CLABSI Prevention & Management:
Mermel LA, Bouza AM, Craven DE, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009:49;1-45.
PMID: 19489710
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O’Grady NP, Burns AM, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011:39;S1-34.
PMID: 21511081
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Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32. Landmark large scale study of 103 ICUs in the state of Michigan demonstrated that implementation of an evidence based protocol led to a significant and sustainable 66% relative reduction of catheter-related infections. The protocol centered on 5 steps, comprising the now widely used “central line bundle” (see IHI.org), including hand hygiene, full-barrier precautions during line insertion, skin cleansing with chlorhexidine, avoiding the femoral site if possible, and removal of unnecessary catheters.
PMID: 17192537
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VAP Prevention:
Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999;354:1851-8. This study found that supine position is an independent risk factor for VAP and that positioning at 45 degrees reduces the risk, especially in patients receiving tube feeds.
PMID: 10584721
van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006;34:396-402. In this seven-day study cited by HOB-elevation skeptics, a randomized trial of over 200 patients found no reduction in VAP with HOB elevation, though the angle difference between intervention and control patients was small (28° vs 10° at day one, 23° vs 16° at day seven).
PMID: 16424720
De Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009; 360:20-31. This large (5,939 patients) multicenter Dutch study found SDD and selective oropharyngeal decontamination (SOD) reduced 28-day mortality by about 3% after logistic regression. There was no emergence of resistant organisms, but the duration of monitoring was limited to the 6 months of the study.
PMID: 19118302
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The SuDDICU Investigators for the Australian and New Zealand Intensive Care Society Clinical Trials Group. Effect of selective decontamination of the digestive tract on hospital mortality in critically ill patients receiving mechanical ventilation: a randomized clinical trial. JAMA. 2022; 328:1911–1921. Multicenter study of 5,982 patients in which ICUs used SDD on a 12-month on/off basis found a non-significant reduction in in-hospital mortality in the SDD group (27.0% vs. 29.1%, p = 0.12). No increase in resistant organisms or C. difficile colitis was observed.
PMID: 36286097
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General Measures:
Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013; 368:2255-2265. A cluster randomized trial comparing the effects of 1) MRSA screening and targeted isolation, 2) MRSA screening with targeted isolation plus treatment, and 3) universal decolonization treatment. Treatment consisted of chlorhexidine baths and nasal mupirocin. Universal decolonization treatment significantly reduced overall bloodstream infections with non significant decreases in MRSA-positive cultures and MRSA bloodstream infections. Strengths include multiple centers (43) and large number of patients (> 43,000). Weaknesses include lack of monitoring for chlorhexidine resistance, inconsistent use of isolation, and unclear definition of “clinical MRSA positive culture”.
PMID: 23718152
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Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care–associated infections: a randomized clinical trial. JAMA 2015; 313:369-378. This was a cluster randomized, controlled trial comparing the daily use of chlorhexidine-impregnated bathing cloths with non-antimicrobial cloths in multiple ICUs. There was no significant difference in the compound primary outcome of CLABSI, CAUTI, VAP, or C difficile infections (intervention 2.86 vs control 2.90, p= 0.95). In contrast to prior studies, these findings do not support daily chlorhexidine bathing of ICU patients. Critics note that the mean LOS was briefer and background MDRO prevalence higher in prior studies, one of which included BMT units. Other concerns include lack of adherence data and blinding.
PMID: 25602496
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