A 72-year-old woman is brought to the emergency department due to lethargy, fever, and confusion. She was found by her family on the floor of her bedroom. The patient is unable to provide further history, but she told her family 2 days ago that she had urinary incontinence and foul-smelling urine. She has a history of hypertension, osteoarthritis, and recurrent urinary tract infections. The patient's medications include lisinopril, amlodipine, and a topical pain medication. She has no known drug allergies. Temperature is 39 C (102.2 F), blood pressure is 74/46 mm Hg, pulse is 133/min, and respirations are 24/min. The patient is lethargic and responds only to simple commands. Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds with no murmurs. The abdomen is soft, nondistended, and nonpainful, but palpation of the right flank causes grimacing. The extremities are warm to the touch with no edema. A chest radiograph is unremarkable. Leukocyte count is 21,000/mm³ with 91% neutrophils. Urinalysis is positive for nitrates and microscopic examination of the urine shows a white blood cell count of 200+/hpf. Intravenous antibiotics are administered. Multiple boluses of isotonic fluid are given peripherally with no improvement in the patient's vital signs. She is prepared for insertion of a central venous catheter. Which of the following is most likely to reduce the risk of catheter-associated infection in this patient?

Question

Quizplus · Accepted Answer

Explanation: Central line-associated bloodstream infection (CLABSI) can prolong hospital stays and increase morbidity and mortality. Most cases are the result of catheter contamination with skin organisms such as coagulase-negative staphylococci, Staphylococcus aureus, Candida species, and aerobic gram-negative bacilli. The risk of CLABSI is greatest when a central intravenous catheter has been left in place >6 days. A comprehensive approach to CLABSI prevention includes the use of the following: A checklist prior to catheter insertion Proper hand hygiene prior to catheter handling An all-inclusive catheter kit Sterile barrier precautions (eg, mask and sterile gown, large drape, gloves) during insertion Chlorhexidine-based antiseptic for preparation of the patient's skin Proper catheter site care Catheter removal when it is no longer needed This patient's provider should ensure that a large sterile drape is used during catheter insertion to avoid contamination with skin organisms. (Choice A) Prophylactic intravenous antibiotics are not recommended as the risk of developing resistant organisms (eg, vancomycin-resistant Enterococcus) outweighs the benefit. (Choice B) Replacement of a catheter using a guidewire results in an increased risk of bloodstream infection. In addition, routine replacement of catheters is not associated with a reduced risk of CLABSI. (Choice D) Placing a central catheter in the subclavian vein (not the internal jugular vein) is considered to be associated with the least risk of infection. However, some studies now suggest no difference in infection rates among the femoral, internal jugular, and subclavian vein sites. (Choice E) Ultrasound guidance for placing central lines can decrease the risk of mechanical complications and the number of placement attempts, but it does not reduce infection rates. Educational objective: Central line-associated bloodstream infections (CLABSI) are usually caused by skin organisms such as coagulase-negative staphylococci, Staphylococcus aureus, Candida species, and aerobic gram-negative bacilli. Risk of CLABSI can be reduced by cleaning the insertion site with chlorhexidine, using maximal barrier precautions (eg, large sterile drape, mask) during insertion, and promptly removing the catheter when it is no longer needed. References: Central line-associated bloodstream infections: prevention and management. (http://www.ncbi.nlm.nih.gov/pubmed/21315995)

A 72-Year-Old Woman Is Brought to the Emergency Department Due