dgkh000208
10.3205/dgkh000208
urn:nbn:de:0183-dgkh0002088
Research Article
Is routine replacement of i.v. administration sets required after each change of intermittently administrated antibiotic infusions?
Muss das Infusionssystem bei Kurzzeitapplikation von Antibiotika mit jedem Wechsel der Infusionsflasche gewechselt werden?
von Au
von Au
Felix
F
Institute of Hygiene and Environmental Medicine, University Medicine, Ernst Moritz Arndt University, Greifswald, Germany
author
Ryll
Ryll
Sylvia
S
Institute of Hygiene and Environmental Medicine, University Medicine, Ernst Moritz Arndt University, Greifswald, Germany
author
Wegner
Wegner
Christian
C
Institute of Hygiene and Environmental Medicine, University Medicine, Ernst Moritz Arndt University, Greifswald, Germany
author
Gessner
Gessner
Stephan
S
Institute of Hygiene and Environmental Medicine, University Medicine, Ernst Moritz Arndt University, Greifswald, Germany
author
Kramer
Kramer
Axel
A
Prof. Dr. med.
Institute of Hygiene and Environmental Medicine University Medicine, Ernst Moritz Arndt University Greifswald, Walther-Rathenau-Straße 49a, 17489 Greifswald, Germany, Phone: +49 (0)3834 515542, Fax: +49 (0)3834 515541Institute of Hygiene and Environmental Medicine, University Medicine, Ernst Moritz Arndt University, Greifswald, Germany
kramer@uni-greifswald.de
author
German Medical Science GMS Publishing House
Düsseldorf
610
CVC
antibiotic-short-infusions
changing of renew infusion
changing of infusion bottle change
ZVK
Antibiotikakurzinfusion
Wechsel des Infusionssystems
Wechsel der Infusionsflasche
2013042920130710
engl
2196-5226
8
1
GMS Hygiene and Infection Control
GMS Hyg Infect Control
08
20130710The ISSN has been corrected.
Zielsetzung: Gemäß Herstelleranweisung ist bei jedem Wechsel der Infusionsflasche der Wechsel des gesamten Systems erforderlich. Es sollte untersucht werden, ob das bei aufeinanderfolgenden Kurzzeitinfusionen ausschließlich von Antibiotika zutrifft. Methode: Beim Wechsel des Infusionssystems nach 72 h wurde die im System verbliebene Restlösung nach Inaktivierung mit Eigelb für 48 h bei 36 °C auf Blutagar zum Nachweis einer Kontamination kultiviert.Ergebnisse: In keiner von 87 untersuchten Proben konnte eine mikrobielle Kontamination nachgewiesen werden. Irrtümlich wurde eine weitere Probe aus einem Zugang entnommen, über den kein Antibiotikum verabreicht wurde. Diese enthielt eine Koloniebildende Einheit von Coagulase-negativen Staphylokokken.Die Ergebnisse sprechen dafür, dass bei aufeinanderfolgenden Kurzinfusionen von Antibiotika das Infusionsystem beim Wechsel der Infusionsflasche nicht gewechselt werden muss. Sofern nicht ausschließlich Antibiotika verabreicht werden, muss der Wechsel jedoch durchgeführt werden, weil eine irrtümlich entnommene Probe aus einem anderen Zugang mikrobiell kontaminiert war. Zur weiteren Abklärung der Fragestellung wird eine Nachfolgestudie mit Einschluss einer größeren Patientenzahl als erforderlich angesehen.Schlussfolgerung: Für den nicht-antibiotischen Zugang muss bei jedem Wechsel der Infusionsflasche auch das Infusionsset gewechselt werden. Die Ergebnisse unserer Pilotstudie sprechen jedoch dafür, dass dieser Wechsel nicht erforderlich ist, sofern nur Antibiotika appliziert werden.
Aim: Manufacturers’ instructions recommend changing the infusion line together with the infusion bottle after each administration. We investigated if the complete infusion line may be microbiologically contaminated after short-time antibiotic and rinse-solution application.Method: Immediately after the change of an infusion administration set after 72 hours the remaining antibiotic solution was inactivated with yolk and cultured on blood agar for 48 hours at 36°C to detect possible contaminants.Results: Among 87 investigated samples no microbial growth was detected. One sample which hadn’t any contact to antibiotics yielded <![CDATA[1 colony</PlainText></TextGroup> forming unit (cfu) of coagulase-negative staphylococci.</Pgraph><Pgraph>These results suggest that in case of consecutive antibiotic-short- and rinse-infusions the infusion line may be in place up to 72 hours without contamination. This, however, may be only the case for infusion sets, which are in contact with antibiotics. If no antibiotic is administered, the infusion bottle and the infusion line must be renewed together for every change. To clarify this question into more detail, a larger consecutive study is required. </Pgraph><Pgraph><Mark1>Conclusion:</Mark1> I.v. administration sets without any contact to antibiotics must be changed together with their infusion bottle after administration. In case of consecutive antibiotic-short- and rinse-infusions our pilot study suggests using the i.v. administration sets for up to 72 hours without renewing it at every infusion-set exchange.</Pgraph></Abstract>
<TextBlock linked="yes" name="Introduction">
<MainHeadline>Introduction</MainHeadline><Pgraph>Manufacturers’ instructions recommend changing the i.v. administration set together with the infusion bottle after each administration. The recommendation of KRINKO <TextLink reference="1"></TextLink> requires similarly, that feed-lines in the case of short infusions must be discarded after the completion of the infusion. However, in practice it is observed in the case of several directly cascaded short infusions for a given drug compatibility usually the same administration line is used.</Pgraph><Pgraph>Particularly in intensive care, a number of different solutions are administered over the limb of the central venous catheter (CVC) daily. Therefore, following the manufacturers’ recommendations is associated with costs and increased workload for healthcare workers.</Pgraph><Pgraph>To the best of our knowledge no studies have investigated if immediate renewing of the complete i.v. administration set together with an emptied infusion bottle is required. Even the very comprehensive CDC's 2011 Guidelines for the prevention of intravascular catheter-related infections <TextLink reference="2"></TextLink> leave this aspect unanswered and categorized it as unresolved issue. Therefore we investigated microbiologically if the complete infusion line may be contaminated after short-time antibiotic and rinse-solution applications. However the issue was limited to short infusions of antibiotics, which were infused over the same limb. A constant limb flow was ensured by intermediate rinse solutions.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Methods">
<MainHeadline>Methods</MainHeadline><Pgraph>The sample collection for the pilot study was performed at the 72-hourly CVS-system-change of the antibiotic short infusions from July 13, 2012 to August 7, 2012 at participating intensive care units. The detailed sequence of sampling is summarized in Table 1 <ImgLink imgNo="1" imgType="table"/>.</Pgraph><Pgraph>The i.v. administration sets together with the infusion bottles containing antibiotics and rinse solution (0.9% NaCl) closed with seals were packaged individually and aseptically and transported to the laboratory in a cool bag (4°C). Remaining fluid residuals were obtained aseptically from the inside lumen of i.v. administration sets inside a lamina-air-flow-bench.</Pgraph><Pgraph>To inactivate the antimicrobial activity of antibiotics residues, samples were neutralized with yolk (1 part sample solutions – 9 parts yolk suspension) from hen eggs of bio-lifestock without antibiotic feeding. Immediately before the usage, the yolk was taken with a sterile syringe suspension and mixed in the ratio of 1:1 with aqua dest. in a sterile tube. The effectiveness of the neutralization was validated in previous in-vitro dilution tests.</Pgraph><Pgraph>Approximately 15 minutes after adding the neutralizer, 0.1 mL of the solution was plated on blood agar and incubated for 48 hours at 36±1°C.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Results">
<MainHeadline>Results</MainHeadline><Pgraph>Among 87 investigated samples no microbial growth was detected. One sample which hadn’t any contact to antibiotics yielded 1 colony forming unit (cfu) of coagulase-negative staphylococci (CoNS).</Pgraph><Pgraph>Within 72 hours the exchanges of the bottles differed between 6 and 36, in average 18 exchange were performed (Table 1 <ImgLink imgNo="1" imgType="table"/>). </Pgraph><Pgraph>The results of our investigation suggest that i.v. administration sets which remain connected to infusion bottles (antibiotic short infusions and rinse solution) under a constant flow may be in place over duration of up to 72 hours without contamination. However for non-antibiotic flow we conclude that the i.v. administration set must be renewed at every change of an infusion bottle, because in the erroneously taken sample without any antibiotic-access 1 cfu CoNS was detected. CoNS can cause severe sepsis especially in neonates <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>, but they are also not harmless for adults <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>.</Pgraph><Pgraph>In order to interpret the results correctly it is important to note that the ICU staff who worked on the CVCs was not specifically instructed in the hygienic principles of changing an infusion bottle before the start of the pilot study. This should prevent the known effect of the training on the suppression of the central-line associated infections <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Conclusion">
<MainHeadline>Conclusion</MainHeadline><Pgraph>I.v. administration sets without any contact to antibiotics must be changed together with their infusion bottle after administration. In case of consecutive antibiotic-short- and rinse-infusions our pilot study suggests using the i.v. administration sets for up to 72 hours without renewing it at every infusion-set exchange.</Pgraph><Pgraph>However, to clarify this question into more detail, a larger consecutive study is required.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Notes">
<MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The study was sponsored by BBraun AG Melsungen, Germany.</Pgraph></TextBlock>
<References linked="yes">
<Reference refNo="1">
<RefAuthor>Anonym</RefAuthor>
<RefTitle>Prävention Gefäßkatheterassoziierter Infektionen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut (RKI)</RefTitle>
<RefYear>2002</RefYear>
<RefJournal>Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz</RefJournal>
<RefPage>907-24</RefPage>
<RefTotal>Prävention Gefäßkatheterassoziierter Infektionen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut (RKI). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2002; 45(11): 907-24. DOI: 10.1007/s00103-002-0499-8</RefTotal>
<RefLink>http://dx.doi.org/10.1007/s00103-002-0499-8</RefLink>
</Reference>
<Reference refNo="2">
<RefAuthor>O'Grady NP</RefAuthor>
<RefAuthor>Alexander M</RefAuthor>
<RefAuthor>Burns LA</RefAuthor>
<RefAuthor>Dellinger EP</RefAuthor>
<RefAuthor>Garland J</RefAuthor>
<RefAuthor>Heard SO</RefAuthor>
<RefAuthor>Lipsett PA</RefAuthor>
<RefAuthor>Masur H</RefAuthor>
<RefAuthor>Mermel LA</RefAuthor>
<RefAuthor>Pearson ML</RefAuthor>
<RefAuthor>Raad II</RefAuthor>
<RefAuthor>Randolph AG</RefAuthor>
<RefAuthor>Rupp ME</RefAuthor>
<RefAuthor>Saint S</RefAuthor>
<RefAuthor> Healthcare Infection Control Practices Advisory Committee</RefAuthor>
<RefTitle>Guidelines for the prevention of intravascular catheter-related infections</RefTitle>
<RefYear>2011</RefYear>
<RefJournal>Am J Infect Control</RefJournal>
<RefPage>S1-34</RefPage>
<RefTotal>O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph AG, Rupp ME, Saint S; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011 May;39(4 Suppl 1):S1-34. DOI: 10.1016/j.ajic.2011.01.003</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.ajic.2011.01.003</RefLink>
</Reference>
<Reference refNo="3">
<RefAuthor>Huang YC</RefAuthor>
<RefAuthor>Wang YH</RefAuthor>
<RefAuthor>Su LH</RefAuthor>
<RefAuthor>Chou YH</RefAuthor>
<RefAuthor>Lien RI</RefAuthor>
<RefAuthor>Lin TY</RefAuthor>
<RefTitle>Determining the significance of coagulase-negative staphylococci identified in cultures of paired blood specimens from neonates by species identification and strain clonality</RefTitle>
<RefYear>2006</RefYear>
<RefJournal>Infect Control Hosp Epidemiol</RefJournal>
<RefPage>70-3</RefPage>
<RefTotal>Huang YC, Wang YH, Su LH, Chou YH, Lien RI, Lin TY. Determining the significance of coagulase-negative staphylococci identified in cultures of paired blood specimens from neonates by species identification and strain clonality. Infect Control Hosp Epidemiol. 2006 Jan;27(1):70-3. DOI: 10.1086/499165</RefTotal>
<RefLink>http://dx.doi.org/10.1086/499165</RefLink>
</Reference>
<Reference refNo="4">
<RefAuthor>Hira V</RefAuthor>
<RefAuthor>Sluijter M</RefAuthor>
<RefAuthor>Goessens WH</RefAuthor>
<RefAuthor>Ott A</RefAuthor>
<RefAuthor>de Groot R</RefAuthor>
<RefAuthor>Hermans PW</RefAuthor>
<RefAuthor>Kornelisse RF</RefAuthor>
<RefTitle>Coagulase-negative staphylococcal skin carriage among neonatal intensive care unit personnel: from population to infection</RefTitle>
<RefYear>2010</RefYear>
<RefJournal>J Clin Microbiol</RefJournal>
<RefPage>3876-81</RefPage>
<RefTotal>Hira V, Sluijter M, Goessens WH, Ott A, de Groot R, Hermans PW, Kornelisse RF. Coagulase-negative staphylococcal skin carriage among neonatal intensive care unit personnel: from population to infection. J Clin Microbiol. 2010 Nov;48(11):3876-81. DOI: 10.1128/JCM.00967-10</RefTotal>
<RefLink>http://dx.doi.org/10.1128/JCM.00967-10</RefLink>
</Reference>
<Reference refNo="5">
<RefAuthor>Sharma P</RefAuthor>
<RefAuthor>Lahiri KK</RefAuthor>
<RefAuthor>Kapila K</RefAuthor>
<RefTitle>Conventional and molecular characterization of coagulase-negative staphylococcus in hospital isolates</RefTitle>
<RefYear>2011</RefYear>
<RefJournal>Indian J Pathol Microbiol</RefJournal>
<RefPage>85-9</RefPage>
<RefTotal>Sharma P, Lahiri KK, Kapila K. Conventional and molecular characterization of coagulase-negative staphylococcus in hospital isolates. Indian J Pathol Microbiol. 2011 Jan-Mar;54(1):85-9. DOI: 10.4103/0377-4929.77331</RefTotal>
<RefLink>http://dx.doi.org/10.4103/0377-4929.77331</RefLink>
</Reference>
<Reference refNo="6">
<RefAuthor>Fernández-Rufete A</RefAuthor>
<RefAuthor>García-Vázquez E</RefAuthor>
<RefAuthor>Hernández-Torres A</RefAuthor>
<RefAuthor>Canteras M</RefAuthor>
<RefAuthor>Ruiz J</RefAuthor>
<RefAuthor>Gómez J</RefAuthor>
<RefTitle>Bacteriemias por Staphylococcus coagulasa negativa: análisis de factores pronóstico e influencia del tratamiento antibiótico</RefTitle>
<RefYear>2012</RefYear>
<RefJournal>Rev Esp Quimioter</RefJournal>
<RefPage>199-205</RefPage>
<RefTotal>Fernández-Rufete A, García-Vázquez E, Hernández-Torres A, Canteras M, Ruiz J, Gómez J. Bacteriemias por Staphylococcus coagulasa negativa: análisis de factores pronóstico e influencia del tratamiento antibiótico [Coagulase-negative Staphylococcus bacteraemia: prognosis factors and influence of antibiotic treatment]. Rev Esp Quimioter. 2012 Sep;25(3):199-205.</RefTotal>
</Reference>
<Reference refNo="7">
<RefAuthor>Liang SY</RefAuthor>
<RefAuthor>Khair H</RefAuthor>
<RefAuthor>Durkin MJ</RefAuthor>
<RefAuthor>Marschall J</RefAuthor>
<RefTitle>Prevention and management of central line-associated bloodstream infections in hospital practice</RefTitle>
<RefYear>2012</RefYear>
<RefJournal>Hosp Pract (Minneap)</RefJournal>
<RefPage>106-18</RefPage>
<RefTotal>Liang SY, Khair H, Durkin MJ, Marschall J. Prevention and management of central line-associated bloodstream infections in hospital practice. Hosp Pract (Minneap). 2012 Feb;40(1):106-18. DOI: 10.3810/hp.2012.02.951</RefTotal>
<RefLink>http://dx.doi.org/10.3810/hp.2012.02.951</RefLink>
</Reference>
<Reference refNo="8">
<RefAuthor>Zack J</RefAuthor>
<RefTitle>Zeroing in on zero tolerance for central line-associated bacteremia</RefTitle>
<RefYear>2008</RefYear>
<RefJournal>Am J Infect Control</RefJournal>
<RefPage>S176</RefPage>
<RefTotal>Zack J. Zeroing in on zero tolerance for central line-associated bacteremia. Am J Infect Control. 2008 Dec;36(10):S176.e1-2. DOI: 10.1016/j.ajic.2008.10.014</RefTotal>
<RefLink>http://dx.doi.org/10.1016/j.ajic.2008.10.014</RefLink>
</Reference>
<Reference refNo="9">
<RefAuthor>Henderson DM</RefAuthor>
<RefAuthor>Staiger TO</RefAuthor>
<RefAuthor>Peterson GN</RefAuthor>
<RefAuthor>Sinanan MN</RefAuthor>
<RefAuthor>Angiulo CL</RefAuthor>
<RefAuthor>Makarewicz VA</RefAuthor>
<RefAuthor>Wild LM</RefAuthor>
<RefAuthor>Whimbey EE</RefAuthor>
<RefTitle>A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-line-associated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections</RefTitle>
<RefYear>2012</RefYear>
<RefJournal>J Healthc Qual</RefJournal>
<RefPage>39-47; quiz 48-9</RefPage>
<RefTotal>Henderson DM, Staiger TO, Peterson GN, Sinanan MN, Angiulo CL, Makarewicz VA, Wild LM, Whimbey EE. A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-line-associated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections. J Healthc Qual. 2012 Sep-Oct;34(5):39-47; quiz 48-9. DOI: 10.1111/j.1945-1474.2012.00213.x</RefTotal>
<RefLink>http://dx.doi.org/10.1111/j.1945-1474.2012.00213.x</RefLink>
</Reference>
<Reference refNo="10">
<RefAuthor>Maki DG</RefAuthor>
<RefAuthor>Botticelli JT</RefAuthor>
<RefAuthor>LeRoy ML</RefAuthor>
<RefAuthor>Thielke TS</RefAuthor>
<RefTitle>Prospective study of replacing administration sets for intravenous therapy at 48- vs 72-hour intervals. 72 hours is safe and cost-effective</RefTitle>
<RefYear>1987</RefYear>
<RefJournal>JAMA</RefJournal>
<RefPage>1777-81</RefPage>
<RefTotal>Maki DG, Botticelli JT, LeRoy ML, Thielke TS. Prospective study of replacing administration sets for intravenous therapy at 48- vs 72-hour intervals. 72 hours is safe and cost-effective. JAMA. 1987 Oct;258(13):1777-81.</RefTotal>
</Reference>
</References>
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<Caption><Pgraph><Mark1>Table 1: Frequency of infusion bottle exchanges within 72 h</Mark1></Pgraph></Caption>
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