Incidence of Blood Stream Infection Influenced by Dressing and Clinical Skin Care in a Patient with Neutropenia

Purpose For cancer-bearing patients, especially for patients with hematological malignancies, blood access is a ‘lifeline’ during chemotherapy, in three senses: administration of chemotherapy for the cancer treatment, intravenous supply of nutrients when a patient’s oral intake is decreased, and injection of many agents for supportive care including antibiotics and G-CSF. For these purposes, we usually use a central venous catheter (CVC) at the subclavian portion. Dressing and skin care of the CVC are critical factors influencing the incidence of catheter-related blood stream infection (CRBSI). To clarify the association between preventative procedures and CRBSI rates, we summarize the effectiveness of annually instituted interventions for the prevention of CRBSI and present the result of surveillance of catheter infection in our hospital for a decade, from 1998 to the present.

Method This is a prospective cohort study analyzing patients seen in our hospital for the treatment of cancer and predicting neutropenia by observation of catheter infection. All of the patients underwent CVC (Microneedle Seldinger Kit, Safe Guide II, Argyle) insertion with a subclavian approach except for patients with subclavian venous troubles such as embolism or occlusion. Each year for the first five years, we instituted new precautions for preventing CRBSI. Those interventions were

1. introducing low-irritant skin tape from 1999,

2. applying the maximal barrier precaution (MBP) procedure from 2000,

3. applying closed injection-line system (Interlink system; Japan Beckton Dickinson, Tokyo, Japan) from 2001,

4. once-a-week dressing using adherent transparent film (Tegaderm; Sumitomo 3M, Tokyo, Japan) from 2002, and

5. usage of one pair of glove in each procedure for an individual patient from 2003.

More than 2 sets (One set means blood samples from peripheral blood and CVC) of blood culture samples were drawn when a patient’s body temperature (axillary) increased to more than 38.0 ºC. Multiple detection of the same isolate in the same individual during a series of febrile episode was considered as one infectious event. Bacteremia was defined as the isolation of at least one pathogen from at least one blood sample. BSI was defined as the recognition of a pathogen from one or more blood cultures that is not related to an infection at another site. CRBSI was defined as bacteremia in a patient with CVC with at least one positive pathogen obtained from a blood culture, and no apparent source for the BSI. We evaluated the duration of CVC insertion, episodes of febrile event, isolated bacteria and bacteremia.

Results A total of 55,469 catheter-days were observed. The incidence of CRBSI per one thousand catheter-days was 8.08±2.76 before our interventions (before 1998), 4.18±2.59 after the low-irritant skin tape, 2.84±1.26 after the MBP procedure, 2.18±1.69 after the closed injection-line system, 2.84±2.17 after once-a-week dressing, and 2.53±2.63 after the individual-gloves intervention. After the introduction of MBP, the incidence of CRBSI was significantly decreased from before the start of interventions (P<0.001). Though the subsequent interventions (closed line system, once-a-week dressing and individual-gloves intervention) did not apparently influence the incidence of CRBSI, they were believed to keep the incidence of BSI low.

Conclusion Applying MBP and low-irritant tape was significantly effective for decreasing the incidence of CRBSI. A concomitant use of MBP and valid taping might be most influential for preventing CRBSI.