Methods for microbial needleless connector decontamination: A systematic review and meta-analysis

Impact of intermittent versus continuous infusions on central line-associated bloodstream infection risk in haemato-oncology patients: a quasi-experimental study

BACKGROUND

Continuous fluid infusions delivered between therapies by piggy-back systems avoid disconnection and reconnection of central venous catheters (CVC), thereby reducing opportunities for line contamination. However, the impact of continuous versus intermittent infusions on central line-associated bloodstream infections (CLABSI) is unknown.

AIM

To investigate the effect of temporary infusion interruption and line disconnection, with or without use of a 70% isopropyl alcohol cap (IPA-C) use on CLABSI rates in haematology patients.

METHODS

Quasi-experimental study in two haemato-oncology units. At baseline (P1, September 2020 - August 2021), continuous intravenous piggy-back infusions were mandatory. In a first intervention phase (P2, September 2021 - August 2022), infusion disconnections were implemented with use of a 70% isopropyl alcohol cap (IPA-C) for passive decontamination. In a second intervention phase (P3, September 2022 - August 2023), infusion disconnections continued without the use of IPA-C. Rates of CLABSI were compared across the three intervention periods using segmented Poisson regression.

FINDINGS

A total of 11,039 catheter-days across 764 CVC and 16,226 patient-days were included. 21 CLABSI were recorded across all intervention periods. Compared with P1, incidence rate ratios (IRRs) for CLABSI did not significantly change in P2 (IRR 0.76 [95% CI 0.27-2.15]) and P3 (IRR 0.79 [CI 95% 0.28-2.22]). No CVCs were removed due to occlusion during the study period. Five of 21 CLABSI were polymicrobial, and coagulase-negative staphylococci were isolated in 19/21 cases (90%).

CONCLUSION

Interruption of continuous infusions in haemato-oncology patients with a CVC was not associated with a substantial change in CLABSI rates, whether or not an IPA-C was used.

In vitro assessment of isopropanol leakage from antiseptic barrier caps into commonly used needleless connectors

BACKGROUND

Needleless connectors (NCs) can be disinfected using antiseptic barrier caps (ABCs) to reduce the risk of catheter-related bloodstream infections. However, recent evidence suggests that isopropanol can leak from the ABC into the NC, posing concern about their safe use. We sought to determine in vitro which ABC and NC parameters influence the leakage of isopropanol through the infusion circuit.

METHODS

We assessed 13 NCs and 4 ABCs available in the European market. In vitro circuits consisting of an isopropanol cap, a NC, and an 11-cm catheter line were created. The circuits were left in place for 1 to 7 days at room temperature to assess the kinetics of isopropanol leakage. Isopropanol content in ABC and in circuit flushing solutions (5 mL NaCl 0.9%) after exposure to the cap were measured using gas chromatography with a flame ionization detector.

RESULTS

The leakage of isopropanol from the cap to the NC was dependent on the NC, but not the cap. The NC mechanism did not predict the leakage of isopropanol. The Q-Syte NC exhibited the most isopropanol leakage (7.01±1.03 mg and 28.32±2.62 mg at 24 hours and 7 days, respectively), whereas the Caresite NC had the lowest isopropanol leakage at 7 days (1.69±0.01 mg).

CONCLUSION

The use of isopropanol ABCs can cause isopropanol leakage into the catheter circuit according to NC parameters. Caution should be exercised when using these devices, especially in the pediatric and neonatal population.

Efficacy of disinfection procedures to reduce Acinetobacter baumanii blaOXA-23 contamination rate of needleless connectors: an in-vitro study

Aim

This study aimed to verify the efficacy of disinfection procedures to reduce Acinetobacter baumannii blaOXA-23 bacterial load in needleless connectors that had been experimentally contaminated.

Methods

Two-way intermediate extender's hub and needle-free valve were contaminated with Acinetobacter baumannii blaOXA-23. To disinfect them, the following procedures were carried out: sterile gauze with 70% ethanol, sterile gauze with Incidin®, and 70% isopropyl alcohol single-use cap, with eight times friction for 10 s, followed by 5 s drying time. The statistical tests Kruskal-Wallis and post-hoc Conover were performed using MedCalc®.

Results

A total of 82 experiments were conducted. All tested disinfection procedures were efficacious in reducing the A. baumannii blaOXA-23 load. The 70% IPA single-use cap was found to be the best method for disinfecting the two-way intermediate extender's hub (87.28%), while all the methods were efficacious for the disinfection of the needle-free valve (more than 90%). During the inoculation period, A. baumannii blaOXA-23 showed less adherence to the needle-free valve during the inoculation period, probably due to the device's design.

Conclusion

The three tested disinfection procedures using sterile gauze with 70% ethanol, sterile gauze with Incidin®, and 70% IPA single-use cap were found to be efficacious in reducing the bacterial load of A. baumanni blaOXA-23 in needleless connectors. Proper disinfection of needleless connectors is a crucial nursing practice to prevent bloodstream infections, as it significantly reduces the bacterial load present in the device.

Effectiveness of Disinfecting Caps for Intravenous Access Points in Reducing Central Line-Associated Bloodstream Infections, Clinical Utilization, and Cost of Care During COVID-19

Purpose

Intravenous (IV) access point protectors, serving as passive disinfection devices and a cover between line accesses, are available to help reduce the risk of central line-associated bloodstream infections (CLABSIs). This low-maintenance disinfection solution is particularly valuable in situations with excessive workloads. This study examined the effect of a disinfecting cap for an IV access point on CLABSI rates, hospital length of stay, and cost of care in an inpatient setting during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

The study utilized data from the Premier Healthcare Database, focusing on 200,411 hospitalizations involving central venous catheters between January 2020 and September 2020. Among these cases, 7423 patients received a disinfecting cap, while 192,988 patients did not use any disinfecting caps and followed the standard practice of hub scrubbing. The two cohorts, Disinfecting Cap and No-Disinfecting Cap groups, were compared in terms of CLABSI rates, hospital length of stay (LOS), and hospitalization costs. The analysis accounted for baseline group differences and random clustering effects by employing a 34-variable propensity score and mixed-effect multiple regression, respectively.

Results

The findings demonstrated a significant 73% decrease in CLABSI rates (p= 0.0013) in the Disinfecting Cap group, with an adjusted CLABSI rate of 0.3% compared to 1.1% in the No-Disinfecting Cap group. Additionally, the Disinfecting Cap group exhibited a 0.5-day reduction in hospital stay (9.2 days versus 9.7 days; p = 0.0169) and cost savings of $6703 ($35,604 versus $42,307; p = 0.0063) per hospital stay compared to the No-Disinfecting Cap group.

Conclusion

This study provides real-world evidence that implementing a disinfecting cap to protect IV access points effectively reduces the risk of CLABSIs in hospitalized patients compared to standard care, ultimately optimizing the utilization of healthcare resources, particularly in situations where the healthcare system is under significant strain or overloaded.

Antiseptic barrier caps to prevent central line-associated bloodstream infections: a systematic review and meta-analysis

BACKGROUND

Reliable and safe venous access is crucial for patients using central venous catheters (CVC). However, such CVCs carry a risk for central line-associated bloodstream infections (CLABSIs). Antiseptic barrier caps (ABCs) are a novel tool in the armamentarium for CVC disinfection. Our aim was to review the efficacy and safety of ABCs.

METHOD

A literature search was conducted using PubMed, EMBASE, Cochrane library, and CINAHL. Primary aim was to compare CLABSI rates in patients using ABCs versus standard care. Secondary aims included efficacy of ABCs in relevant subgroups (age, ABC brand, clinical setting), safety, compliance, and costs. Fifteen studies were included in the meta-analysis.

RESULTS

In total, 391 CLABSIs in 273,993 catheter days occurred in the intervention group versus 620 CLABSIs in 284,912 days in the standard care group, resulting in a risk ratio of 0.65 (95%CI 0.55-0.76; P<0.00001). Subgroup analyses showed similar effects, except for non-intensive care unit. In general, ABCs were safe, highly appreciated by patients and caregivers, and cost-effective, while compliance was easy to monitor. In most studies, a substantial risk of bias was observed.

CONCLUSION

In conclusion, while available evidence suggests that ABCs are effective, safe, easy in use, and cost-effective. However, due to the poor methodological quality of most available studies, more robust data should justify their use at this point.

[Update of the recommendations of the Bacteraemia Zero Project]

El proyecto Bacteriemia Zero (BZ) fue el primero de los Proyectos Zero que se implementó en las Unidades de Cuidados Intensivos (UCI), consiguiendo una disminución de las tasas de infección relacionadas con catéter por debajo de las recomendadas por los estándares de calidad de las sociedades científicas. A raíz de la pandemia causada por el SARS-CoV-2 en las UCI, se ha observado un incremento importante de estas tasas de infección. El incremento de las tasas de infección y la necesidad de incorporar en la práctica clínica la mejor evidencia disponible, justifica la necesidad de actualizar las recomendaciones del proyecto BZ. Se constituyó un grupo de trabajo formado por miembros de las diferentes sociedades científicas que consideró que el paquete de medidas obligatorias del proyecto no debía modificarse debido a su eficacia demostrada y decidió incorporar, después de su revisión, las siguientes medidas opcionales: uso de catéteres impregnados con antimicrobianos, uso de apósitos impregnados con clorhexidina, uso de tapones con solución antiséptica en los conectores e higiene corporal diaria con clorhexidina.

Desinfecção de hubs e conectores de cateteres intravenosos

Objetivo: identificar métodos de desinfecção de hubs e conectores sem agulha dos cateteres intravenosos em pacientes hospitalizados e verificar a efetividade das intervenções para a prevenção de infecções de corrente sanguínea associada a cateter intravenoso. Método: revisão de escopo seguindo as recomendações de Joanna Briggs Institute. Busca realizada em bases de dados eletrônicas Pubmed, Embase, Cochrane Library, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Base de Dados Enfermagem e Bibliografía Nacional en Ciencias de la Salud Argentina, e estudos indicados por experts. A busca foi atemporal até setembro de 2020. Protocolo registrado na Open Science Framework. Resultados: foram incluídos 27 estudos, sendo que cinco foram Guidelines e 22 foram artigos publicados em periódicos. Existe grande variedade de métodos de desinfecção de hubs e de conectores. Para a desinfecção ativa, foram indicados Gluconato de Clorexedina, Isopropanol e Iodopovedina; para a desinfecção passiva, Gluconato de Clorexedina e Isopropanol. A quantidade do agente desinfetante variou de 0,25 mL a 0,6 mL. O tempo de fricção na desinfecção ativa variou de cinco segundos a 30 segundos, e o tempo de contato na desinfecção passiva variou de três minutos a sete dias. O tempo de secagem de agentes desinfetantes foi superior a cinco segundos. Conclusão: verifica-se variedade de métodos de desinfecção; no entanto, não há consenso sobre a melhor indicação. Necessita-se de estudos que evidenciem a quantidade de desinfetante, a pressão e o tempo de fricção e o tempo de secagem. Pesquisas com práticas de desinfecção utilizadas no Brasil e ensaios clínicos randomizados são necessários. 

Evaluating methods for the use and decontamination of needleless connectors: A qualitative inquiry

BACKGROUND

Needleless connectors (NCs) are essential devices designed to provide safe, needle-free connection between venous access devices, syringes and infusions. There is a variety of designs, and associated decontamination products and practices; the resulting confusion can cause detrimental patient outcomes. This study aimed to explore nurses' attitudes, techniques, and practices around the use and decontamination of NCs in clinical practice.

METHODS

Qualitative inquiry was conducted with seven focus groups of 4-6 participants each in the cancer and surgical units of a large tertiary hospital in Australia between January and March 2019. Participants comprised nurses who had taken part in a recent clinical trial of NC decontamination. Focus group sessions were recorded, transcribed and synthesised using content analysis.

RESULTS

Seven focus groups were conducted (total, N = 30 participants), lasting 16-20 min. Six major themes were identified surrounding needleless connector use and decontamination: 'safety and utility'; 'terminology and technological understanding'; 'clinical practice determinants'; 'decontamination procedures and influencers'; 'education and culture'; and 'research and innovation'.

CONCLUSION

The participants articulated positive attitudes towards needleless connector use for needle-stick and infection prevention, however rationales for care and maintenance practices demonstrated limited understanding of guidelines (e.g., disinfection time) and specific NC function (e.g., positive, negative pressure). The findings indicated the need for targeted, standardised needleless connector education, to enhance staff confidence, improve consistency of care and ensure patient safety.

Antiseptic barrier caps in central line-associated bloodstream infections: A systematic review and meta-analysis

OBJECTIVES

To evaluate the evidence concerning the effectiveness of antiseptic barrier caps vs. manual disinfection in preventing central line-associated bloodstream infection (CLABSI).

METHODS

The protocol of this systematic review and meta-analysis was pre-registered in PROSPERO (CRD42021259582). PubMed, Cochrane Library and Web of Science databases were searched from 2011 to 2021. Randomized-controlled trials (RCT) and observational studies on hospitalized patients of any age were included.

RESULTS

Fourteen studies were included. Compared with manual disinfection, antiseptic barrier caps significantly reduced CLABSI rate per 1000 line-days (Standardized Mean Difference [SMD]: -0.02; 95%CI: -0.03 to -0.01) and number of CLABSI per patient (RR: 0.60; 95%CI: 0.41-0.89). Subgroup analysis showed that antiseptic barrier caps were more effective in reducing CLABSI rate per 1000 line-days in ICU (SMD: -0.02; 95%CI: -0.03 to -0.01) and non-ICU patients (SMD: -0.03; 95%CI: -0.05 to -0.01), adults (SMD: -0.02; 95%CI: -0.04 to -0.01), as in observational studies (SMD: -0.02; 95%CI: -0.02 to -0.01). Antiseptic barrier caps also significantly reduce CLABSI risk in ICU patients (RR: 0.65, 95%CI: 0.42-1.00), adults (RR: 0.50, 95%CI: 0.29-0.86), and observational studies (RR: 0.54; 95%CI: 0.32-0.91). No differences were found when only children or RCTs were taken into account. Median cost savings amongst studies were $21,890 [IQR 16,350-45,000] per CLABSI.

CONCLUSIONS

Antiseptic barrier caps appear to be effective in reducing CLABSI. The real-world impact needs to be confirmed by RCTs.

Preventing Central Line Blood Stream Infections in Critical Care Patients

Currently, the Centers for Disease Control reports close to 40,000 central line-associated bloodstream infections (CLABSI) occur in acute care facilities in the United States each year. Most are considered preventable. Evidence-based practices such as the CLABSI bundle and central line maintenance bundles have demonstrated their effectiveness in reducing CLABSI. This article reviews these best practices and provides a framework for consistent implementation.

Vascular Access Device Care and Management: A Comprehensive Organizational Approach

The Infusion Nurses Society asserts that a comprehensive organizational approach to vascular access device (VAD) care and management is imperative to ensure safe and efficacious patient care. It is essential that each organization (1) develops policies and procedures to align VAD care and management with recognized standards of practice; (2) integrates unique aspects of organization-selected VAD care products into policies and procedures and establishes expectations for adherence to these organizational directives; (3) develops a framework for gathering and analyzing clinical data related to patient outcomes for VAD care and management; (4) utilizes quality outcome data to facilitate evidence-based best practices within the organization; and (5) evaluates and facilitates educational programming to validate clinician competency.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

What is new in catheter use and catheter infection prevention in the ICU

PURPOSE OF REVIEW

Short-term intravascular catheters are instrumental in the care of critically ill patients. Despite their benefits, they also are potential entries for systemic infections. There is a growing body of literature on catheter use and the prevention of intravascular catheter infections in intensive care. This review highlights major recent contributions to the topic and put them into perspective to recommendations on best practice procedures.

RECENT FINDINGS

Many studies published in the last years have evaluated prevention strategies applying technology and addressing behavior change. Skin disinfection with 2% alcoholic chlorhexidine-gluconate (CHG) and CHG-impregnated dressings are increasingly used in clinical practice. However, the role of universal CHG bathing remains controversial. A number of new and innovative technologies are in development. Recent qualitative research offers new perspectives about behavior change interventions to improve implementation.

SUMMARY

Many options for effective intravascular catheter infection prevention are currently available. A number of recent systematic reviews and meta-analyses not only confirmed measures targeting best practice and technology at catheter insertion and catheter care but also challenged interventions, such as CHG bathing. More focus should be put to implementation strategies.

Peripheral intravenous catheter needleless connector decontamination study-Randomized controlled trial

BACKGROUND

Needleless connectors (NCs) were introduced to reduce health care work needlestick injuries (NSIs). If not decontaminated prior to use, NCs can be a portal for patient blood stream infections. The optimal disinfectant, and its application duration, for NC decontamination has not been empirically established.

METHODS

Factorial design randomized controlled trial comparing 70% isopropyl alcohol (IPA) and 2% chlorhexidine gluconate (CHG) in 70% IPA for 5, 10, or 15 seconds, in adult medical patients with peripheral intravenous catheters.

RESULTS

At baseline, 153 of 300 NCs (51%) grew microorganisms commonly found on the skin. Decontamination was successful in 150/153 (98%). There was no significant difference in decontamination between 70% IPA or 2% CHG in 70% IPA (P = .62), or decontamination for 5, 10, or 15 seconds (P = .21).

CONCLUSIONS

There was no difference in the effectiveness of 70% IPA and 2% CHG in 70% IPA for NC decontamination for peripheral intravenous catheters in the clinical environment. Successful decontamination was not different for applications of 5, 10, and 15 seconds; 15 seconds did not always remove all microorganisms. Factors such as cost, feasibility of compliance, and low risk of allergy support 5 seconds decontamination with 70% IPA as an acceptable approach.