Sources of Contamination and Issues of Infection

Hello Nancy,

Once again I need some help with a few questions that have been sent to my customers. I find it difficult to answer them alone, which is why I ask for your opinion.

Situation 1: Pat with CRP increase, Blood culture peripherally positive, blood culture by PICC negative, PICC ESS reddened, PICC pulled, CRP reduced. Drug adaptation unknown

Questions: Can the reddened ESS have caused the CRP increase or was it an organic problem? We were irritated that the blood culture from the PICC was negative. What is your hypothesis?

Situation 2: Pat with CRP increase and antibiotic therapy by PICC, Pat was transferred to hospital because of AZ deterioration. Feedback from the hospital was that the PICC was contaminated.

Questions: Is contamination due to unhygienic work? Is a germ transmission always from the outside or can it also get from inside the body (blood) through the blocked liquid into the tube? What is your hypothesis?

Situation 3: Pat admission from the hospital, According to the hospital, the PICC must be rinsed once a day due to the risk of clogging. We only needed the PICC for blood sampling but no therapy. When I wanted to take the blood, it was not possible to rinse, so I aspirated and then slowly tried to rinse, a blood coagula became visible in the PICC coat, I was able to remove it with the rejection tube of the blood sample. The 3-way valve from the hospital was changed and a microclave attached, flushed, rinsed and blocked. 2 days later I aspirated out of caution, there was again a coagula visible about 1 cm long, the PICC was then pulled.

Questions: Why did these coagulas arise despite flushing, flushing and blocking? Was the PICC defective? Logically, should not blood flow back into the PICC tube? What is your hypothesis?

I thank you in advance for your highly esteemed opinion and wish you a nice rest of the day. —C.B. Switzerland

Hello, You have many high level questions. I will do my best to answer or provide references for you to consider.

First the definition of CRP: C-reactive protein is an annular, pentameric protein found in blood plasma, whose circulating concentrations rise in response to inflammation. A high level of CRP in the blood is a marker of inflammation. It can be caused by a wide variety of conditions, from infection to cancer. High CRP levels can also indicate that there’s inflammation in the arteries of the heart, which can mean a higher risk of heart attack.

Any inflammation, internal or external, can cause CRP to increase. Rising CRP does not necessarily indicate infection. External site infection could cause the problem and could have potentially be treated by ointment.

How contamination occurs causing a catheter infection:

  1. From the skin or clinician hands/gloves to needleless connector (NC)
  2. Failure to adequately clean NC
  3. Poor design of NC making it impossible to adequately clean
  4. Bacteria enter and permanently attach to NC
  5. From the skin down the catheter track
  6. During insertion from the skin
  7. From the infusate with poor mixing practices or with additives
  8. Contamination of hub during NC change from clinician hands/gloves
  9. Touch contamination to key sterile parts (ANTT) during connection/disconnection – unhygienic work
  10. Translocation from an infection within the body – this would show up as a positive blood culture

Contamination can occur at any time during the insertion or life of a catheter. Once bacteria enters the NC and catheter it can attach permanently, grow biofilm to protect it and increase the colony size to the point that supercharged bacteria is released into the bloodstream causing infection greater than antibiotics can contain.

Blood reflux is a problem with all catheters. Certain needleless connectors have anti-reflux, you should use those! See the articles I have attached on HOW to rinse/flush. Push Pause Push Pause 10ml over 6 seconds.

Nancy Moureau, PhD, RN, CRNI, CPUI, VA-BC

Chief Executive Officer – PICC Excellence, Inc, Hartwell, GA, USA

Vascular Access Specialist, Adjunct Associate Professor, Griffith University, Brisbane, Australia

Alliance for Vascular Access Teaching and Research (AVATAR) Group, Queensland, Griffith University, Brisbane, Australia

Contact: Office 706-377-3360

Kelly, L. Jones, T, Kirkham, S. 2017 Needle-free devices: keeping the system closed. British Journal of Nursing (IV Therapy Supplement) 26:(2)

Hull, G, Moureau, N., Sengupta, S., Quantitative assessment of reflux in commercially available needle-free IV connectors. JVA ISSN 1129-7 298

Btaiche, I., Kovacevich, D., Khalidi, N., Papke, L., 2011 The Effects of Needless Connectors on Catheter-Related Thrombotic Occlusions. JIN 34(2):89-95

Elli, S., Abbnezzese, C., Cannizzo, L., Lucchini, A., 2016 In vitro evaluation of fluid reflux after flushing different types of needleless connectors. JVA ISSN 1129-7 298

Casey, A., Karpanen, T., Nightingale, P., Elliott, T., 2018 The risk of microbial contamination associated with six different needle-free connectors. BJN 2(2) Link to pdf

Ferroni, A., Gaudin, F., Guiffant, G., etal 2014 Pulsative flushing as a strategy to prevent bacterial colonization of vascular access devices. Med Dev (Auck) 7:379-383 Link to pdf

Guiffant, G., Durussel, J., Merckx, J., etal 2012 Flushing of intravascular access devices (IVADS) – Efficacy of pulsed and continuous infusions. JVA 13(1):75-78

Moureau, N., Flynn, J., 2015 Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review. Nurs Rev and Prac Vol 2015 Article ID 796762, 20 p Link to pdf

Moureau, N., 2014 Catheter-associated bloodstream infection prevention: what is missing? Brit Jour Healthcare Mgmnt 20(11):506-10

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