1. The ideal management of the
exit site: antisepsis, dressing,
securement
Giancarlo Scoppettuolo
Catholic University, Rome

4. Targeting Zero
Targeting Zero is the philosophy that every
healthcare institution should be working toward a
goal of zero healthcare-associated infections
(HAIs). While HAI prevention is challenging and
complex, APIC believes that all organizations
should set the aspirational goal of elimination and
strive for zero infections. Every HAI impacts the
life of

6. VAD SELECTION
AND HEALTHCARE WORKERS INSERTION
EDUCATION AND TRAINING
CRBSI Prevention
DISINFECTION OF CATHETER HUBS,
CARE OF EXITE SITE
CONNECTORS AND INJECTION PORTS

7. Prevention of extra and intraluminal
colonization
CHG Skin CHG Eluting Disk
Preparation (applied after catheter
insertion and with every
(applied before catheter dressing change)
insertion and with every Swabable
dressing change)
Needleless
Connector
Intraluminal
colonization
Extraluminal
colonization
Modified, Courtesy of R. Garcia, MD

8. Why Proper CL Maintenance is Critical
Insertion
Period
= 30 min
= 0.3%
Maintenance Period = 167.5h = 99.7%
0 1 2 3 4 5 6 7
Average Central Line Days
Modified, courtesy of J. LeDonne, MD

9. Manteinance of Exit Site
• Which antiseptic?
• Which Dressing?
• When to change?
• Is there any indication for chlorhexidine
impregnated dressing?
• Which securement?

10. Guidelines for CRBSI Prevention
• CDC Atlanta 2002
• RCN 2005
• INS 2006
• BCSH 2006
• EPIC 2007
• SHEA/IDSA 2008
• ESPEN 2009
• RCN 2010
• INS 2011
• CDC 2011

11. WHICH ANTISEPTIC?

15. Advantages of chlorhexidine
• Bactericidal
• Broad activity against Gram positive and Gram
negative bacteria, facultative anaerobes, yeasts and
some lipid-enveloped viruses, including HIV (but not
sporicidal)
• Rapid onset of activity
• Prolonged antimicrobial effect
• Synergistic effect with alcohol
• Lack of inactivation when exposed to blood and
serum

17. Figure 1
Prospective, randomized trial of two antiseptic solutions for prevention of
central venous or arterial catheter colonization and infection in intensive care
unit patients.
Mi moz, Ol ivier; Pi eroni, Laurence; La wrence, Christine; Edouard, Alain; Costa,
Ya nnick; Samii, Ka mran; Brun-Buisson, Christian
Cri ti ca l Care Medicine. 24(11):1818-1823, November 1996.
Fi gure 1 . Ti me to occurrence of ca theter colonization i n
the chl orhexidine group (closed s quares) and the
povi done iodine group (open squares). The risk of
ca theter colonization was significantly greater in the
povi done iodine group than in the chlorhexidine group (p
< .01, Log-ra nk test).
© Wi l liams & Wilkins 1996. All Rights Reserved. Published by Li ppincott Williams & Wi lkins, Inc. 5

22. Premature Infant Skin
• Stratum corneum
poorly developed or
absent
• Thin epidermis
• Dermis not fully
formed and deficient
of structural proteins
“Shaping the Future of Pediatric Vascular Access 2012”

23. Full Term Infant Skin
Healthy infants
• Well-formed stratum
corneum…..note
multiple layers
• Thick epidermis
• Structural proteins
present in the dermis
“Shaping the Future of Pediatric Vascular Access 2012”

24. CHG Safety in Premature Infants
• Issues: systemic absorption, skin toxicity
• Concern: hexachlorophene caused neurotoxicity
• Hexachlorophene:
– Bacteriostatic
– disrupts bacterial cell wall
– slow onset efficacy
• CHG:
– Bacteriocidal
– increases cell membrane permeability
– rapid onset
– binds to SC proteins
Chapman A, et al. J Perinatol (2012); 32(1):4-9
“Shaping the Future of Pediatric Vascular Access 2012”

26. CHG versus PI in Neonates
• Pilot parallel comparison: 2% CHG (alcohol) vs. 10% Povidone
Iodine
• 48 neonates ≥ 1500 g (~ 30wks GA) and ≥ 7 days
• No catheter related BSIs in either group
• No dermatitis - CHG or PI (i.e., ≥ 2,no pink-red all area)
• CHG absorption occurred:
• 7 of 10 had blood CHG between 13 – 100 ng/ml
• No neurotoxicity
Studies needed in younger preterms
Garland J, et al. J Perinatol (2009); 29:808-813
“Shaping the Future of Pediatric Vascular Access 2012”

29. CHG Use in NICUs
• A survey of 90 NICU training units found:
55 Used CHG, central venous catheter care
27 No restrictions
28 Restrictions: GA, actual age or birth weight
28 Reported adverse reactions, all skin related
17 burns, 2 erosions, 9 erythema
55 Had concerns: Off label use, Immature skin, Limited
safety data
Tamma P, et al. Infect Control Hosp
Epidemiol (2010);31(3):846-849
“Shaping the Future of Pediatric Vascular Access 2012”

31. 2010

35. WHICH DRESSING?
AND WHEN TO CHANGE?

44. Advantages of Semipermeable
Transparent Dressing
• Visibility of insertion site
• Better stabilization of catheter, avoiding “in and out”
movements
• Better protection against secretions, mostly if
catheter’sexit site is near tracheostomy or oral and
nose secretions
• Longer time between dressing changes (7 days vs 2
days)

45. Is there any indication for
chlorhexidine impregnated
dressing?

56. WHICH SECUREMENT?

59. Disadvantages of sutures
• Sutures disrupt the skin around the catheter exit site,
causing inflammation and heavy colonization
• Bad securement of catheter, with movement of “in
and out” and increased risk of thrombosis and
infection
• Patient discomfort
• Risk of sharps injury to healthcare workers from
inadvertent needlestick injury

61. RCN 2005
RCN 2010
INS 2006
INS 2011
BCSH 2006
CDC 2011

63. Conclusions
• A proper care of the catheter exit site is critical for
CRBSI prevention
• The preferred antiseptic for skin during the dressing
change is 2% chlorhexidine (preferably in isopropyl
alcohol)
• To cover and protect the exit site , you can use gauze
and tapes or semipermeable transparent dressing,
taking into account the differences in terms of
replacing (2 vs 7 days)
• To secure the catheter, use sutureless devices instead
of sutures.

64. Last Conclusion…
• All this works and is really effective
not as an isolate strategy, but only if
it is part of a bundle of
recommendations…

65. • Hands hygiene and maximal barrier precautions
• Ultrasound guided insertion
• Use of 2% chlorhexidine, for skin antisepsis before
insertion and for continous or discontinous
antisespis of exit site
• Use of sutureless devices for catheter securement,
whenever possible
• Use of transparent dressings, whenever possible
• Prompt removal of unnecessary lines

66. Targeting zero CLABSI in patients with
PICC lines: a case-control study
G. Scoppettuolo§, L. Dolcetti§, C. Taraschi§, C. Chiarini§,
C. Donato§, S. Lardo§, A. La Greca*, M. Pittiruti*
§ Clinic of Infectious Diseases, * Dpt. of Surgey, Catholic
University, Rome
AVA 2011

67. Results
CASES CON TROLS P
( I nfe ct ious ( Ot h e r w a r ds)
D ise a se s)
CRBSI 0 14 < 0.001
CLABSI / 1 0 0 0 ca t h e t e r da y s 0 2.66 < 0.001
D ia gn osis
· D TP 10
· Blood cu lt u re + t ip 4
cult ur e
M e dia n t im e for CLABSI NA 21+12
on se t
Et iology of CLABSI NA
· Ca n dida a lbica n s 3
· Ca n dida pa r a psilosis 2
· CON S 3
· S. a u r e u s 1
· E. coli 3
· K. pn e u m on ia e 2
CLABSI r e la t e d de a t h s 0 0 NS

69. Thank you for your attention!
Giancarlo Scoppettuolo, MD
Catholic University
“ A. Gemelli” Hospital, Rome
E-mail: g.scoppettuolo@rm.unicatt.it
Web: www.gavecelt.info
www.evanetwork.info
www.policlinicogemelli.it