In the News

Preventing bloodstream infections, management of unstable angina and non-ST-elevation MI, and more.

Updated guidelines on preventing bloodstream infections released

Updated guidelines for preventing intravascular catheter-related infections were jointly released in April by more than a dozen governmental agencies and professional organizations.

The guidelines, which replace a 2002 edition, were released by the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee (HICPAC), and developed by a working group led by clinical scientists from the National Institutes of Health Clinical Center Critical Care Medicine Department, along with 14 other professional organizations. Major areas of emphasis include educating and training health care personnel, using maximal sterile barrier precautions during catheter insertion, cleaning skin with chlorhexidine, and avoiding routine replacement of central venous catheters. Specific recommendations include:

  • Only trained personnel who demonstrate competence should undertake insertion and maintenance of intravascular catheters, and they should be periodically assessed for knowledge of and adherence to guidelines.
  • In adults, use an upper extremity site for insertion of a peripheral or midline catheter. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible.
  • Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days.
  • Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications such as pneumothorax, thrombosis and hemothorax. Promptly remove any intravascular catheter that is no longer essential.
  • Avoid using the femoral vein for central venous access in adult patients. Use a subclavian site, rather than a jugular or femoral site, in adult patients to minimize infection risk for nontunneled central venous catheter placement.
  • Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis.
  • Use ultrasound guidance (if this technology is available) to place central venous catheters to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique.
  • Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of central venous catheters, PICCs, or guidewire exchange.
  • Prepare skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion. Prepare skin with a greater than 0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives.

The guidelines working group was led by the Society of Critical Care Medicine in collaboration with the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Surgical Infection Society, American College of Chest Physicians, American Thoracic Society, American Society of Critical Care Anesthesiologists, Association for Professionals in Infection Control and Epidemiology, Infusion Nurses Society, Oncology Nursing Society, American Society for Parenteral and Enteral Nutrition, Society of Interventional Radiology, American Academy of Pediatrics, Pediatric Infectious Diseases Society, and the HICPAC.

ACC, AHA release focused update on management of unstable angina, non-ST-elevation MI

The American College of Cardiology/American Heart Association released a focused update this week to their guidelines on management of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). The guidelines were originally issued in 2007.

For this update, the guideline writing committee examined areas of new research: the timing of acute interventional therapy in patients with NSTEMI; the timing, duration and application of dual-antiplatelet therapy and triple-antiplatelet therapy in high-risk patients and dual-antiplatelet therapy in low- and moderate-risk patients; the role of invasive therapies in patients with advanced renal dysfunction; and the effect of participation in a quality-of-care data registry for UA/NSTEMI on quality improvement for acute coronary syndromes.

New recommendations in the focused update include:

  • Patients with UA/NSTEMI for whom percutaneous coronary intervention (PCI) is planned should receive a loading dose of a thienopyridine.
  • Clopidogrel, 75 mg/d, or prasugrel, 10 mg/d, should be given for at least a year after PCI, unless the risk of bleeding outweighs the potential benefits.
  • In patients with UA/NSTEMI who are planning to have PCI and have a history of stroke or transient ischemic attack, prasugrel may be harmful if used as dual-antiplatelet therapy.
  • Platelet function testing may be considered in patients with UA/NSTEMI receiving thienopyridine therapy to evaluate platelet inhibitory response if the results of such testing might change management.
  • An early invasive treatment strategy (within 12 to 24 hours of hospital admission) is considered reasonable in stabilized high-risk patients with UA/NSTEMI. A delayed invasive approach is considered reasonable for patients who are not at high risk.
  • Patients with chronic kidney disease who are having cardiac catheterization with contrast media should receive adequate hydration beforehand.
  • Clinicians and hospitals caring for patients with UA/ NSTEMI may reasonably participate in a standardized quality-of-care data registry to track and measure outcomes, complications and adherence to evidence-based care.

The focused update appeared in the May 10 Journal of the American College of Cardiology and was also published by Circulation.

Off-label recombinant factor VIIa common but potentially harmful in U.S. hospitals

Off-label use of recombinant factor VIIa (rFVIIa) is widespread in U.S. hospitals but could increase risk of adverse events, according to two recent studies.

The procoagulant rFVIIa was approved by the FDA in 1999 for treatment of surgical or spontaneous bleeding in patients with hemophilia A or B who have inhibitors to factor VIII or IX. However, it is often used off-label to treat or prevent bleeding in patients with other conditions, and several trials have indicated a potential for thrombotic complications.

In the first study, researchers reviewed records for 12,644 patients who received rFVIIa during a hospital stay between 2000 and 2008. In that time period, off-label use increased by 140-fold, whereas use for thrombophilia increased less than four-fold, the authors found. Ninety-six percent of in-hospital rFVIIa use from 2000 to 2008 and 97% in 2008 were for off-label indications, such as body and brain trauma, cardiovascular surgery and intracranial hemorrhage. The authors noted that they could not verify the accuracy or completeness of the discharge diagnoses or medication records, but concluded that off-label use of rFVIIa is much more common than use for approved indications.

A second study, a meta-analysis involving several of the same authors, evaluated published research to determine the benefits and harms of in-hospital, off-label use of rFVIIa for intracranial hemorrhage, cardiac surgery, trauma, liver transplantation and prostatectomy. In 64 articles published from inception through 2010, off-label use of rFVIIa appeared to have no mortality benefit. Patients who received rFVIIa for intracranial hemorrhage had an increased risk for arterial thromboembolism with medium and high doses, and adults who received it for cardiac surgery had an increased risk for thromboembolism. The authors noted that evidence was limited overall and that they could not exclude publication bias, but concluded that off-label use of rFVIIa for these common five indications did not help and could in some conditions cause harm.

The authors of an accompanying editorial suggested that physicians may have begun prescribing rFVIIa for indications besides hemophilia to try to protect patients from excessive bleeding. However, they emphasized that such use does not appear to benefit patients, increases risk for thrombotic events, and costs approximately $10,000 per dose. “Allowing physician autonomy to choose medications is appealing, but not when it results in unhelpful, dangerous, and costly decisions,” they wrote.

Both studies and the editorial appeared in the April 19 Annals of Internal Medicine.

Bulk of patients with MI after noncardiac surgery don't have ischemic symptoms

More than 65% of patients who have a myocardial infarction (MI) within 30 days of noncardiac surgery don't experience ischemic symptoms, a new study found.

For a cohort study, researchers recruited 8,351 patients from 190 centers in 23 countries who were having noncardiac surgery, were at least 45 years old, had or were at risk of atherosclerotic disease, and were expected to stay in the hospital at least 24 hours. They evaluated MIs within 30 days of randomization by measuring four cardiac biomarker or enzyme assays within three days of noncardiac surgery, and by using serial electrocardiograms at 6 to 12 hours and on the first, second, and 30th days after surgery. MI was defined by autopsy findings, or an elevated level of a cardiac biomarker or enzyme and at least one of the following: ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI. Results were published in the April 19 Annals of Internal Medicine.

Five percent (n=415) of patients had a perioperative MI, 74.1% of which occurred within 48 hours of surgery and 65.3% with no ischemic symptoms of MI. The 30-day mortality rate was 11.6% among patients who had a perioperative MI and 2.2% among those who didn't (P<0.001). Among patients with a perioperative MI, mortality rates were elevated and similar between those with and without ischemic symptoms (9.7% vs 12.5%, goodness-of-fit test P=0.84). A total of 697 patients (8.3%) had elevated levels of an isolated cardiac biomarker or enzyme (but did not fulfill the study criteria for MI); such patients had a greater risk for nonfatal cardiac arrest and nonacute coronary revascularization than patients with no perioperative MI and no elevated cardiac biomarker or enzyme levels. Among those 697 patients with elevated biomarker or enzyme levels, 360 had elevated troponin levels and 337 had elevated creatine kinase-MB levels. A substantial proportion of patients with a perioperative MI didn't receive cardiovascular medications known to be effective in managing patients with nonoperative MI.

Given that the highest risk for death after perioperative MI occurs in the first 48 hours, there is a “need to quickly diagnose and intensely monitor and implement treatments for perioperative MI, just as with nonoperative MI,” they wrote. Until definitive trials are done, offering patients with coronary artery stenosis “long-term management with secondary prophylaxis cardiac interventions known to be beneficial...seems reasonable,” they advised. Also, since most patients who have a perioperative MI won't have ischemic symptoms, perioperative troponin should be monitored to avoid missing these MIs, they wrote.