A comparative study of polyantibiotic and iodophor ointments in prevention of vascular catheter-related infection

Antiseptic measures during the insertion and manipulation of vascular catheters

Several measures related to asepsis for preventing catheter-related bloodstream infection have been proposed. The aseptic measures recommended by scientific societies include hand hygiene of the person who is inserting or manipulating the catheter; maximum sterile barrier precautions during catheter insertion; disinfection of catheter hubs; the use of needle-less connectors and injection ports; the avoidance of antibiotic ointments (except in hemodialysis catheters); change the dressing if it is soiled, loose or damp; and aseptic technique during dressing changes. Other measures only recommended by the most recently published guides (possibly due to the publication of recent studies reporting their beneficial effects) are the use of antimicrobial-impregnated dressings, changing transparent dressings every 7 days, and bathing of the patient with chlorhexidine. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.

Skin antisepsis for reducing central venous catheter-related infections

BACKGROUND

The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs.

OBJECTIVES

To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities.

SEARCH METHODS

In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs).

MAIN RESULTS

Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data.Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidone-iodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidone-iodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study.There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency).Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events.

AUTHORS' CONCLUSIONS

It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

Background:

Although many catheter-related blood-stream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented.

Objective:

To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs.

Data Sources:

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.

Studies Included:

Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations.

Outcome Measures:

Reduction in CRBSI, catheter colonization, or catheter-related infection.

Synthesis:

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis).

Conclusion:

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Catheter-related and infusion-related sepsis

This article focuses on the pathogenesis, diagnosis, prevention, and management of infectious complications of intravascular cannulation and fluid infusion. Although continuous vascular access is one of the most essential modalities in modern-day medicine, there is a substantial and underappreciated potential for producing iatrogenic complications, the most important of which is blood-borne infection. Clinicians often fail to consider the diagnosis of infusion-related sepsis because clinical signs and symptoms are indistinguishable from bloodstream infections arising from other sites. Understanding and consideration of the risk factors predisposing patients to infusion-related infections may guide the development and implementation of control measures for prevention.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Double-blind prospective randomized study comparing topical mupirocin and placebo for the prevention of infection associated with central venous catheters

OBJECTIVE

To compare the incidence of exit site colonization, local catheter-related infection and catheter-related bacteremia in patients randomized to receive either topical 2% mupirocin or placebo at the catheter exit site.

PATIENTS AND METHODS

Patients requiring central venous catheters for more than three days were randomized to receive in a double-blind fashion either topical mupirocin or an identical placebo at the exit site three times weekly at the time of dressing change. Insertion, site care and removal of catheters were standardized. Serial semiquantitataive cultures of the skin at the catheter insertion site were performed using a sterile 25 cm(2) template. The distal and proximal catheter segments were cultured using a standardized semiquantitative technique, and any suspect catheter-related bacteremia was investigated with two sets of peripheral blood cultures, a 10 mL sample of infusate and clinical assessment. Both univariate and multivariate analyses were conducted on individual risk factors to determine factors that might influence the outcomes of local or systemic catheter-related infection.

RESULTS

Local catheter-related infection (defined as more than 15 colony forming units [cfu] on culture of the proximal or distal catheter segment) occurred in six of 57 (10.5%) in the mupirocin group versus 18 of 69 (26%) in the placebo group (P<0.05) for the distal catheter segments and in one of 40 (2.5%) versus 13 of 47 (27.6%) for the proximal segments in the mupirocin and placebo groups (P<0.006), respectively. Catheter-related bacteremia occurred in one of 57 (1.8%) of the mupirocin group but in five of 69 (7.2%) of the placebo group (P=0.15). Stepwise logistic regression revealed that cutaneous colonization at the insertion site of at least 10(3) cfu/mL/25 cm(2) (OR 2.6; CI 1.0 to 6.9) and the use of placebo (OR 3.3; CI 1.2 to 9.0) were significant factors predicting local catheter-related infection; whereas mupirocin was associated with reciprocal protective effect (OR 0.3; 95% CI 0.1 to 0.8).

CONCLUSIONS

These findings suggest that patients receiving topical mupirocin at the exit site for long term central venous catheters have significantly less local catheter-related infection, and there is a trend towards less catheter-related bacteremia.

Topical honey: for bears, not for ICU catheters?

Catheters are most often colonized and become infected via the skin and their external surfaces in the ICU. Therefore, topical antimicrobials, including medical honey, placed at the insertion site should decrease skin colonization and catheter infections. This commentary reviews the main studies on, and the possible reasons of, topical antimicrobial failure in ICUs compared to the reported efficacy of chlorhexidine-impregnated dressings.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

Catheter-related bloodstream infections

Tunneled, cuffed, double-lumen catheters are commonly used for long-term venous access in hemodialysis patients. Complications of these catheters, including catheter-related infection, are a major cause of morbidity and resource utilization in the hemodialysis population. Treatment of catheter-related bloodstream infections includes the use of antibiotics and evaluation of the need for catheter removal or exchange. Measures to prevent catheter-related infections include use of an aseptic technique and antiseptic cleaning solution, elimination of Staphylococcus aureus nasal carriage, topical exit site application of antibiotics, use of antibiotic lock solutions, and use of catheters and cuffs coated or impregnated with antimicrobial or antiseptic agents. This review article will provide an update on the prevalence, diagnosis, treatment, and prevention of catheter-related infections in the hemodialysis population.

Central venous catheterization

OBJECTIVE

To provide current information related to central venous catheterization.

DESIGN

Review of literature relevant to central venous catheterization and its indications, insertion techniques, and prevention of complications.

RESULTS

Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. Operator experience, familiarity with the advantages and disadvantages of the various catheterization sites, and strict attention to detail during insertion help in reducing mechanical complications associated with catheterization. Strict aseptic technique and proper catheter maintenance decrease the frequency of catheter-related infections.

CONCLUSIONS

Appropriate catheter and site selection, sufficient operator experience, careful technique, and proper catheter maintenance with removal as soon as possible are associated with optimal outcome.

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Pediatric catheter-related bloodstream infections: latest strategies to decrease risk

Central venous catheters are often mandatory devices when caring for critically ill children. They are required to deliver medications, nutrition, and blood products, as well as for monitoring hemodynamic status and drawing laboratory samples. Any foreign object that is introduced to the body is at risk for infection. Central venous catheters carry a particularly high risk of infection and these infections can be life threatening. Advanced practice nurses possess the power to influence catheter-related line infections in their critical care units. Understanding current recommendations for catheter material selection, site selection, site preparation, and site care can affect rates of catheter-related bloodstream infections. This article discusses risk factors for developing catheter-related bloodstream infections in critically ill children, as well as measures to decrease incidence of catheter-related bloodstream infections, including a review of recommendations from the Centers for Disease Control and Prevention.

Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study

BACKGROUND

Infections of short term, nontunneled, intravascular catheters are often caused by migration of organisms from the insertion site. The aim of this study was to evaluate the effectiveness and safety of a chlorhexidine gluconate-impregnated dressing for the reduction of central venous catheter (CVC) colonization and CVC-associated bloodstream infections in infants and children after cardiac surgery.

METHODS

This prospective, randomized, controlled study was conducted in the pediatric cardiac intensive care unit of a tertiary care pediatric medical center. Patients 0-18 years of age who were admitted to the pediatric cardiac intensive care unit during a 14-month period and required a CVC for >48 hours were randomized to receive a transparent polyurethane insertion site dressing (control group) or a chlorhexidine gluconate-impregnated sponge (Biopatch) dressing covered by a transparent polyurethane dressing (study group). The main outcome measures were rates of bacterial colonization, rates of CVC-associated bloodstream infections and adverse events.

RESULTS

Seventy-one patients were randomized to the control group and 74 to the study group. There were no significant between group differences in age, sex, Pediatric Risk of Mortality score or cardiac severity score. CVC colonization occurred in 21 control patients (29%) and 11 (14.8%) study patients (P = 0.0446; relative risk, 0.6166; 95% confidence interval, 0.3716-1.023). Bloodstream infection occurred in 3 patients (4.2%) in the control group and 4 patients (5.4%) in the study group. Local redness was noted in 1 control patient and 4 study group patients.

CONCLUSIONS

The chlorhexidine gluconate-impregnated sponge is safe and significantly reduces the rates of CVC colonization in infants and children after cardiac surgery.

Prevention of catheter-related bloodstream infections: An appraisal of developments in designing an infection-resistant 'dream dialysis-catheter' (Review Article)

With the increasing number of elderly, diabetics and debilitated patients being accepted for haemodialysis (HD), the use of central venous catheters (CVCs) as vascular access has become more widespread, with an inevitable inherent risk of catheter-related bloodstream infections (CRBSI) and ensuing mortality. No reliable plans for the effective management of CRBSI without actually sacrificing vascular access sites are presently available. Therefore, the onus really falls on renal physicians to make effective use of the established supportive guiding principles, practices, policies and programs to prevent CRBSI among HD patients. A huge body of research in polymer industry has aimed at alterations of physical, chemical, biological and immunological properties of CVCs to prevent the bacterial colonization of catheters. Developing an infection-resistant dialysis catheter has been an elusive dream. This article analyses the current state-of-the-art strategies aimed at preventing CRBSI and also reviews the progress made to date, in the direction of development of a 'bioactive' thrombosis and infection-resistant dialysis catheter.

Perioperative antibiotics and practice

Perioperative antibiotic administration and anesthetic practice have major impacts on infectious complications. Anesthesiologists need to place high importance on perioperative antibiotic administration to allow patients to receive optimal benefit from this therapy and to minimize risk. Many aspects of perioperative care ranging from thermoregulation to glycemic control may have profound longterm affects on infection rate and thereby patient outcome.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentration at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications of these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

Mucosa or skin as source of coagulase-negative staphylococcal bacteraemia?

Nosocomial bacteraemia is associated with significant morbidity, mortality, and cost worldwide, and is most commonly caused by coagulase-negative staphylococci (CONS). Establishing the source of CONS bacteraemia is therefore important in the prevention and management of this infection. CONS infections are presumed to originate at the cutaneous sites of central venous catheters (CVCs), a belief that has led to prevention strategies that focus almost exclusively on the skin. However, mucosal colonisation by CONS is well established, suggesting that mucosal sites might be an important source of CONS bacteraemia. We review the published material that evaluates the source(s) of CONS. We included only studies that used a strict definition of CONS bacteraemia, evaluated skin and other potential sources of CONS, and studied the molecular association between CONS blood isolates and their potential sources. Three published reports fulfilled our criteria. In cancer patients with CONS or CONS bacteraemia, most of the colonising strains that had a molecular match with the strain recovered from the blood of the same patient were mucosal isolates; by contrast, no association was seen between CONS blood and skin isolates. Furthermore, in several patient populations evidence was reported of mucosal colonisation by CONS and in several reports experimental and clinical mucosal translocation of CONS with subsequent bacteraemia was documented. Together these data indicate that mucosal sites are an important source of CONS bacteraemia. Clinical strategies for the treatment of patients with a positive blood culture for CONS, the widespread use of antimicrobial-coated CVCs, and maximum barrier protection for CVC insertion should be reassessed, and strategies to decrease mucosal colonisation by CONS should be developed.

Vascular access for dialysis in the intensive care unit

Management of the vascular access (VA) for renal replacement therapy (RRT) in acute renal failure (ARF) patients is faced with a twofold problem: first, the creation of an angio-access that is adequate for RRT in the acute setting; second, the preservation of the patient's vascular network in order not to preclude further use of the vessel in the event of evolution to chronic renal failure. Central venous catheters are the preferred VA for RRT in the intensive care setting. Semi-rigid double-lumen polyurethane catheters may be considered for short-time use (up to 2-3 weeks). Soft silicone double-lumen or twin-catheters, preferably with subcutaneous tunnelling, are highly desirable for prolonged RRT (over 3 weeks). The femoral route is the first option in the presence of associated risk factors (respiratory failure, pulmonary oedema, bleeding...). The internal jugular route should be considered for mid-term use in order to facilitate the patient's mobilization and to reduce the risk of infection. The subclavian route should be avoided because of the risk of stenosis and/or thrombosis of the outflow vein. Catheter insertion must be performed by a trained physician with ultrasound guidance using either skin mapping or continuous vein guidance. Catheter handling and care should comply with best practice guidelines and should be part of a continuous quality improvement programme in order to reduce catheter-related morbidity. Preservation of the upper limb vascular network of the patient consists of sparing the native vessels (artery and vein) of the patient and preserving the functionality of the permanent VA in chronic renal failure patient. This 'lifeline' of chronic renal failure patients may be maintained by preventing inflammation, infection and thrombosis of the superficial vessels of the arm and forearm of patient.

Guidelines for the prevention of intravascular catheter-related infections

BACKGROUND

Although many catheter-related bloodstream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented.

OBJECTIVE

To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs.

DATA SOURCES

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.

STUDIES INCLUDED

Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations.

OUTCOME MEASURES

Reduction in CRBSI, catheter colonization, or catheter-related infection.

SYNTHESIS

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis).

CONCLUSION

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device–Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e., education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

Guidelines for the prevention of intravascular catheter-related infections

BACKGROUND

Although many catheter-related bloodstream infections (CR-BSIs) are preventable, measures to reduce these infections are not uniformly implemented.

OBJECTIVE

To update an existing evidenced-based guideline that promotes strategies to prevent CR-BSIs.

DATA SOURCES

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.Studies Included: Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiological investigations.

OUTCOME MEASURES

Reduction in CR-BSI, catheter colonization, or catheter-related infection.

SYNTHESIS

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e. education and training, maximal sterile barrier precautions and 2% chlorhexidine for skin antisepsis).

CONCLUSION

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Efficacy of subcutaneous tunneling for prevention of bacterial colonization of femoral central venous catheters in critically ill children

BACKGROUND

Blood stream infections are a common and serious complication of central venous catheters (CVCs). To decrease catheter colonization, some authors advocate tunneling the catheter in the subcutaneous tissue during insertion. This technique has proved effective in adults, but there are no data on its safety and efficacy in critically ill children. Our objective was to evaluate the efficacy and safety of subcutaneous tunneling of short term, noncuffed CVCs for the prevention of CVC-related infections in critically ill children.

METHODS

A prospective randomized controlled trial was performed at a tertiary children's medical center in Israel and included children ages 0 to 18 years admitted to the pediatric intensive care unit or the pediatric cardiac intensive care unit from September 2000 to April 2001 who required placement of a femoral central venous catheter for >48 h. The children were randomized for tunneled or nontunneled insertion. The main outcome measures were bacterial colonization of proximal and distal catheter segments tested by semiquantitative technique and infectious or noninfectious complications of the CVC.

RESULTS

Of 98 eligible children, 49 received tunneled catheters and 49 received nontunneled catheters. Patients' age ranged from 1 month to 16.5 years (mean, 3.07 +/- 2.48 years). There were no significant differences between the groups in age, sex, disease severity [Pediatric Risk of Mortality III (PRISM) score], duration of catheterization and underlying diseases. Bacterial colonization was found in 11 (22.4%) catheters in the nontunneled group compared with 3 (6.1%) in the tunneled group (P = 0.004). Proximal segment colonization occurred in 7 (14.2%) nontunneled catheters and 2 (4.8%) tunneled catheters (P = 0.07), and distal segment colonization occurred in 3 (6.1%) and 9(18.3%) tunneled and nontunneled catheters, respectively (P = 0.053). The main pathogens were coagulase-negative staphylococci, Pseudomonas spp. and Klebsiella spp. There was no statistically significant difference between the groups in the rate of bloodstream infection (2 in the tunneled group, 3 in the nontunneled). Except for 1 case of subcutaneous hematoma, which resolved, there were no immediate or late complications of the tunneling procedure.

CONCLUSION

Subcutaneous tunneling of CVCs in the femoral site is a safe procedure and decreases significantly the rate of CVC colonization in critically ill children.

A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies

Strategies for preventing central venous catheter (CVC)-related bloodstream infection are most likely to be effective if guided by an understanding of the risk factors associated with these infections. In this critical review of published studies of risk factors for CVC-related bloodstream infection that were prospective and used multivariable techniques of data analysis or that were randomized trials of a preventive measure, a significantly increased risk of catheter-related bloodstream infection was associated with inexperience of the operator and nurse-to-patient ratio in the intensive care unit, catheter insertion with less than maximal sterile barriers, placement of a CVC in the internal jugular or femoral vein rather than subclavian vein, placement in an old site by guidewire exchange, heavy colonization of the insertion site or contamination of a catheter hub, and duration of CVC placement > 7 days. Prospective studies or randomized trials of control measures focusing on these risk factors have been shown to reduce risk significantly: formal training in CVC insertion and care, use of maximal sterile barriers at insertion, use of chlorhexidine rather than povidone-iodine for cutaneous antisepsis, applying a topical anti-infective cream or ointment or a chlorhexidine-impregnated dressing to the insertion site, and the use of novel catheters with an anti-infective surface or a contamination resistant hub. Better prospective studies of sufficient size to address all potential risk factors, including insertion site and hub colonization, insertion technique, and details of follow-up care, would enhance our understanding of the pathogenesis of CVC-related bloodstream infection and guide efforts to develop more effective strategies for prevention.

Guidelines for the prevention of intravascular catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for Disease Control and Prevention, U.S

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device-Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

Nosocomial infections

Nosocomial infections and antimicrobial resistance are topics that have been intensely studied in human medicine because of their significant impact on human health. In recent years, concerns have been raised that the use of antibiotics in veterinary medicine, animal husbandry, and agriculture may be contributing to the development of resistance in common bacterial species affecting human beings. Although there is inadequate proof at this time that the resistance is transmitted from animals to people, if antibiotics continue to be used indiscriminately in veterinary medicine, veterinarians may find themselves facing regulations restricting the use of some antibiotics. Nosocomial infections have been reported in veterinary medicine and are likely to increase in prevalence with the increase in intensive care practices in many hospitals. Prolonged hospitalization and the use of invasive devices and procedures increase the risk of nosocomial disease. As in human medicine, organisms isolated in the nosocomial infections reported in veterinary patients have an increasingly broad spectrum of antimicrobial resistance. Despite these findings, the use of empiric and prophylactic antibiotic therapy is still widespread in veterinary medicine. Nosocomial infections and antimicrobial resistance may have a serious impact on the future of [table: see text] veterinary medicine, because the cost and ability to treat our patients may be affected by the loss of access to or effectiveness of antimicrobial drugs. Despite the millions of dollars spent on research to reduce the incidence of nosocomial infections in human patients, the strategies that have consistently proven successful are simple and inexpensive to implement. The most important factor in preventing nosocomial infections is improving the hygiene practices of health care providers. Hand-washing or the use of disposable gloves can dramatically reduce the transmission of bacteria between patients. Aseptic technique should be used in the placement and management of all invasive devices. All staff members should be educated on the risks and symptoms associated with nosocomial infections so that cases can be detected early and treated appropriately. We in the veterinary profession have the opportunity to learn from the experiences of the human medical profession and can take steps to prevent the escalation of nosocomial infections and their impact on our profession.

Preventing intravascular catheter-related bloodstream infections in the critical care setting

Although intravascular catheters are indispensable for managing the care of critically ill patients, they can be associated with serious infection. Catheter-related bloodstream infections (CR-BSI) are a major cause of morbidity and mortality in the critical care setting. These infections are largely preventable. This article reviews the epidemiology and pathogenesis of these infections, the role of the critical care nurse in the diagnostic evaluation of CR-BSI, and strategies for their prevention.

Applying the science to the prevention of catheter-related infections

BACKGROUND

Catheter-related bloodstream infection (CR-BSI) remains a leading cause of nososcomial infection, despite the fact that many CR-BSIs are preventable. Simple principles of infection control and the use of novel devices to reduce these infections are not uniformly implemented.

OBJECTIVE

To review and summarize the evidence that promotes strategies to prevent CR-BSIs.

DATA SOURCES

The Medline database and bibliographies of review articles and book chapters were searched for relevant articles.

STUDIES INCLUDED

In vitro and in vivo laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations.

OUTCOME MEASURES

Reduction in CR-BSI, catheter colonization, tunnel infection, or local site infection.

SYNTHESIS

The recommended prevention strategies with strong supportive evidence include educating and training of health care providers who insert and maintain catheters; using full barrier precautions during central venous catheter insertion; using a 2% chlorhexidine preparation for skin antisepsis; eliminating the practice of scheduled replacement of central venous catheters for prevention of infection; and using antiseptic/antibiotic impregnated short-term central venous catheters.

CONCLUSION

Simple interventions can reduce the risk for serious catheter-related infection. Health care provider awareness and adherence to these prevention strategies is critical to reducing the risk for CR-BSI, improving patient safety, and promoting quality health care.

The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices

Intravascular devices (IVDs) are widely used for vascular access but are associated with substantial risk of development of IVD-related bloodstream infection (BSI). The development of novel technologies, which are based on an understanding of pathogenesis, promises a quantum reduction in IVD-related infections in an era of growing nursing shortages. Infections of short-term IVDs (that is, those in place <10 days), including peripheral venous catheters, noncuffed and nontunneled central venous catheters (CVCs), and arterial catheters, derive mainly from microorganisms colonizing the skin around the insertion site, which most often gain access extraluminally. More-effective cutaneous antiseptics, such as chlorhexidine, a chlorhexidine-impregnated sponge dressing, CVCs with an anti-infective coating, anti-infective CVC hubs, and novel needleless connectors, have all been shown to reduce the risk of IVD-related BSI in prospective randomized trials. The challenge for the future will be to identify new preventative technologies and to begin to adapt more widely those technologies already shown to be efficacious and cost-effective.

Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection

Intravascular catheters have become essential tools for the management of patients in modern medical practice, but there are complications. In particular, catheter-related infection remains a major cause of nosocomial infection and primary septicemia. The development of preventive strategies to reduce the incidence of catheter-related infection is an important goal for all health providers. Over recent years, significant advances in prophylactic measures for the prevention of catheter-related infection have been made. This paper reviews strategies based on antibiotic prophylaxis such as systemic administration of antibiotics, application of antibiotic ointments to the skin insertion site as well as catheter flushing with antibiotics, the antibiotic-lock technique and the use of antimicrobial impregnated catheters.