Infection
New IDSA guidelines aim to reduce death, disability, and cost of prosthetic joint infections Of the one million people each year who get hips and knees replaced, as many as 20,000 will get an infection in the new joint, a number that is expected to skyrocket in the next 20 years. Multispecialty physician teams need to work together to reduce disability, death and costs associated with the ever-growing number of these prosthetic joint infections, note the first guidelines on the topic being released by the Infectious Diseases Society of America (IDSA). Hips, knees and other joint replacements – such as shoulders and elbows – can become infected during the surgery or months or even years later. The guidelines, which were published in the journal Clinical Infectious Diseases, outline the evidence and opinions regarding methods that are appropriate to diagnose the infections early and treat them most effectively, according to patients’ specific situations. Most infections require long courses of antibiotics and surgery, which can range from washing out the infected area to removal and replacement of the joint to permanent removal of the prosthesis to amputation. Multidisciplinary teams should include an orthopedist and an infectious diseases specialist, as well as other specialists on a case-by-case basis. In rural areas with few specialists, doctors should consider consulting with infectious diseases specialists or orthopedists at referral centers. Among the recommendations in the guidelines:
INFECTION PREVENTION Prevention Update IV-site care
Improved practices, advanced technology reap optimal outcomes by Susan Cantrell, ELS
f pathogenic organisms could love, they would l-o-v-e catheters. What better could they ask for to accomplish their mission of infection than to be routed directly into the source of life?
I
“Central line–associated blood stream in- fections (CLABSIs) are important and dead- ly HAIs [healthcare-acquired infections], with reported mortality of 12%–25%,” the CDC tells us.1
That is the bad news, but
• Physicians should suspect a prosthetic joint infec- tion in a patient who has any of the following: persistent wound drainage in the skin over the joint replacement; sudden onset of a painful prosthesis, or ongoing pain after the prosthesis has been implanted, especially if there had been no pain for several years or if there is a history of prior wound healing problems or infections. In patients with prosthetic joint infections:
•Those with a well-fixed prosthesis without an open wound to the skin who had surgery less than 30 days previously are likely candidates for debridement, which means re-opening the incision and cleaning out the wound.
•Those who have more extensive infection that has affected the bone and tissue may need to have the prosthesis replaced, either in the same surgery in which the prosthesis is removed, or in a later surgery.
•Patients who cannot walk and who have limited bone stock, poor soft tissue coverage and infections due to highly resistant organisms may need to have the implants permanently removed. In some cases the joint may need to be fused. •Amputation of the limb may be necessary, but only as a last resort. Prior to amputation, the patient should be referred to a center with specialist ex- perience in prosthetic joint infections, if his or her condition allows. Four to six weeks of intravenous or highly bioavail-
able oral antibiotic therapy is almost always necessary to treat prosthetic joint infections.
fortunately there is also really good news on that front. “In 2001, an estimated 43,000 CLABSIs occurred among patients hospi- talized in ICUs [intensive care units] in the United States. In 2009, the estimated number of ICU CLABSIs had decreased to 18,000 ... an estimated 25,000 fewer CLABSIs ... than in 2001, a 58% reduction. This represents up to 6,000 lives saved and $414 million in potential excess health-care costs in 2009 and approximately $1.8 billion in cumulative excess health-care costs since 2001.” The reduction in CLABSIs is a product of state and federal agencies coming together to develop recommended practices in catheter care and of healthcare workers across the nation conscientiously and diligently imple- menting these best practices. The resulting success is so astounding that “The model of federal, state, facility, and health-care provid- er collaboration that has proven so suc cessful in CLABSI prevention should be applied to other HAIs and other health-care–associated conditions,”1
said the CDC. Phenelle Segal, RN, CIC, President, Infec-
tion Control Consulting Services (ICCS), Delray Beach, FL, talked in more detail about use of catheters and what can be done to mitigate related infections. “Intravenous therapy is infused via many routes, including peripheral and central catheters. Selecting a catheter is dependent on many factors, but the most important factor is selecting the smallest gauge and length, as few lumens as possible, and the least invasive device. Peripheral cath- eters are the number one choice, if possible, for infusing medications, as the risk of HAIs is far less than central catheters, which have the potential to become infected at the time of insertion and during site maintenance.” An approach that includes all caregivers in- volved with catheter insertion and care is the
24 January 2013 • HEALTHCARE PURCHASING NEWS •
www.hpnonline.com
best, noted Segal. “IV-insertion and site-care best practices preferably should be a multi- disciplinary approach, as studies have shown repeatedly that a team of diligent healthcare workers striving for the common goal of pa- tient safety, including prevention of HAIs, is far more effective than a single effort.” Segal also talked about best practices for
IV-site care. “Peripheral and central catheters require aseptic technique insertion with hand-hygiene and glove practices enforced. Skin preparation should occur using an anti- septic such as chlorhexidine (not to be used in patients under 2 months of age), povidone- iodine, or 70% alcohol. A no-touch technique should be used: insertion site should not be palpated after the skin is cleaned unless ster- ile gloves are worn; IV-site care, including dressing changes, must be performed asep- tically with the emphasis on hand-hygiene, wearing of gloves (donned before removing the old dressing and donned again before replacing the old dressing with the new one); and prevention of contamination of the new dressing. Central-catheter dressing changes should occur on a regular schedule and immediately if the integrity of the dress- ing is compromised or signs of infection are present. Peripheral IV catheter dressings are not changed routinely unless the dressing is soiled or no longer intact.”
Antimicrobial-impregnated catheters
Technique is vital, but technology plays an important role, too. Industry has responded to the quest for fewer infections and other com- plications related to catheters with improved, advanced products.
See INFECTION PREVENTION on page 26 The ARROW ErgoPack from Teleflex provides
procedural efficiency and defense against BSI.
INFECTION PREVENTION
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