was carried out by the resident physicians, supervised by the physician responsible for the unit.Only one of the ICUs referred its patients for catheterization at the Surgery Center.Despite the absence of standardized routines for all ICUs, in all punctures, the physicians used surgical gloves, mask, cap and gown.
There exists a consensus about the benefits of using chlorhexidine dressings, although 70% alcohol and 10% alcoholic PVPI also protect against infection.
In this study, we observed the lack of standardization of the antiseptic agent used on the puncture site, both at the time of catheter installment and dressing replacement.In most cases, PVPI was used and, if absent, cleaning was done using physiological serum.
This lack of standardization did not allow us to assess the use of antiseptic agent as a risk factor for blood stream infection.
The dressing used on the puncture site should be permeable to water steam, comfortable for the patient and easy to handle for health professionals and/or patients.It can be transparent or using gauze fixed with adhesive tape.The advantage of transparent dressings is that they permit the visualization of the insertion orifice, promote a barrier against dirt and that changes are less frequent, as they favor constant assessment by health professionals.There is no consensus about infection risk and its association with intravascular catheter dressings.What is important is that the gauze dressing should be replaced whenever humid, dirty or loose.
In the catheters followed in this study, the dressings of the insertion site were replaced by nurses every 48 hours or whenever necessary, in line with the above orientations, using sterile gauze and the available antiseptic agent.The site was protected with sterile gauze and adhesive tape.As the used antiseptic agent was not standardized, dressing change could not be assessed either as a risk factor for infection.
Among the complications related to the CVC, 45.4% of the patients presented fever, 3.5% pneumothorax, 2.5% presence of secretion on the insertion site and 1% accidental catheter loss.All 40 patients who developed blood stream infection had a temperature e" 38ºC.were inserted in the right subclavian vein, which can justify the incidence of 50% of BSI when this access was used, and 75% when adding the access through the left subclavian vein.The occurrence of infections was very considerable when the right and left jugular vein were used.
We found a higher blood stream infection coefficient in patients were neurological pathologies (30%), followed by heart diseases (17.5%).The remainder was distributed in smaller percentages: patients with gastro-intestinal (12.5%), respiratory (12.5%), orthopedic (10%), kidney (7.5%), gynecological-obstetric (5%) and infectious pathologies (5%).In Table 4, we observe that most of the invasive procedures used in the patients at the 7 ICUs revealed to be associated with the blood stream infection, with a high level of statistical significance.
In tracheotomy patients, a relative risk (RR) of 4.93 is observed, followed by the use of total parenteral nutrition and double lumen catheter for hemodialysis, with an RR of 3 and 2.9 respectively.As to infectious agents (Table 5), grampositive Staphyloccus aureus and gram-negative Pseudomonas aeruginosa stand out as the most frequently isolated microorganisms, with 35% and 32.5%, respectively.However, in the general sum, gram-negative organisms were more prevalence, which goes against other publications (7-8)   .Forty-five percent (18) of the patients with blood stream infection were transferred to other units in the same hospital; 40% (16) died due to a cause that was not specified as related to the infection.In the remaining group, 5% (2) were referred to other institutions and 10% (4) remained at the ICU until the end of the study.

DISCUSSION
Although it is acknowledged that central venous catheters are important for patients, they entail a predisposition to infectious complications (9) .In this study, the 6.4% infection rate we found was associated with the duration of hospitalization, catheter dwelling time, location in the right subclavian vein, use of double lumen catheter and the concomitant presence of tracheotomy, parenteral nutrition catheter and double lumen catheter for hemodialysis.
These findings are in line with other studies that appoint the duration of the catheterization as a risk factor for blood stream infection (1) .Effective measures to reduce the risk associated with catheter dwelling include the cautious indication of catheter use, as well as a well trained team for their insertion, maintenance and removal (4,10) .
Other studies, including this one, found an extension of the hospitalization period due to the incidence of blood stream infection (10) .The extension of the hospital stay in itself favors an increased risk of infection, the reduced availability of beds and the increase of hospital costs, among others.
When the catheter is inserted in an emergency situation, this can lead to the breaking of asepsis techniques, besides the risk of traumatic vessel injuries.In these cases, the catheter should be changed as quickly as possible.However, with respect to the frequency of central catheter replacement, no advantage has been observed in terms of infection reduction.The programmed routine replacement, using the guide wire or a new puncture, is not indicated because it does not reduce infection rates (5) .
The protection barrier is cheap and should be considered a standard practice in the insertion of all catheter types, as it favors infection control.When advantage in the cost/benefit assessment (5) .In this study, we alert to the importance of the team's autonomy to implant a change in the professionals' behavior, and the need for support from hospital managers.It is highlighted that the NNISS found higher BSI rates in large teaching hospitals (more than 500 beds).
As opposed to other references (8) , this study found a higher incidence of infection in subclavian vein catheterizations.However, catheterization of the femoral vein is associated with a higher risk of infectious and thrombosis complications than the subclavian vein in ICU patients (11) .It is also associated with higher rates of mechanical complications like arterial puncture and hematoma (12) .Despite a lower risk of complications caused by the insertion, jugular vein catheters concur for the highest probability of developing infection (12) .In a study carried out in children, the most used catheter insertion site was the internal jugular vein, followed by the subclavian vein (9) .Central catheters can be inserted peripherally, by means of a puncture in the cephalic or basilic vein as, favored by the lower colonization, oiliness and humidity of the antecubital fossa, they provide for easy maintenance and longer dwelling time and present lower infection rates than non-implantable central catheters.These routes can be an option for the procedure, also due to the high contamination probability of the catheter inserted in the subclavian and jugular veins, due to the drainage of respiratory secretion found in patients using orotracheal tubes and tracheotomies which, in this study, represented important risk factors for infection.Venous dissection should be avoided because of the higher risk of infection than puncture, due to tissue trauma and because there is no appropriate catheter for this procedure (8) .
As to the choice of the catheter type with respect to the number of lumens, the need and/or severity of the patient's case should be assessed, as well as the number of medications and nutritional support.References indicate that each lumen increases handling by 15 to 20 times per day (5) .A randomized study in patients using subclavian vein catheters for more than a week for an incidence level of 2.6% of blood stream infection for single lumen, against 13.1% for triple lumen catheters (13) .However, generally, it are the most severe patients who are hospitalized at ICUs, most frequently use multi-lumen catheters and, consequently, present greater infection risks.In this study, we found higher usage and, consequently, higher incidence levels of infection in case of double lumen catheters.
Gram-positive Staphylococcus aureus and coagulase-negative Staphylococcus are the organisms most frequently involved in vascular access infections, mainly in patients whose immune system is compromised and have used a catheter for a long time.Candida spp has revealed to be an important and emerging pathogen in recent years, increasing its participation in blood stream infections (5) .Probably, this occurrence is partially related with the indiscriminate use of last-generation antimicrobial agents and with the increased use of CVC.
Studies appoint that the health team's education can be the most important measure to prevent complications deriving from the use of central venous catheters (10) .Hand washing is highlighted as a primordial measure to prevent hospital infections.
Therefore, in combination with the sensitization of the professional team, adequate conditions need to be favored to carry out the procedure.
We consider the following study limitations: realization at ICUs with distinct peculiarities, each of which with different risks of acquiring HI; the presence of multiple teams for catheter insertion and the non standardization of criteria for the duration of its use.
The use of the total number of patients using CVC and not of patients per day and catheters per day to calculate the indicators, which would help to control for the variation in the patient's stay at the ICU, was also considered a limiting factor.
Culture of the catheter tip through the semiquantitative method helps to distinguish between infection and contamination, providing for a more specific diagnosis of catheter-related sepsis.However, the quantitative method can be used through vigorous shaking in the culture medium or through ultrasonic treatment, in order to increase the specificity of the diagnosis (8) .Using qualitative techniques to diagnose catheter-related infections is not recommended, as one single contaminating microorganism can lead to a positive culture (8) .
Although outside the scope of this study, the economic problems the hospitals faced at the time of the study have definitely contributed to the patients' greater exposure to infection risks.In this period, Bloodstream infections among... Mesiano ERA, Hamann EM.
antiseptic agents, antibiotics and hand washing products were frequently lacking.
We hope that these results will stimulate the implantation of BSI prevention actions, such as the creation of the Catheter Group to standardize catheter insertion, maintenance and withdrawal routines, besides orientations for cautious catheter use and care professionals' adherence to the standardized protocols for catheter care.Another important factor is the incorporation of knowledge into hand washing practices, which will favor the reduction of infections in general, and not only of blood stream infections.
It is important to carry out specific studies per ICU type, as the duration of the patients' stay at these units varies and, consequently, catheter dwelling times, leading to variations in the infection rates related to the invasive procedures.In this sense, we agree with the orientation that, in order to prevent hospital infection, both physiopathology and epidemiology should be kept in mind (14)   .Therefore, accompanying historical series of infection occurrence is recommendable in order to apply hospital infection control and prevention measures.The elaboration of incidence density indicators, using the number of central venous catheters-day, will help to control for the patient's permanence time at the ICU.Although there does not exist an acceptable value for hospital infections, Argentinean data register 2.92% of catheter-related blood stream infections in medical/ surgical and cardiology (3) ICU patients, that is, with similar characteristics to this study.

Clinical
Blood Stream Infection (C-BSI) was diagnosed when the patient presented at least one of the signs or symptoms without another identified cause: fever (temperature e" 38º C), pain, erythema or heat of the involved vascular site and >15 Colony Forming Units (CFU), isolated from the tip of the intravascular catheter, and blood culture with a negative result or not accomplished.Catheter-Related Blood Stream Infection (CR-BSI) occurred when the patient presented the above criteria associated with positive blood culture, with the same microorganism isolated from the catheter tip.

Table 1 -
Frequency distribution of patients with and

Table 2 -
Frequency distribution of patients with and

Table 3 -
Frequency distribution of patients with and

Table 5 -
Frequency distribution of patients with blood