This essay is going to discuss the sociological idea of stigma and its effect on an individual, furthermore this essay will also define other concepts in relation to stigma such as the ‘Hidden Distress Model’. We will also discuss examples of this health illness in order to demonstrate the impact of stigmatization and their ‘Coping Strategies’. Moreover this essay will study how different individuals within society react to people with mental disabilities and other health illness for instance HIV and AIDS and how some individual in society find stigma more fearful than the condition they have been diagnosed in, for example a person who has been in a socially stigmatizing condition may feel discriminated and isolation and pain due to their illness.

To address the issue of stigmatization, firstly it’s important to clarify whether or not there is a link between social integration and health. A study carried out by Berkman and Syme (1979) states the extent of individual’s integration within society has a significant effect on their health. In their research they identified two forms of ‘network scores’. They established that those with ‘low network scores’ had a higher mortality rate compared to those that had high ‘network scores’ (Nettleton 2006).

Stigma refers to a negatively well-defined condition, attribute, trait or behaviour conferring a deviant status which is socially, culturally or historically not the same. (Gabe

et al,

2004). The word stigma was defined by the Greeks, they used the term to refer to the bodily signs a person had this could be cuts or burns. They intended the term to those whom they believed to be socially outsiders such as slaves or criminals, mainly those who were unhygienic or diseased would be avoided by people. (Gabe

et al,

2004)

Goffman (1963) refers stigma as the difference between the virtual social identity, which is the stereotyped made in everyday life and the real social identity and stigma is the relationship between characteristics and stereotype. This two concepts – ‘Virtual Social Identity’ which is the stereotypes attributes we think we attain and ‘Actual Social Identity’ relates to the attributes an individual actually has.

We will pay particular attention to Actual Social Identity, this concept is when a person actually possess the signs of a stigma. Goffman says that ‘stigma is a special kind of relationship between attribute and stereotype’, and therefore people get stigmatized for the reason that their illness is obvious, for instance if a patient is deaf, blind or unable to walk therefore in a wheelchair or uses a hearing aid, in society they are seen as being abnormal because they don’t have the abilities of a normal person and for that reason they are socially undesirable or inferior also Goffman (1963) states ‘people with such ‘abnormalities’ are said to be stigmatized’ (Armstrong, 2003, p.42) . Although some illnesses can be obvious others can be relatively concealed, however they can still feel and ‘experience ‘felt stigma’ because they still see’ themselves to be inferior and they feel they are hiding a discreditable part of their personality from the outside world’ (Scamber and Hopkins, 1986, cited in Armstrong, 2003, p.42).

In today’s society the term stigma is used to refer to an individual who is culturally unacceptable with any condition, characteristic or behaviour (Gabe

et al,

2004). According to Goffman (1968) his ideas added felt and enacted stigma, the former is the feeling that we are being discriminated against and the latter is actually being stigmatised through discrimination.

Goffman recognised three types of stigma that he explained as:

1. Stigma of the body, which relates to blemishes or physical deformities;
2. Stigma of character which relates to the mentally ill or criminals, and finally
3. Stigma associated with social factors which can be either racial or tribal throughout different cultures. Goffman goes on to say that his types of stigma can vary differently between social, cultural or historical environments (Goffman 1963, cited in Gabe
   
   et al.
   
   , 2004, p.69).

While Goffman mentioned three types of stigma, Scambler mentioned two types of stigma. He combined his ideas in what he calls the ‘Hidden Distress Model’ which had been developed to explain the way in which an individual overcomes felt stigma in order to prevent experiences that play part of stigma. This, Scambler described it to be carried out by ‘Non-Disclosure’ which focuses attention on the fact that individuals would want to keep their condition from others in a hope to hide any information about their health condition and only will ever reveal their condition if it is necessary to do so. (Scambler, 2008).

The approach of the ‘Hidden Distress Model’ explains the reasons of the concealment of a condition, it is that because of the fear of associated stigma, moreover felt stigma is very easily seen so that one can avoid the occurrence of enacted stigma. Experiencing strong felt stigma could lead to higher stress which then leads to putting the patient harder circumstances in order to control their illness, which later on makes their illness worse over time due to the energy released through the concealment of their condition.

Moreover in relation to this Scambler (2008) states

“Paradoxically, felt stigma is more disruptive of people’s lives and well-being than enacted stigma… ”

he also says that felt stigma tends to increase the anxiety levels of an individual more so that enacted stigma.

To apply these concepts in real life circumstances, we will present how the avoidance of enacted stigma through felt stigma can worsen risks of various health issues ultimately deteriorating their health condition. Research study carried out on HIV and AIDS, has shown that people with such stigma are only known to their doctors and many chose not to kept it a secret and to disclose this information because of the way society thinks of AIDS and HIV. Patient might decide to avoid routine checks or treatment in the hope that they will not experience enacted stigma from others, for instance when they are entering or exiting the sexual health clinic or attending local HIV screening tests because of the stigmatising assumptions that are related to HIV /AIDS such as being gay or heavy drug user (Lubkin and Larson, 2012). Additional example can be seen with women who is avoiding screening for the sexually transmitted disease called HIV and AIDS for the fear of other people acting unreasonably towards them because they feel that they will be judged against behaviour associated with a lot of sexual partners. (Lubkin and Larson, 2012). And because this is associated with the person fearful of being treated different or labelled. People may not always seek medical help for their stigma conditions because of their fears of being faced with enacted stigma, however Zola (1973 has looked in to the timing of when individuals may decide to seek medical help, and in he discovered that majority of the people wait and put up with their symptoms for a while before they actually choose to seek medical assistance. Research study carried out on HIV and AIDS, has shown that people with such stigma are only known to their doctors and many chose not to kept it a secret and to disclose this information because of the way society thinks of AIDS and HIV.

As mentioned above avoidance of sexual health screening can lead to worsening health problems, a person with the health illnesses mentioned above could have life threatening diseases for the individual if he or she continue to express the ideas of the hidden distress model.

There are many studies that prove that is stigma is based on social concept. This study suggests that stigma is more about social concept rather than a characteristic of an individual. Parker and Aggleton (2003) ‘point out, processes of stigmatization remain part and parcel of processes of power, domination and discrimination; what becomes stigmatized is bound up with usual norms and values. Therefore it is socialized, not an individual, concepts (Nettleton, 2006, p.96). Therefore this study says felt stigma is more powerful than any accrual episodes of enacted stigma and for that reason it makes people more stigmatized.

Moving on to the concept of ‘Coping Strategies’ has been formed to explain the ways in which an individual copes with the effects of an illness. The term ‘coping’ refers to the “

Cognitive processes whereby an individual learns to tolerate illness”

and strategy relates to the actions people take in the face of illness (Bury 1991 cited in Nettleton 2006).

The term coping is used to maintain the feeling of self-worth and a sense of belief during an illness (Gerhardt 1989 cited in Bury 1991). The thought of normalisation can be used in ‘coping’ with an illness; this can be expressed in two with in the ‘Coping Strategies’. The first is to supress any negativity related to the illness so that the person can maintain their own personal identity which they held prior to their diagnosis; the second is to look at normalisation in terms of treatment where the treatment routine should not be remote place so that the individual can integrate with other people and not be isolated (Kellecher 1988, cited in Bury 1991). Bury (1991)

This further explains that it is the values of the individual that can determine how others respond to them in regards to their illness.

The model of ‘strategy’ is the actions that are taken in order to ‘

maximise favourable outcomes

’. (Bury, 1991). Moreover how a person responds to health illness experience regarding their condition does determine the extent to which they perform their strategies, the more negative experience they have can develop greater awareness in their everyday lives so as to escape or reduce the experience of enacted stigma. The controlling of illness through the use of strategies can differ from the influence of social settings to the forms that are developed in order to deter any focus to the condition as well as achieving set goals so that they can maintain their own sense of value and their belief of what their everyday life requires.

Goffman (1963) states that the way in which an individual copes with a stigmatising condition differs depending on the actual type of condition, he has specified two terms in relation to this –

‘discredited’

and

‘discreditable’

; the first one is regarding an individual whose condition is widely known and the second refers to those whose condition is concealed. It’s described that those who have a discredited condition will find it harder to manage their stigma.

There are three different ways in which an individual can cope their own stigmatising condition the first is

‘Passing’

this is where one would try to fit in to the society as ‘normal’ usually the stigmatised individuals would constantly try to conceal their condition because they do not want anyone else to know if their illness; and for those with felt stigma are more likely to choose the passing approach for instance an individual with hard of hearing condition may decide to not use the hearing aid so that they can ‘fit in’ more with the society (Lubkin and Larson, 2012; Armstrong, 2003).

The second one is

‘Covering’

this refers to an individual with a discrediting attribute where they will try their utmost to conceal the significance of their stigmatising condition. (Goffman, 1963; Armstrong, 2003), in this situation the individual would try and take off the focus from his or her condition in order to avoid the experience of enacted stigma, the process could be amusing towards the situation which would reassure a less tense atmosphere making it to be more easy to manage (Lubkin and Larson, 2012).

Stigma is the result of a reaction expressed through the society that ultimately spoils identity of unacceptable norms that affect the stigmatised individual in a negative way. (Gabe

et al

, 2004). Nettleton (2006) states

“Stigma is not an attribute of individuals, but is rather a thoroughly social concept which is generated, sustained and reproduced in the context of social inequalities.”

Some people are stigmatised because the part of the individual that is different is considered to be self-inflicted and in the ‘normal’ people’s eyes they are less worthy of help (Lubkin and Larson, 2012)

Parsons (1951) describes illness as a deviance form the norm and he also perceives illness as capable of cracking the social structure as the sick are unable to accomplish their social role within society. It can be expected that when an individual is sick they respond on the reaction of others, while society responds depending on the nature of the illness. (Lemert, 1967) suggests that there is three stages of deviance and he identifies these as primary deviance, which is related to an actual defined of a state or behaviour, and he claims that inside the law an action that was seen to be normal can become illegal or deviant, moreover secondary deviance refers to ‘the changes in behaviour that occur as a consequence of labelling’, for instance the stress of being discriminated and stereotyped can make an individual’s behaviour change over time. And the last stage is Tertiary deviance, which is the stigmatised individual’s reaction to the stigma from others leads to master status, for example categorising and stereotyping dominate individuals behaviours.

Scambler (2008) mentions that social factors is a major factor, which has impact people’s behaviour when they faced with what they recognize and recognise to be danger to their health and well-being. Freidson (1970) draws ‘societal reaction’ (Nettleton, 2006, p.73) furthermore he argues that there is three types of legitimacy. The first legitimacy is the ‘cases where it is achievable for a person to recover from illness, so they can get treatment for their condition, in addition their access to the sick role is conditional, the second is the incurable condition and their access to the sick role must be unconditionally, due to the fact that person might not get well and the last one is the illness being stigmatized by others and access to the sick role is to be treated as illegitimate (Nettleton, 2006, p.73).

According to Reidpath (2005) ‘ the fear of being stigmatized and subjected to discrimination many case some people to avoid or delay seeking medical help’ and this is because of fear, that people with stigmatized conditions feel socially isolated and often rejected moreover they are alienated in the society. For several stigmatized individuals, in order to to feel normal or socially accepted in the society they might join a talk group to form their own communities in order to meet people with similar issues (Armstrong, 2003). Many stigmatized people use copying mechanism in order to cope with their conditions and according to Goffman (1963) ‘a person with a stigmatizing condition could pursue several copying strategies that were largely based on the salience of the stigma he or her carried.

Scamber and Hopkins (1986), cited in Scamber, 2008, p.210, they described individuals ‘fearing discrimination, tend to conceal their epilepsy each time possible Certain ways they appear as normal included covering up their illness, a person with discrediting behaviour has no opportunity to go about it as normal but can still try to reduce the signs of his or her stigma and alternative way of passing as normal is managing expectations. This will l will lead the person to withdrawing from society and their social life, in order to avoid embarrassment and shame. An example people with conditions such as epilepsy, or HIV/Aids are able to hide away their condition when out in community, from partners, family and friends but they still do end up feel some kind of felt stigma due to them hiding some parts of their characters, nevertheless the individual way of avoiding social response to their illness and this is an case of passing as normal, concealing and managing expectations. People with stigma also get labelled unpleasant names such as handicap because they are being judged on their appearance and the abnormality they lack.

Conclusion

To conclude this essay, we agree with the idea of that felt stigma being more powerful than enacted stigma because individuals are more fearful of being stigmatized then the actually illness itself. This statement showed to be true by research studies that have been carried out this these areas. In this essay we have seen that before individuals are diagnosed with illness they prefer to hide from their illness and ignore their symptoms and refuse to seek medical attention they require also individuals develop fear of their community and the society because of their health condition, likewise they fear their family, friends look and treating them differently.

We have also looked into in to some research on stigma, we recognise why people are more fearful about the health condition than the illness because in society we tend to judge and isolate individuals on how they appear to look, before we even personally know them, for instance people in a with wheelchair we label them disabled. As Scrambler and Hopkins 1989, says that people with stigmatized illnesses are essentially outcasts and this is because they are socially rejected from society, due to their signs or symptoms and we see them as inferior. Nettleton (2006) suggests that illness reminds us that the normal functioning of our minds and is important to social action and relations with others, and this an significant fact and part of the reason proves why people are more fearful about their condition because they believe that people will be looking at them differently, judging and discriminating against them before it even happens. In addition to that we think people with serious health condition sexually transmitted diseases for instance HIV and AIDS should not tell their condition to others, for their own protection because some people have strong views and opinion on these conditions and these condition are associated with having many sexual partners and unhygienic. Scheff (1966) suggests that mental illness is a product of society’s opinions and reaction to the individual’s illness, we do believe that society’s has developed ways of just labelling people with all sort of illnesses especially people who are mentally ill and they are labelled as crazy and therefore they are treated different to others and stigmatized.

References

Armstrong, D. (2003)

Outline of Sociology as Applied to Medicine

5

^th

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Berkman, L. Syme, S. (1979) Social Networks, host resistance and mortality: a nine year follow up of Alameda County Residents.

American Journal of Epidemiology

109 (2) pp. 186-204

Calnan, M. (1987) Health and illness. London: Tavistock

Bury, M. (2005) Health and illness. Cambridge : Polity Press

Bury, M, R. (1991) The Sociology of Chronic Illness: A Review of Research and Prospects’,

Sociology of Health and Illness

13 (4) pp. 451-468

Gabe, J. Bury, M. Elston, A, M. (2004) Stigma,

Key Concepts in Medical Sociology

. London: Sage Publications pp. 68-69

Goffman, E. (1963)

Stigma: Notes on the management of spoiled identity

. New York: Simon & Schuster

Lubkin, M, I. Larson, D, P. (2012)

Chronic Illness: Impact and Intervention


Eighth Edition

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The Sociology of Health and Illness

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Sociology as Applied to Medicine

(eds.). Elsevier Limited.

Literature Review: Reducing Incidences of Central Line-Associated Blood Stream Infections

A bundle is a group of interventions related to a disease process, that when executed together, produce better outcomes than when implemented individually. Numerous studies done in the developed countries have shown that proper implementation of evidence based practices grouped together as central venous catheter bundle had brought a dramatic reduction in the incidence of CLABSI. Studies in developing countries had also shown high incidence of CLABSI and reduction in CLABSI rate albeit lesser than that of developed countries.

Studies from India have a shown a higher incidence of CLABSI and poor adherence to central line catheter bundle. Morbidity and mortality due to CLABSI is considerably high despite underreporting of such events. The development and publication of guidelines often does not lead to changes in clinical behavior and guidelines are rarely if ever, integrated into bedside practice in a timely fashion. The most effective means for achieving knowledge transfer remains an unanswered question across all medical disciplines. Our study aims to determine the compliance with CVC bundle in management of patients in medicine wards and ICU at All India Institute of Medical Sciences New Delhi and the impact of intervention in the form of periodic physician education and feedback in compliance with CVC bundle and central line catheter related complications.

Review of literature

Ever since the introduction of central venous catheters in the early 1950s, it had varied uses and later numerous studies revealed that it was associated with a varied number of complications. Although mechanical complications were common in the early years of CVC use CLABSIs quickly became recognized as a serious complication associated with their usage.

Central venous catheter

is defined as a catheter whose tip terminates in the great vessels. The great vessels are the aorta, pulmonary artery, superior vena cava,inferior vena cava, brachiocephalic veins, internal jugular veins,subclavian veins, external iliac veins, common iliac veins,femoral veins, and, in neonates, the umbilical artery/vein.

Types :

Common types of central venous catheters are Non tunneled catheters, Tunneled catheters, Implantable ports, PICC.

A peripherally inserted central catheter (PICC) is peripherally placed, but is considered a central catheter because its tip terminates in the central circulation. These venous catheters can also have single, double or triple lumens although single lumens are frequently used and are for intermediate to long term therapy for blood draws or infusions.

Complications of CVC:

Mechanical complications

(4,9)include

Complication	Risk of complication at catheterization site
	Internal jugular	Subclavian	Femoral
Pneumothorax	<0.1 to 0.2	1.5 to 3.1	NA
Hemothorax	NA	0.4 to 0.6	NA
Arterial punctures (%)	3	0.5	6.25
Malposition	Low risk (into inferior vena cava, passing through right atrium)	High risk (crossing to ascending internal jugular vein ,contralateral subclavian vein)	Low risk (lumbar venous plexus)

Pneumothorax is a common complication with subclavian and IJV cannulations without the use of ultrasound. The use of real time ultrasound reduces the number of attempts and associated with a significantly lower failure rate with internal jugular vein ( Relative risk 0.14, 95% confidence interval 0.06 to 0.33).

Limited evidence also exists for sublclavian and femoral routes in this metanalysis. Thus the chances of pneumothorax will be greatly reduced.

Pneumothorax is usually apparent immediately on Chest X rays and management may vary from simple observation to ICD placement with needle drainage needed for tension pneumothorax as emergency(11). Delayed pneumothorax is also known to occur with an incidence of 0.4%, more common with subclavian and with multiple attempts(12). Bedside ultrasonography allows diagnosis of pneumothorax to be made immediately with high sensitivity by clinician but is operator dependent(13).

Misplacement of catheters occur commonly such as tip malposition or rarely such as within artery. It is common practice to assess tip position lying above carina for right sided catheters assuming pericardial reflection below carina and below carina for left sided catheters in view of acute angulation to superior venacava(14). Management varies depending on the complication such as repositioning of tip for tip malposition lying below carina or when lying with an artery, interventional radiologist or vascular surgeon opinion is sought and removed accordingly(15).

Arterial injuries are more common with femoral and internal jugular rather than subclavian approach. A systematic review of complications of central venous catheters revealed significantly more arterial punctures (3.0% vs 0.5%) and less malpositions(5.3% vs 9.3%) with jugular access(16). It leads to hematoma in approximately 40% of patients. The best way to prevent arterial injury is by ultrasound assistance during cannulation(17). Other rarer complications are local hematomas,cerebrovascular accidents mostly seen with arterial injuries via internal jugular access, arrhythmias, perforation of the vein or right atrium, chylothorax, pseudo aneurysm, AV fistulas, cardiac tamponade, guidewire loss and catheter embolisation etc. have been reported. These complications largely depend on the site of insertion and on operator experience. Such complications can be prevented by ultrasound guidance and proper techniques.

Infectious complications are most dreaded as it is associated with mortality rates upto 25% and in developing countries even up to 60% and prolong the duration of hospital stay and are largely preventable. Evidence based guidelines have been developed as the central venous catheter bundle which significantly decreases the incidence of infections as shown in below studies.CVC use in non ICU settings is associated with at least a 2 fold rise in infection rate than in ICU settings. However studies are very limited on the infection rates as well as on the preventive measures in non ICU settings.

Thrombotic complications

range from 1.2 to 3 % in subclavian veins to up to 8 to 34% in femoral cannulations. Merrer et al in a randomized control trial found significantly increased incidence of thrombotic complications(21.5% vs1.9%,p<0.001)(18).This can be avoided by judicious site selection and proper flushing techniques (9).

Every day the central venous catheters are accessed for a variety of purposes which may include frequent CVP monitoring to IV infusions. Every time the catheter is accessed it should be done in a sterile way after the port is scrubbed with antiseptics else the infection rate increases. Dressings should be changed regularly depending on the type and as indicated.

Risk factors for CLABSI :

Intrinsic factors	Extrinsic risk factors
Age – children more likely	Prolonged hospitalization before CVC insertion
Underlying diseases or conditions—hematological and immunological deficiencies, cardiovascular disease, and gastrointestinal diseases	CVC duration, with the risk increasing with CVC dwell time
Male gender	Parenteral nutrition administration
	Femoral or internal jugular access site
	Multilumen CVCs
	Lack of maximal sterile barriers
	CVC insertion in an ICU or emergency department Heavy microbial colonization at insertion site

The semi quantitative analysis of culture of

Maki

proved to be an effective and cost effective measure for the diagnosis of central venous catheter infections(19).

The study conducted by

Pronovost et al

in US which five basic measures hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with Chlorhexidine, avoiding the femoral site if possible and removal of unnecessary catheters significantly reduced the incidence of central venous line infections and served as a landmark study in the development of central venous catheter bundle(5). The study was conducted across 103 ICUs in Michigan in US and the rates of infection per 1000 catheter days were measured at 3 monthly intervals and the mean rate of infections decreased from 7.7 to 1.4 after 18 months.

After this study numerous studies were conducted which reinforced the effectiveness of the central venous catheter bundle.

Parra et al demonstrated that even a simple educational program like 15 min lecture given to ICU personnel highlighting 10 evidence based strategies can result in a reduction in CLABSI rates. In his study CLABSI rates decreased from 4.22 to 2.94 infections per 1000 catheter days(20).

WHO

conducted the

Bacteremia zero project

(21) to assess the applicability and effectiveness of the Michigan keystone ICU project in Spanish ICUs. This multifactorial nationwide intervention project was implemented between April 2008 and June 2010, with data collected at regular intervals to evaluate the progress of the project. A total of 192 ICUs (68% of all Spanish ICUs) participated in the project. The intervention was effective in reducing the incidence of CRBSI by approximately 50%in hospitals.

Burrel et al

demonstrated the benefit of having a checklist incorporating both the clinician and patient bundle(22). During this study they found that the compliance with the checklist improved significantly and the infection rate decreased by 50% when the compliance was good.

A nationwide study was conducted in US by

Furuya et al

(23) to find out the central line bundle implementation in ICU and its impact on Bloodstream infections. They found that CL bundle is associated with lower infection rates only when compliance is high. Complying with any one of three CL Bundle elements resulted in decreased CLABSI rates of 38%. This study clearly demonstrated the compliance should be very high to show a demonstrable decrease in the central line infection rate and that on-going evaluation was necessary.

Previously it was uniformly thought that femoral line insertion were associated with a greater incidence of infections .However recent studies have shown that the difference to be insignificant. A study was conducted by

Kedar S Deshpande

(24) in New York where they found that there was no stastically significant difference in the incidence of infections between the three routes in case of major infections when catheter is inserted optimally, catheter care is performed by trained by trained intensive care unit staff although there was a higher case of infections in the femoral group(0.881/1000 catheter days subclavian, 2.0/1000 catheter days internal jugular vein, 5.96/1000 catheter days femoral catheter p=0.1338)

Blood stream infections :

NNIS (National Nosocomial Infection Surveillance system) now renamed as

NHSN

(National Healthcare Safety Network) defines blood stream infections as presence of a recognized pathogen cultured from one or more blood cultures and organism cultured from blood not related to infection at another site or presence of at least one of fever, chills and hypotension with signs and symptoms and positive results not related to infection at another site and presence of at least one of the following: Common skin contaminant (e.g.diphtheroids, bacillus species, propionibacterium species, coagulase negative staphylococci or micrococci) cultured from two or more blood samples drawn on separate occasions or Common skin contaminant cultured from at least one blood culture in a sample from a patient with an intravascular catheter or Positive antigen test on blood (e.g.,

Haemophilusinfluenzae

,

Streptococcus pneumoniae

,

Neisseria meningitidis

, or group B streptococcus)(25).

CLABSI vs CRBSI :

Further 2 distinct terminologies are used in relation to central line infections these are used interchangeably usually though they are different.

A

CLABS

I ( central line associated blood stream infections) is defined as BSI if a CVC was present at the time of or within 48 hrs before the defining blood culture was obtained. There is no requirement to identify the organism on the catheter. This definition was developed for surveillance, not for diagnosis.

In contrast, a

CRBSI

(catheter related blood stream infection) requires that the CVC be in place at the time the positive blood culture was obtained and a positive quantitative or semi quantitative culture of the same organism from the catheter or time to positivity.

The CLABSI definition is more practical than the CRBSI definition for surveillance. However, it may overestimate the true rate of CVC–related infections, as it can sometimes be difficult to determine infections related to the central line rather than remote unrecognized infections (for example, urinary tract infections, pneumonia, intra-abdominal abscess). Interobserver variability and a lack of standardization in CLABSI surveillance are other important limitations(26).

Usually the organism grown on culture is likely to be significant only when atleast 15 CFU or 10 *3 colonies are isolated of the same organism.

Catheter infection and colonization:

Catheter infection and colonization can occur by 3 routes –

• Extra luminal from organisms migrating along the catheter surface,
• Intraluminal through the ports or through contaminated fluids rarely,
• Hematogenous from a source of infection elsewhere in the body.

Terminologies commonly used with regard to catheter infection and colonization are defined as follows (24)

1. Catheter infection

A. 15 CFU on catheter tip with the same bacteria and sensitivities (one different sensitivity included) in one or more blood cultures.

B. Resolution of clinical signs and symptoms of infection in 24–48 hrs after catheter removal regardless of bacterial growth either in blood or on catheter tip.

C. 15 CFU on catheter tip with local signs of infection regardless of blood culture bacterial growth.

2. Catheter colonization

A. Catheter tip with 15 CFU without growth in blood cultures and another source of infection found.

B. Catheter tip with 15 CFU and bacteria in peripheral blood cultures from another source of infection.

3. Contamination: <

15 CFU on catheter tip without bacterial growth in blood cultures or bacteria in blood cultures from another source of infection.

Till date most of the studies have emphasized in catheter related infections as proposed by NHSN but as of date due to the aggressive use of broad spectrum antibiotics culture negativity is more common. So to remove this confounding factor any fever in a patient with central line which has no proven focus of infection elsewhere and resolves within 2 days after removal of central line can be taken as CLRI. This is based on the fact that catheter infection is “cured” only with removal or a prolonged course of intravenous antibiotics; the relatively short courses of antibiotics used for ICU infections could not truly affect the catheter infection end point. However antibiotic use can result in negative cultures results even in the presence of catheter infection.

This definition was implemented in a study by

Kedar S Deshpande et al

(24)in New York where they found that the overall incidence of central line infection is low whatever the route may be and there was no stastically significant increase in infections in the femoral route provided proper strict aseptic insertion and maintenance techniques are followed. Thus the dangerous mechanical complications of pneumothorax can be avoided.

Developing countries scenario:

Rosenthal et al

(27)showed that the neonatal blood stream infections to be 5 times higher in developing countries than the developed countries. INICC conducted a surveillance study in 36 countries involving 422 ICUs and found a overall increased incidence of HAI. CLABSI rates were found to be 3 times higher when compared with USA (6.8 per 1000 CL days vs 2 per 1000 CL days). There was increased resistance to multiple gram negative organisms and MRSA was also more frequent in developing countries(28). Unadjusted crude excess mortality rate was also higher in developing countries both for CLABSI and VAP in the range of 7.3% to 15.2%

Reasons for the differences in the degree of burden of HAIs in developing countries include the following: Limited knowledge and training in basic infection prevention and control , Limited awareness of the dangers associated with HAIs , Inadequate infrastructure and limited resources, Poor adherence to routine hand hygiene, Reuse of equipment (for example, needles, gloves) , Poor environmental hygiene and overcrowding, Understaffing, Inappropriate and prolonged use of antimicrobials and invasive devices , Limited local and national policies and guidelines, Variable adherence to official regulations or legal frameworks, where they exist and Insufficient administrative support.

A quasi experimental study was conducted by Apisarnthanarak et al in Thailand where he found improved adherence to central line bundle particularly hand hygiene improved significantly after intervention from 8% to 54% and CA-BSI decreased significantly from 14 per 1000 catheter days to 1.4 per 1000 catheter days(29) .

Indian scenario:

Indian studies have shown that the incidence if central venous catheter infections are 3 to 4 times higher in our settings and that gram negative bacteria and fungi are more common in our settings compared to gram positive infections in western settings(30)(31), The Study conducted by

Pawar et al

in Escort hospital revealed that gram negative bacilli had a higher prevalence ( 71% ) as against western settings where gram positive organisms account for 70 % . They also found that the duration of catheterization, coexistent infections and increased temperature were the important predictors of CLABSI.

A study was conducted in 12 Indian ICUs by

INICC

which revealed a higher incidence in our settings and a overall poor adoption of the catheter bundle practices and the incidence gradually and progressively decreased after proper practices (6,18). Prospective surveillance in Indian ICUs yielded a central venous catheter-related bloodstream infection (CVC-BSI) rate of 7.92 per 1000 catheter-days(18). The incidence of central venous catheter infections then decreased subsequently after the adoption of proper practices. The study also revealed that proper education; performance feedback and outcome and process surveillance of CLABSI rates significantly improved infection control practices and brought a 54% decline in CLABSI incidence(6)

.

INICC

conducted a prospective before and after cohort study in eight Indian cities where they found implementation of six components of INICC simultaneously resulted in a significant reduction in CLABSI from 6.4 CLABSIs per 1000 central line days to 3.9 CLABSIs per 1000 central line days resulting in 53% CLABSI rate reduction which was highly significant(31).

Some studies had shown that empowering the nurses with the central venous bundle and to interfere if the proper practices are not followed will go a long way in the further reduction of CLABSIs. However in spite much of the reported successes in ICU population the non ICU population are still at a significant risk of infection. In developing countries empowering the nurses is still a long way to go as understaffing and proper techniques are still not adopted(15,6). Still application of inexpensive and practical infection prevention efforts, such as improved hand hygiene and removal of CVCs when they are no longer needed, can have a major impact on CLABSI rates.

IHI central venous catheter bundle was implemented as a project in 5 million lives campaign(32). Essential features are

Hand Hygiene

:

The cornerstone of WHO’s “

Clean Care Is Safer Care

” campaign, the “

My 5 Moments for Hand Hygiene

” approach, has resulted in the development of resources, including localized country-specific tools, to facilitate adherence to hand hygiene guidelines(33).

To minimize the risk of CLABSI associated with direct contact of the hands of health care personnel, the 2011 USCDC guideline recommends that hand hygiene be performed at the following times: before and after palpating the site of catheter insertion, before and after inserting the catheter, before and after accessing, replacing, repairing, or dressing the catheter. In addition, after the antiseptic has been applied to the site, further palpation of the insertion site should be avoided, unless aseptic technique is maintained (34).

Adherence to hand hygiene is generally suboptimal with rates under 40 % in multiple studies. Improving hand hygiene can be achieved through multiple educational interventions.

Maximum sterile barrier precautions

:

Raad et al

conducted a prospective randomized control study to determine the effectiveness of the maximum sterile precautions .they found that the control group had 6 times higher infection rates and the infections occurred early and mostly were caused by skin microorganisms(35).

Skin preparation:

Reducing colonization at the insertion site is a crucial part of CLABSI prevention. It can be done with aqueous povidone iodine, aqueous chlorhexidine, alcoholic chlorhexidine or alcoholic povidone iodine. A recent meta analysis revealed that the 2 %chlorhexidine is associated with a 50% decrease in the CLABSI rates compared to povidone iodine(36). However, a recent study by

Furuya et al

(23) identified the importance of allowing chlorhexidine to dry fully before CVC insertion in order to optimize the use of this agent. An economic analysis suggested that using chlorhexidine rather than povidone iodine would result in a 1.6% decrease in CLABSIs and a 0.23% decrease in mortality, as well as save $113 per catheter used(37). The proposed mechanism is believed to be prolonged antimicrobial effect, its lack of inactivation to blood and serum and synergistic effect with alcohol. However whether chlorhexidine alcohol combination is superior to alcoholic povidone iodine is still unresolved. The role of alcohol as antiseptic agent is often forgotten while describing chlorhexidine(38). CDC recommends >0.5% chlorhexidine alcohol to be used in case of central line insertion. However a recent Indian study conducted in 2013 by Kulkarni et al found that both povidone iodine and chlorhexidine had zero colony counts in skin preparation(39).

Maintenance:

Catheter site dressings can be done by transparent to semitransparent dressings or gauze dressings. The advantage with sterile dressings is that visual inspection can be done daily and they need to be changed once in 7 days unless gauze dressings which needs to be changed every 2 days. However if patient is in DIC or there is bleeding at the site of insertion gauze dressings are preferred(40).

The current recommendations are to assess the continued need for the catheter every day, perform catheter site care with Chlorhexidine at dressing changes, replace administration sets and add-on devices no more frequently than every 72 hours, unless contamination occurs, replace tubing used to administer blood, blood products, or lipids within 24 hours of start of infusion, change caps no more often than 72 hours or according to manufacturer’s recommendations and whenever the administration set is changed(41).

Shapey et al conducted a prospective audit in a university teaching hospital and found that several breaches were there in CVC post insertion care with a failure rate of 44.8% mostly in caps, dressings and proposed that focus should be shifted to best practice implementation rather than further teaching(42)

The significance of catheter maintenance or post insertion bundle was demonstrated by Guerin et al who showed that implementation of a post insertion bundle in hospitals with good compliance to insertion bundle resulted in decrease in CLABSIs from 5.7 to 1.1 CLABSIs per catheter days. He emphasized that insertion bundle by itself was not sufficient. The interventions done were assessing the catheter site daily, changing dressings if necessary, application of chlorhexidine sponge at the catheter site, assessing the need for catheter daily, performing hand hygiene and alcohol scrub before accessing hub each time(43).

Using closed container systems than open container infusion systems had significantly reduced the incidence of CLABSI in many studies. This was demonstrated by Maki et al who conducted a study in 4 countries and found that switching to closed infusion containers decreased CLABSIs from 10.1 to 3.3 per 1000 catheter days RR 0.33 p<0.001(44).

Prompt removal of catheters:

Zingg et al

in his study found that in several site visits, neither the nurse nor the treating physician knew why the patient had a CVC particularly in non ICU settings. They also showed that catheters in non ICU settings had a longer dwell time and lesser utilization(45) .

Trick et al

in his study found that 4.6% of catheter-days were not justified. Both of these research groups also found differences in CVC use between ICU and non-ICU settings: unjustified CVC–days were more common in the non-ICU settings. The median duration of CVC days were more common for catheters that were unjustified rather than justified. They also proposed as to consider removal of CVC if needed when patient is getting transferred out of ICU (46).