Strategies to reduce catheter-related bloodstream infections (CR-BSI) in adult intensive care unit (ICU) at a public Brazilian hospital

Background: CR-BSI are common, costly and with high morbidity and mortality rates. On the other hand, it is one of the most preventable healthcare associated infections. Through implementation of prevention bundles, CVC-BSI rates have been markedly reduced at many facilities. We present the impact of interventions at a community Brazilian hospital in a poor area of Sao Paulo.
Objective: To reduce incidence of CR-BSI in adult intensive care unit at a Brazilian public hospital.
Methods: The study was conducted in a 217 bed community hospital in Itapecerica da Serra County in the metropolitan area of Sao Paulo from May to October 2009 . In May 2009, the Infection Control Team discussed a bundle of CR-BSI prevention with the ICU staff and hospital administration. Interventions were initiated in July and the strategies were: continuous educational program on CR-BSI prevention and hand hygiene; implementation of a checklist during central line catheter insertion emphasizing hand hygiene technique, adhesion to maximal sterile barrier precautions and use of an alcoholic-based antiseptic for skin preparation; interventions to improve disinfection of catheters hubs, needleless connectors and injection ports with alcohol before manipulating the catheter; educational strategies to improve dressing care; emphasis on nonessential catheters removal; implementation of process indicators like soap and antiseptics  availability, insertion techniques and dressing aspect; monthly feedback of results to ICU  team.

 Results: The main observed inadequacies during catheter insertion during pre-intervention observation were:  break of maximal barrier precautions by auxiliary professionals (16%), use of small sterile drapes (13%) and inappropriate dressing care (6%).The density of incidence of CR-BSI decreased from 8,1 at baseline to 3,7 at 3 months after implementation of the intervention and catheter central-line utilization rates decreased from 0,58 to 0,45 per 1000 patients -day. Alcohol 70%, alcoholic chlorhexidine and degermant chlorhexidine solutions were available at each bed, for hand hygiene and skin preparation, in 42%, 73,6%, 73,6% during pre-intervention period and 83,3%, 83,3% and 89% during post-intervention period respectively.

 Conclusions: These initial results show that a bundle focused on reducing the incidence of CR-BSI is feasible and not expensive for developing countries. Continuous educational strategies are important to maintain reduced rates.