Reducing Bloodstream Infection Risk in Central and Peripheral Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection

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.

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.

Effect of the use of an antiseptic barrier cap on the rates of central line-associated bloodstream infections in neonatal and pediatric intensive care

BACKGROUND

The use of antiseptic barrier caps reduced the occurrence of central line-associated bloodstream infections (CLABSI) in adult intensive care settings. We assessed the effect of the use of antiseptic barrier caps on the incidence of CLABSI in infants and children and evaluated the implementation process.

METHODS

We performed a mixed-method, prospective, observational before-after study. The CLABSI rate was documented during the "scrub the hub method" and the antiseptic barrier cap phase. Main outcomes were the number of CLABSIs per 1,000 catheter days (assessed with a Poisson regression analysis) and nurses' adherence to antiseptic barrier cap protocol.

RESULTS

In total, 2,248 patients were included. The rate of CLABSIs per 1,000 catheter days declined from 3.15 to 2.35, resulting in an overall incidence reduction of 22% (95% confidence interval, -34%, 55%; P = .368). Nurses' adherence to the antiseptic barrier cap protocol was 95.2% and 89.0% for the neonatal intensive care unit and pediatric intensive care unit, respectively.

DISCUSSION

The CLABSI reducing effect of the antiseptic barrier caps seems to be more prominent in the neonatal intensive care unit population compared with the pediatric intensive care unit population.

CONCLUSIONS

The antiseptic barrier cap did not significantly reduce the CLABSI rates in this study.

Minimising Blood Stream Infection: Developing New Materials for Intravascular Catheters

Catheter related blood stream infection is an ever present hazard for those patients requiring venous access and particularly for those requiring long term medication. The implementation of more rigorous care bundles and greater adherence to aseptic techniques have yielded substantial reductions in infection rates but the latter is still far from acceptable and continues to place a heavy burden on patients and healthcare providers. While advances in engineering design and the arrival of functional materials hold considerable promise for the development of a new generation of catheters, many challenges remain. The aim of this review is to identify the issues that presently impact catheter performance and provide a critical evaluation of the design considerations that are emerging in the pursuit of these new catheter systems.

Strategies for the successful implementation of disinfecting port protectors to reduce CLABSI in a large tertiary care teaching hospital

Disinfecting port protectors are a supplement to the central line-associated bloodstream infection prevention bundle as an optional recommendation from the Centers for Disease Control and Prevention. Despite evidence of effectiveness, few centers have successfully reported systematic, sustained implementation of these devices. In this article, we discuss a successful implementation in a large tertiary care teaching hospital, using an evidence-based, multidisciplinary approach. Infection prevention; Bacteremia; Ethanol caps; Bundle measures; Quality improvement; Hub infection.

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

BACKGROUND

The objective of this review was to compare the effectiveness of connector decontamination with 70% alcohol wipes, alcoholic chlorhexidine gluconate wipes, or alcohol impregnated caps to prevent catheter-associated bloodstream infection (CABSI).

METHODS

A systematic search was conducted in CINAHL, Cochrane Central Register of Controlled Trials, Medline, and PubMed. The primary outcome was CABSI, with randomized and observational studies included. The inclusion criteria were: English language, any age group, no date limitations, and reporting connector decontamination interventions to prevent CABSI. The exclusion criteria were: multimodal interventions, letters, and conference abstracts. Quality assessment with the Newcastle-Ottawa Scale, a narrative synthesis, and meta-analysis were conducted. Pooled data used a random effects model for pair-wise comparisons, due to clinical heterogeneity. Statistical heterogeneity was investigated by visual model inspection, χ², and I² statistics.

RESULTS

Ten studies compared 70% alcohol wipes with 70% alcohol-impregnated caps, and 2 studies (n = 1,216) tested an alcoholic chlorhexidine gluconate wipe. Alcoholic chlorhexidine gluconate wipes were associated with significantly less CABSI than 70% alcohol wipes (risk ratio, 0.28; 95% confidence interval, 0.20-0.39). Alcohol-impregnated caps were associated with significantly less CABSI than 70% alcohol wipes (risk ratio, 0.43; 95% confidence interval, 0.28-0.65). Studies were of low to moderate quality.

CONCLUSIONS

Alcohol impregnated caps and alcoholic chlorhexidine gluconate wipes were associated with significantly less CABSI than 70% alcohol wipes. This requires confirmation in randomized controlled trials.

The case for using a disinfecting cap for needlefree connectors

Catheter-related bloodstream infections (CRBSIs) are a signification cause of infection. When CRBSI rates are high, the cost to the patient and the organisation can be significant. More than ever before, there is a high demand for vascular access. Advances in treatment often entail extended indwell times for central vascular access devices. The care and maintenance of these devices is crucial in avoiding complications such as infection. Using care bundles in conjunction with other simple interventions, such as passive disinfecting caps, can help reduce CRBSI rates. The published evidence demonstrates that passive disinfecting caps can help reduce infection rates associated with different types of central venous catheters by protecting needlefree connectors from colonisation by pathogens and serving as a clear indicator that the line has been disinfected.

NURSING PRACTICES IN PERIPHERAL VENOUS CATHETER: PHLEBITIS AND PATIENT SAFETY

ABSTRACT Objective: to understand the nursing practices related to peripheral venous catheter and to identify deviations related to the scientific evidence regarding the prevention of phlebitis. Method: qualitative study with data collection by means of participant observation techniques and semi-structured interviews, with 26 and 15 nurses, respectively, from a Portuguese hospital. Data content analysis was performed. Results: In the category “nursing actions”, nursing practices related to: selection of catheter insertion site and its caliber size, evaluation of insertion site for signs of inflammation, insertion site dressing, disinfection of accessories, hand hygiene and patient participation in care emerged. There were situations of deviations in these practices in relation to scientific evidence. Conclusion: Nursing practices presented deviations in relation to scientific evidence, and were influenced by the size of the institution, patient characteristics, and lack of knowledge of nurses regarding certain actions that pose a risk to patient safety. The creation of protocols and the implementation of continuous education are fundamental for the acquisition of competencies by nurses, for correcting deviations and providing a safe quality nursing care to the patient.

A Bundled Approach to Decrease the Rate of Primary Bloodstream Infections Related to Peripheral Intravenous Catheters

Background: Peripheral intravenous catheters (PIVs) have been considered as having lower risk of infection than central lines. However, research is limited regarding numbers of primary bloodstream infections related to peripheral lines and prevention of peripheral line-associated bloodstream infections (PLABSI).

Methods: Our aim was to create and monitor compliance with a new PIV maintenance bundle using disinfecting caps and tips and to assess whether this bundle would lead to a decrease in PLABSI rates. Weekly audits were conducted to measure compliance with both the new PIV bundle and our existing central line-associated bloodstream infection (CLABSI) bundle. We also audited the disconnection method used for intravenous line tubing (peripheral and central lines) before and during the study intervention period.

Results: A compliance rate of close to 90% with the use of the disinfecting caps and tips was attained. Using a PLABSI bundle successfully decreased primary bloodstream infections due to PIVs (from 0.57 infections per 1000 patient-days preintervention to 0.11 infections per 1000 patient-days; p < 0.001). We confirmed that improving care for PIVs would decrease primary bloodstream infections associated with these devices.

Conclusions: Using a PIV maintenance bundle including disinfecting caps and tips can effectively lower the rate of primary bloodstream infections attributable to PIV lines.

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

BACKGROUND

Microorganisms can intraluminally access a central venous catheter via the catheter hub. The catheter hub should be appropriately disinfected to prevent central line-associated bloodstream infections (CLABSIs). However, compliance with the time-consuming manual disinfection process is low. An alternative is the use of an antiseptic barrier cap, which cleans the catheter hub by continuous passive disinfection.

OBJECTIVE

To compare the effects of antiseptic barrier cap use and manual disinfection on the incidence of CLABSIs.

DESIGN

Systematic review and meta-analysis.

METHODS

We systematically searched Embase, Medline Ovid, Web-of-science, CINAHL EBSCO, Cochrane Library, PubMed Publisher and Google Scholar until May 10, 2016. The primary outcome, reduction in CLABSIs per 1000 catheter-days, expressed as an incidence rate ratio (IRR), was analyzed with a random effects meta-analysis. Studies were included if 1) conducted in a hospital setting, 2) used antiseptic barrier caps on hubs of central lines with access to the bloodstream and 3) reported the number of CLABSIs per 1000 catheter-days when using the barrier cap and when using manual disinfection.

RESULTS

A total of 1537 articles were identified as potentially relevant and after exclusion of duplicates, 953 articles were screened based on title and abstract; 18 articles were read full text. Eventually, nine studies were included in the systematic review, and seven of these nine in the random effects meta-analysis. The pooled IRR showed that use of the antiseptic barrier cap was effective in reducing CLABSIs (IRR=0.59, 95% CI=0.45-0.77, P<0.001).

CONCLUSIONS

Use of an antiseptic barrier cap is associated with a lower incidence CLABSIs and is an intervention worth adding to central-line maintenance bundles.

Prescribing Errors with Levetiracetam Oral Solution/Communicate Insulin Dose and Concentration on Separate/Lines Risperidone and Ropinirole Mix-ups/IV Line Disinfection Caps Can Become Foreign Bodies

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Protected Clinical Indication of Peripheral Intravenous Lines: Successful Implementation

Background: A large, urban community hospital developed an insertion bundle to support the safe implementation of a policy of extended dwell time (clinical indication) for inpatient peripheral intravenous lines (PIVs).

Methods: Internal evaluation of practices through direct observations as well as evidence-based guidelines and historic data on PIV-related bloodstream infections helped drive the bundle elements. A surveillance plan was in place to continue measurement of these outcomes during the postimplementation period.

Results: At 12 months following implementation, the organization documented a 37% reduction (P = .03) in primary bacteremias (combining PIV and central line-associated bloodstream [CLABSI] infections) and a 19% percent reduction in PIV bloodstream infections. CLABSI rates were also reviewed, as 20% of CLABSI were noted to also have peripheral access present during the year prior to implementation. CLABSI standardized infection ratios for the publicly reported intensive care units decreased from 1.3 to 0.32 (P = .02). In addition, intravenous line start kit use decreased 48% during the year following bundle implementation.

Conclusions: Careful planning and development of an education bundle and an insertion bundle in a community hospital setting allowed for longer dwell times and a trend of decreased bloodstream infections.

Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review

Background. Needleless connectors (NC) are used on virtually all intravascular devices, providing an easy access point for infusion connection. Colonization of NC is considered the cause of 50% of postinsertion catheter-related infections. Breaks in aseptic technique, from failure to disinfect, result in contamination and subsequent biofilm formation within NC and catheters increasing the potential for infection of central and peripheral catheters. Methods. This systematic review evaluated 140 studies and 34 abstracts on NC disinfection practices, the impact of hub contamination on infection, and measures of education and compliance. Results. The greatest risk for contamination of the catheter after insertion is the NC with 33-45% contaminated, and compliance with disinfection as low as 10%. The optimal technique or disinfection time has not been identified, although scrubbing with 70% alcohol for 5-60 seconds is recommended. Studies have reported statistically significant results in infection reduction when passive alcohol disinfection caps are used (48-86% reduction). Clinical Implications. It is critical for healthcare facilities and clinicians to take responsibility for compliance with basic principles of asepsis compliance, to involve frontline staff in strategies, to facilitate education that promotes understanding of the consequences of failure, and to comply with the standard of care for hub disinfection.