Use of Vancomycin-Containing Lock or Flush Solutions for Prevention of Bloodstream Infection Associated with Central Venous Access Devices: A Meta-Analysis of Prospective, Randomized Trials

Nitric Oxide-Releasing Hemodialysis Catheter Lock Solutions

In an attempt to address the significant morbidity, mortality, and economic cost associated with tunneled dialysis catheter (TDC) dysfunction, we report the development of nitric oxide-releasing dialysis catheter lock solutions. Catheter lock solutions with a range of NO payloads and release kinetics were prepared using low-molecular-weight N-diazeniumdiolate nitric oxide donors. Nitric oxide released through the catheter surface as a dissolved gas was maintained at therapeutically relevant levels for at least 72 h, supporting clinical translatability (interdialytic period). Slow, sustained NO release from the catheter surface prevented bacterial adhesion in vitro by 88.9 and 99.7% for Pseudomonas aeruginosa and Staphylococcus epidermidis, respectively, outperforming a burst NO-release profile. Furthermore, bacteria adhered to the catheter surface in vitro prior to lock solution use was reduced by 98.7 and 99.2% for P. aeruginosa and S. epidermidis, respectively, when using a slow releasing NO donor, demonstrating both preventative and treatment potential. The adhesion of proteins to the catheter surface, a process often preceding biofilm formation and thrombosis, was also lessened by 60-65% by sustained NO release. In vitro cytotoxicity of catheter extract solutions to mammalian cells was minimal, supporting the non-toxic nature of the NO-releasing lock solutions. The use of the NO-releasing lock solution in an in vivo TDC porcine model demonstrated decreased infection and thrombosis, enhanced catheter functionality, and improved outcome (i.e., likelihood of survival) as a result of catheter use.

Phyto-assisted synthesis of zinc oxide nanoparticles for developing antibiofilm surface coatings on central venous catheters

Medical devices such as Central Venous Catheters (CVCs), are routinely used in intensive and critical care settings. In the present scenario, incidences of Catheter-Related Blood Stream Infections (CRBSIs) pose a serious challenge. Despite considerable advancements in the antimicrobial therapy and material design of CVCs, clinicians continue to struggle with infection-related complications. These complications are often due colonization of bacteria on the surface of the medical devices, termed as biofilms, leading to infections. Biofilm formation is recognized as a critical virulence trait rendering infections chronic and difficult to treat even with 1,000x, the minimum inhibitory concentration (MIC) of antibiotics. Therefore, non-antibiotic-based solutions that prevent bacterial adhesion on medical devices are warranted. In our study, we report a novel and simple method to synthesize zinc oxide (ZnO) nanoparticles using ethanolic plant extracts of Eupatorium odoratum. We investigated its physio-chemical characteristics using Field Emission- Scanning Electron Microscopy and Energy dispersive X-Ray analysis, X-Ray Diffraction (XRD), Photoluminescence Spectroscopy, UV-Visible and Diffuse Reflectance spectroscopy, and Dynamic Light Scattering characterization methods. Hexagonal phase with wurtzite structure was confirmed using XRD with particle size of ∼50 nm. ZnO nanoparticles showed a band gap 3.25 eV. Photoluminescence spectra showed prominent peak corresponding to defects formed in the synthesized ZnO nanoparticles. Clinically relevant bacterial strains, viz., Proteus aeruginosa PAO1, Escherichia coli MTCC 119 and Staphylococcus aureus MTCC 7443 were treated with different concentrations of ZnO NPs. A concentration dependent increase in killing efficacy was observed with 99.99% killing at 500 μg/mL. Further, we coated the commercial CVCs using green synthesized ZnO NPs and evaluated it is in vitro antibiofilm efficacy using previously optimized in situ continuous flow model. The hydrophilic functionalized interface of CVC prevents biofilm formation by P. aeruginosa, E. coli and S. aureus. Based on our findings, we propose ZnO nanoparticles as a promising non-antibiotic-based preventive solutions to reduce the risk of central venous catheter-associated infections.

Supportive interventions for childhood cancer: An umbrella review of randomized evidence

Therapeutic advancements have improved pediatric cancer prognosis, shifting the interest towards the management of psychosocial burden and treatment-related morbidity. To critically appraise the available evidence, we conducted an umbrella review of meta-analyses of randomized controlled trials on supportive interventions for childhood cancer. Thirty-four publications (92 meta-analyses, 1 network, 14,521 participants) were included. The most concrete data showed a reduction in procedure-related pain and distress through hypnosis. Moreover, exercise improved the functional mobility of the patients. Regarding pharmacological interventions, most of the meta-analyses pertained to the treatment of nausea/vomiting (ondansetron was effective) and infections/febrile neutropenia [granulocyte-(macrophage) colony-stimulating factors showed benefits]. Substantial heterogeneity was detected in 31 associations. Conclusively, supportive interventions for pediatric cancer are being thoroughly evaluated. However, most of the studies are small and of moderate quality, highlighting the need for more randomized evidence in order to increase precision in improving the quality of life of patients, survivors and their families.

Vancomycin Use in Children and Neonates across Three Decades: A Bibliometric Analysis of the Top-Cited Articles

Vancomycin is frequently prescribed in pediatrics, especially in intensive care unit settings, to treat Gram-positive bacterial infections. This work aims to collect the top-cited articles of pediatric and infectious diseases areas to gather the current evidence and gaps of knowledge on the use of vancomycin in these populations. The most relevant journals reported in the "pediatrics" and "infectious diseases" categories of the 2019 edition of Journal Citation Reports were browsed. Articles with more than 30 citations and published over the last three decades were collected. A bibliometric analysis was performed and 115 articles were retrieved. They were published in 21 journals, with a median impact factor of 4.6 (IQR 2.9-5.4). Sixty-eight of them (59.1%) belonged to "infectious diseases" journals. The most relevant topic was "bloodstream/complicated/invasive infections", followed by "antibiotic resistance/MRSA treatment". As for population distribution, 27 articles were on children only and 27 on neonates, most of which were from intensive care unit (ICU) settings. The current literature mainly deals with vancomycin as a treatment for severe infections and antibiotic resistance, especially in neonatal ICU settings. Lately, attention to new dosing strategies in the neonatal and pediatric population has become a sensible topic.

Indications for medical antibiotic prophylaxis and potential targets for antimicrobial stewardship intervention: a narrative review

BACKGROUND

Most of the antimicrobial stewardship (AMS) literature has focused on antimicrobial consumption for the treatment of infections, for the prophylaxis of surgical site infection and for the prevention of endocarditis. The role of AMS for medical antibiotic prophylaxis (AP) has not been adequately addressed.

AIMS

To identify targets for AMS interventions for medical AP in adult patients.

SOURCES

Targeted searches were conducted in PubMed.

CONTENT

The various indications for medical AP and relevant evidence from practice guidelines are outlined. The following were identified as potential targets for AMS interventions: (a) addressing under-utilization of antibiotic-sparing strategies (e.g. for recurrent urinary tract infections, recurrent soft-tissue infections, recurrent exacerbations associated with bronchiectasis or chronic obstructive pulmonary disease), (b) reducing unnecessary AP beyond recommended indications (e.g. for acute pancreatitis, bite wounds, or urinary catheter manipulations), (c) reducing the use of AP with a broader spectrum than necessary, (d) reducing the use of AP for longer than the recommended duration (e.g. AP for prevention of osteomyelitis in open fractures or AP in high-risk neutropenia), (e) evaluating the role of antibiotic cycling to prevent the emergence of resistance during prolonged AP (e.g. in recurrent urinary tract infections or prophylaxis for spontaneous bacterial peritonitis), and (f) addressing research gaps regarding appropriate indications or antibiotic regimens for medical prophylaxis.

IMPLICATIONS

This review summarizes current trends in AP and proposes targets for AMS interventions.

S-Nitroso-N-acetyl-l-cysteine Ethyl Ester (SNACET) Catheter Lock Solution to Reduce Catheter-Associated Infections

Antimicrobial-lock therapy is an economically viable strategy to prevent/reduce the catheter-related bloodstream infections (CRBSI) that are associated with central venous catheters (CVCs). Herein, we report the synthesis and characterization of the S-nitroso-N-acetyl-l-cysteine ethyl ester (SNACET), a nitric oxide (NO)-releasing molecule, and for the first time its application as a catheter lock solution to combat issues of bacterial infection associated with indwelling catheters. Nitric oxide is an endogenous gasotransmitter that exhibits a wide range of biological properties, including broad-spectrum antimicrobial activity. The storage stability of the SNACET and the NO release behavior of the prepared lock solution were analyzed. SNACET lock solutions with varying concentrations exhibited tuneable NO release at physiological levels for >18 h, as measured using chemiluminescence. The SNACET lock solutions were examined for their efficacy in reducing microbial adhesion after 18 h of exposure toStaphylococcus aureus (Gram-positive bacteria) andEscherichia coli (Gram-negative bacteria). SNACET lock solutions with 50 and 75 mM concentrations were found to reduce >99% (ca. 3-log) of the adhered S. aureus and E. coli adhesion to the catheter surface after 18 h. The SNACET lock solutions were evaluated in a more challenging in vitro model to evaluate the efficacy against an established microbial infection on catheter surfaces using the same bacteria strains. A >90% reduction in viable bacteria on the catheter surfaces was observed after instilling the 75 mM SNACET lock solution within the lumen of the infected catheter for only 2 h. These findings propound that SNACET lock solution is a promising biocidal agent and demonstrate the initiation of a new platform technology for NO-releasing lock solution therapy for the inhibition and treatment of catheter-related infections.

Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter-related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020

Background and Purpose

Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.

Methods

This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.

Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.

Results

This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.

Conclusion

In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.

Abbreviations list

ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO₂: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization

How to cite this article

Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.

Early central line-associated blood stream infections in children with cancer pose a risk for premature catheter removal

AIM

This study examined the clinical characteristics of central line-associated blood stream infections occurring within 30 days after insertion versus later infections in paediatric cancer patients and the subsequent risk for premature catheter removal.

METHODS

This was a retrospective study of children aged 0-18 years who were diagnosed with cancer from 2013 to 2014 at the Astrid Lindgren Children Hospital, Sweden. Clinical and microbiology data for each patient were collected for 365 days after the central venous catheter (CVC) was inserted.

RESULTS

During the study period, 154 children received a CVC. The overall incidence of central line associated blood stream infections was 2.0 per 1000 catheter days. A total of 108 infectious episodes were identified in 44/154 (29%) patients. Of those, 15/44 children (29%) had an early infection within 30 days and alpha-haemolytic Streptococci and coagulase-negative Staphylococci dominated. Children with early infections were more likely to have a haematological malignancy and to need premature removal of the CVC due to repeated infections.

CONCLUSION

We observed a high prevalence of early CVC associated blood stream infection mainly in patients with haematological malignancies. Our study highlights the importance of preventive measures in reducing infections in paediatric cancer patients.

Ethanol lock is effective on reducing the incidence of tunneled catheter-related bloodstream infections in hemodialysis patients: a systematic review and meta-analysis

PURPOSE

The purpose of this meta-analysis is to evaluate the effect of ethanol lock on the incidence of catheter-related bloodstream infection (CRBSI) in patients with central venous catheters.

METHODS

RCTs comparing ethanol lock with another solution lock for prevention of CRBSI were obtained by searching databases of PubMed, Embase, Web of Science and Cochrane Central Register of clinical trials for eligible randomized controlled trials (inception to December 2017). Two researchers separately selected the RCTs and assessed their quality. Data on patient characteristics and ethanol protocols were collected. The primary outcome was the incidence of CRBSI, and the secondary outcomes were catheter colonization, exit infection and thrombosis.

RESULTS

A total of 2575 patients with 3375 catheters from 7 eligible RCTs were included. Overall, ethanol lock significantly decreased the risk of CRBSI, with RR 0.54 (95% CI 0.38-0.78; I2 = 0%; p = 0.001); no obvious heterogeneity was observed in the fixed-effects model (I2 = 0%). Of note, subgroup analysis demonstrated that ethanol lock conferred significant benefit in studies with tunneled catheters (RR 0.46; 95% CI 0.30-0.72) but not in studies with untunneled catheters. Only two studies provided data regarding catheter colonization, and no significant difference was found (RR, 1.09; 95% CI, 0.87-1.38; I2 = 41%; p = 0.45). Moreover, pooled data did not show significant differences between ethanol and control groups with regard to the incidence of thrombosis (RR 1.05; 95% CI 0.91-1.22; I2 = 0%; p = 0.48).

CONCLUSIONS

Our meta-analysis suggests that ethanol lock is effective on reducing the incidence of CRBSI in hemodialysis patients with tunneled central venous catheters.

Administration of taurolidine-citrate lock solution for prevention of central venous catheter infection in adult neutropenic haematological patients: a randomised, double-blinded, placebo-controlled trial (TAURCAT)

Background

Catheter-related bloodstream infection (CRBSI) is one of the most frequent complications in patients with cancer who have central venous catheters (CVCs) implanted and is associated with substantial morbidity and mortality. Taurolidine is a non-antibiotic agent with broad-spectrum antimicrobial activity, which has been used as a lock solution to prevent CRBSI in some settings. However, little is known about its usefulness in high-risk adult neutropenic patients with cancer. This prospective randomised clinical trial aims to test the hypothesis that taurolidine-citrate lock solution is more effective than placebo for preventing catheter infection in neutropenic haematological patients.

Methods

This study is a prospective, multicentre, randomised, double-blinded, parallel, superiority, placebo-controlled trial. Patients with haematological cancer who are expected to develop prolonged neutropenia (> 7 days) and who have a non-tunnelled CVC implanted will be randomised to receive prophylactic taurolidine-citrate-heparin solution using a lock technique (study group) or heparin alone (placebo group). The primary endpoint will be bacterial colonisation of the CVC hubs. The secondary endpoints will be the incidence of CRBSI, CVC removal, adverse events, and 30-day case-fatality rate.

Discussion

The lock technique is a preventive strategy that inhibits bacterial colonisation in the catheter hubs, which is the initial step of endoluminal catheter colonisation and the development of infection. Taurolidine is a nontoxic agent that does not develop antibiotic resistance because it acts as an antiseptic rather than an antibiotic. Taurolidine has shown controversial results in the few trials conducted in cancer patients. These studies have important limitations due to the lack of data on adult and/or high-risk neutropenic patients, the type of catheters studied (tunnelled or ports), and the lack of information regarding the intervention (e.g. dwelling of the solution, time, and periodicity of the lock technique). If our hypothesis is proven, the study could provide important solid evidence on the potential usefulness of this preventive procedure in a population at high risk of CRBSI, in whom this complication may significantly impair patient outcome.

Trial registration

ISRCTN, ISRCTN47102251. Registered on 9 September 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2647-y) contains supplementary material, which is available to authorized users.

Urokinase Lock or Flush Solution for Prevention of Bloodstream Infections Associated with Central Venous Catheters for Chemotherapy: A Meta-Analysis of Prospective Randomized Trials

Background

Intravascular devices (IVDs) carry significant risk of device-associated bloodstream infection (BSI). Catheter thrombosis increases the likelihood of microbial colonization of the catheter and BSI. Urokinase has been studied for the prevention of BSI associated with IVDs. We undertook a systematic review to determine the efficacy of urokinase-heparin lock or flush solution compared with heparin alone in preventing IVD-associated BSI.

Methods

Computerized databases were searched for relevant publications in English from January 1966 to 1 January 2007. We identified randomized controlled trials comparing a urokinase-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term IVDs. Summary effect sizes were calculated with assessment of heterogeneity.

Results

Five randomized, controlled trials involving a total of 991 patients being treated with IVDs met the inclusion criteria; all five studies were conducted among patients with cancer; three of these studies were undertaken in children and two in adults. The summary risk ratio with a urokinase-heparin lock solution for IVD-associated BSI was 0.77 (95% confidence interval [CI], 0.60–0.98; p=0.01). Results of the test for heterogeneity were not statistically significant (p=0.53).

Conclusions

Use of a urokinase lock solution in high-risk patient populations being treated with long-term central IVDs may reduce the risk of BSI. However, there are few randomized trials and methodologic limitations of these preclude more robust recommendations regarding the use of urokinase to prevent BSI. Further adequately powered studies should seek to evaluate the efficacy of urokinase and optimize dosage and instillation regimen.

Role of Antibiotic Lock Therapy for the Treatment of Catheter-Related Bloodstream Infections

Catheter-related bloodstream infections are often difficult to treat because they are caused by organisms that embed themselves in a bio film layer on the catheter surface, resulting in an increased resistance to antimicrobial agents. Systemic antibiotics are usually administered but, although generally effective in eliminating circulating bacteria, they frequently fail to sterilize the line, leaving the patient at a continuing risk of complications or recurrence. A successful approach to managing these infections requires making an appropriate decision regarding whether the catheter should be removed or retained using antibiotic lock therapy; and choosing the type and duration of antimicrobial therapy based on the type of organism and its resistance pattern. Studies that have evaluated antibiotic lock therapy have varied in the types of antibiotics and concentrations used, the addition of heparin to the solutions, and dwell times in the catheter lumen. Guidelines from the Infectious Diseases Society of America include use of antibiotic lock therapy as a therapeutic option for intraluminal infections when the device is not removed and, although not routine, as prophylaxis for catheter-related infection in select patient populations. However, there are no published guidelines on the concentration of heparin or antibiotics that should be used, and minimal published data on the stability of heparin combinations with antibiotics. It is to be hoped that antibiotic locks will be subject to randomized controlled trials of sufficient power to confirm or refute their use.

Current treatment paradigms in pediatric short bowel syndrome

Pediatric short bowel syndrome (SBS) is a serious condition which occurs in children with congenital or acquired reduction in length of the small intestine. SBS results in excessive fluid loss, nutrient malabsorption, electrolyte abnormalities, increased susceptibility to infections, parenteral nutrition associated complications and affects weight gain and growth. In children, SBS is debilitating and uniformly fatal without treatment. The primary goal of treatment is to restore enteral autonomy and reduce long-term dependence on parenteral support by increasing the absorptive potential of the remnant intestine. In this review, the medical and surgical management of SBS including pharmacologic agents, parenteral nutrition, dietary strategies, surgical lengthening procedures, and small bowel transplant will be discussed.

Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis

Bacterial bloodstream infections (BSI) cause significant transplant-related morbidity and mortality following allogeneic hematopoietic cell transplantation (allo-HCT). This manuscript reviews the risk factors for and the bacterial pathogens causing BSIs in allo-HCT recipients in the contemporary transplant period. In addition, it offers insight into emerging resistant pathogens and reviews clinical management considerations to treat and strategies to prevent BSIs in allo-HCT patients.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

A Cautionary Tale on the Central Venous Catheter: Medical Note for Oral Physicians

Complexity in the health status of patients with kidney disease forces to seek the aid of medical devices such as the central venous catheter (CVC) that is essential in order to perform hemodialysis. Elementary information about the CVC, as required for the oral healthcare professionals, has been documented so as to serve as a medical manual. This communication is the first of its kind that conjointly delineates vital considerations, which precede dental maneuvers in patients implanted with a CVC.

Antibiotic lock for the prevention of catheter-related infection in neonates

BACKGROUND

Use of a central venous catheter (CVC) in neonates is associated with an increase in nosocomial infection. Numerous strategies exist to prevent catheter-related bloodstream infection (CRBSI); however, CRBSI continues to be a major problem. Antibiotic locking catheters is a new and promising treatment that potentially prevents this severe condition.

OBJECTIVES

To assess the effectiveness of antibiotic lock versus no antibiotic lock or alternative antibiotic lock in the prevention of catheter-related infections in newborn infants of any gestational age during their initial stay in the neonatal unit and to study any relevant adverse effects from antibiotic lock therapy.

SEARCH METHODS

Methods followed those of the Cochrane Neonatal Review Group (CNRG). We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 5); MEDLINE (via PubMed); EMBASE (hosted by EBCHOST); CINAHL; abstracts from Pediatric Academic Societies, European Society for Paediatric Research and trials registries; and references cited in our short listed articles using keywords and MeSH headings, up to April 2015.

SELECTION CRITERIA

We considered all trials utilising random or quasi-random participant allocation. Participants included all newborn infants of any postmenstrual age who required any type of CVC. We compared an antibiotic lock technique with no antibiotic lock or placebo, such as heparinised saline, for any duration of time.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the CNRG. Two review authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our dichotomous results using risk ratio (RR) with their 95% confidence intervals (CIs). We assessed for heterogeneity using the I(2) statistic.

MAIN RESULTS

We included three trials (271 infants) in this review. Two of the three included studies had an overall low risk of bias and the remaining study had high risk of selection and performance biases. The use of an antibiotic lock decreased the incidence of confirmed catheter-related infection (typical RR 0.15, 95% CI 0.06 to 0.40; 3 studies, 271 infants) (high-quality evidence). The typical absolute risk reduction (ARR) was 18.5% and the number needed to treat for an additional beneficial outcome (NNTB) was 5. The effect of use of an antibiotic lock on suspected catheter infection was imprecise (typical RR 0.65, 95% CI 0.22 to 1.92) (moderate quality evidence). Confirmed and suspect infection rates combined were lower in the antibiotic lock group (absolute rates, RR 0.25, 95% CI 0.12 to 0.49; rate per 1000 catheter days, RR 0.17, 95% CI 0.07 to 0.40). The ARR was 20.5% and the NNTB was 5. None of the studies report resistance to the antibiotic used during the lock treatment. There was no significant difference in the detectable serum levels of antibiotic. When the data from two studies were pooled, there were significantly fewer episodes of hypoglycaemia in the treatment arm (typical RR 0.51, 95% CI 0.28 to 0.92). There was no statistically significant difference for mortality due to sepsis between the control and intervention group.

AUTHORS' CONCLUSIONS

Based on a small number of trials and neonates, antibiotic lock solution appeared to be effective in preventing CRBSI in the neonatal population. However, as each included study used a different antibiotics and antibiotic resistance could not be reliably assessed, the evidence to-date is insufficient to determine the effects of antibiotic lock on infections in neonates.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Biofilm-related infections: bridging the gap between clinical management and fundamental aspects of recalcitrance toward antibiotics

Surface-associated microbial communities, called biofilms, are present in all environments. Although biofilms play an important positive role in a variety of ecosystems, they also have many negative effects, including biofilm-related infections in medical settings. The ability of pathogenic biofilms to survive in the presence of high concentrations of antibiotics is called "recalcitrance" and is a characteristic property of the biofilm lifestyle, leading to treatment failure and infection recurrence. This review presents our current understanding of the molecular mechanisms of biofilm recalcitrance toward antibiotics and describes how recent progress has improved our capacity to design original and efficient strategies to prevent or eradicate biofilm-related infections.

Sepsis in head and neck cancer patients treated with chemotherapy and radiation: Literature review and consensus

The reporting of infection/sepsis in chemo/radiation-treated head and neck cancer patients is sparse and the problem is underestimated. A multidisciplinary group of head and neck cancer specialists from Italy met with the aim of reaching a consensus on a clinical definition and management of infections and sepsis. The Delphi appropriateness method was used for this consensus. External expert reviewers then evaluated the conclusions carefully according to their area of expertise. The paper contains seven clusters of statements about the clinical definition and management of infections and sepsis in head and neck cancer patients, which had a consensus. Furthermore, it offers a review of recent literature in these topics.

Maintenance dialysis in developing countries

Patients with end-stage renal disease require renal replacement therapy with maintenance hemodialysis or chronic peritoneal dialysis while awaiting transplantation. In addition to economic issues and limited state funding for advanced health care, the lack of trained medical personnel contributes to scarce dialysis facilities for children in developing countries. The establishment and operation of a hemodialysis unit with multidisciplinary facilities is both cost- and labor-intensive. Hemodialysis is usually carried out three times a week in a hospital setting and affects the curricular and extracurricular activities of the patient. Chronic ambulatory or cyclic peritoneal dialysis is technically simpler and allows better nutrition and growth, but is expensive for the majority of patients who must pay out of their own pocket. Multiple initiatives to enhance the training of pediatricians and nurses in skills related to initiating and managing patients on maintenance dialysis have resulted in the improved survival of children with end-stage renal disease. Support from state governments and philanthropic institutions have helped in establishing pediatric nephrology units that are equipped to provide renal replacement therapy for children.

Wide Variability in the Use of Antimicrobial Lock Therapy and Prophylaxis among Infectious Diseases Consultants

We surveyed infectious diseases physicians to determine their practice patterns with regard to both antimicrobial lock prophylaxis and antimicrobial lock therapy. Antimicrobial lock prophylaxis is relatively uncommon; only 19% of infectious diseases physicians reported using it at least once. Although antimicrobial lock therapy is more commonly used, we found a significant variation in practice patterns.

Risk Factors for Central Line–Associated Bloodstream Infection in Pediatric Intensive Care Units

Objective.

We sought to identify risk factors for central line-associated bloodstream infection (CLABSI) to describe children who might benefit from adjunctive interventions.

Design.

Case-control study of children admitted to the medical-surgical intensive care unit (ICU) or cardiac ICU from January 1, 2004, through December 31, 2007.

Setting.

Children's Hospital Boston is a freestanding, 396-bed quaternary care pediatric hospital with a 29-bed medical-surgical ICU and a 24-bed cardiac ICU.

Patients.

Case patients were patients with CLABSI who were identified by means of prospective surveillance. Control subjects were patients with a central venous catheter who were matched by ICU admission date.

Methods.

Multivariate conditional logistic regression models were used to identify independent risk factors for CLABSI and to derive and to validate a prediction rule.

Results.

Two hundred three case patients were matched with 406 control subjects. Independent predictors of CLABSI included duration of ICU central access (odds ratio [OR] for 15 or more days, 18.41 [95% confidence interval {CI} 4.10-82.56]; P < .001), central venous catheter placement in the ICU (OR for 2 or more ICU-placed catheters, 8.63 [95% CI, 2.63-28.38]; P = .001), nonoperative cardiovascular disease (OR, 7.44 [95% CI, 2.13-25.98]; P = .012), presence of gastrostomy tube (OR, 3.48 [95% CI, 1.55-7.79]; P = .003), receipt of parenteral nutrition (OR, 3.12 [95% CI, 1.55-6.32]; P= .002), and receipt of blood transfusion (OR, 2.55 [95% CI, 1.21-5.36]; P = .014). By use of risk factors known before central venous catheter placement, our model predicted CLABSI with a positive predictive value of 54% and a negative predictive value of 79%.

Conclusions.

Duration of central access, receipt of parenteral nutrition, and receipt of blood transfusion were confirmed as risk factors for CLABSI among children in the ICU. Newly identified risk factors include presence of gastrostomy tube, nonoperative cardiovascular disease, and ICU placement of central venous catheter. Children with these risk factors may be candidates for adjunctive interventions for CLABSI prevention.

Antibiotic lock therapy: review of technique and logistical challenges

Antibiotic lock therapy (ALT) for the prevention and treatment of catheter-related bloodstream infections is a simple strategy in theory, yet its real-world application may be delayed or avoided due to technical questions and/or logistical challenges. This review focuses on these latter aspects of ALT, including preparation information for a variety of antibiotic lock solutions (ie, aminoglycosides, beta-lactams, fluoroquinolones, folate antagonists, glycopeptides, glycylcyclines, lipopeptides, oxazolidinones, polymyxins, and tetracyclines) and common clinical issues surrounding ALT administration. Detailed data regarding concentrations, additives, stability/compatibility, and dwell times are summarized. Logistical challenges such as lock preparation procedures, use of additives (eg, heparin, citrate, or ethylenediaminetetraacetic acid), timing of initiation and therapy duration, optimal dwell time and catheter accessibility, and risks of ALT are also described. Development of local protocols is recommended in order to avoid these potential barriers and encourage utilization of ALT where appropriate.

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.

Antibiotic-lock therapy for long-term catheter-related bacteremia: a review of the current evidence

Catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and mortality, especially among patients receiving hemodialysis, parenteral nutrition and chemotherapy. Antibiotic-lock therapy (ALT) represents a promising technique in the modern treatment of CRBSIs. In this review, we attempt to clarify the potential role of ALT in the treatment of long-term catheter-related bacteremia, based on the available evidence from published studies reporting on this issue. We identified 28 articles that were considered appropriate to be included in our review, only three of which were comparative studies. There is some evidence that ALT administered concurrently with systemic therapy may represent a significant therapeutic approach for CRBSIs involving long-term catheters. Prolonged infection-free catheter survival in the reported series is suggestive of sterilization of the catheters by ALT. The only reported comparison shows better outcome with ALT than with catheter exchange. Immunodeficient states, such as HIV, and the use of totally implanted devices instead of tunneled catheters may predispose to CRBSI treatment failure. No serious adverse effects, such as emergence of resistance or increased infectious complications, were found to be associated with the use of ALT in the reviewed studies. However, more comparative studies should be performed to examine this important therapeutic issue further.

Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology

BACKGROUND

Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted.

PATIENTS AND METHODS

A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held.

RESULTS

Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients.

Clinical practice guidelines--Nursing management for pediatric patients with small bowel or multivisceral transplant

PURPOSE

Small bowel or multivisceral transplant is a relatively new treatment for irreversible intestinal damage, and no published practice guidelines exist. The purpose of this article is to report evidence regarding the best plan of care to achieve adequate nutrition and appropriate development for children.

DESIGN AND METHODS

An integrative review was conducted with 54 articles related to management of this transplant population. A nine-member nursing team integrated the findings.

PRACTICE IMPLICATIONS

This resulting guideline represents the best research and best practices on which to base staff education and competency validations to manage this medically fragile patient population.

Central venous catheters and catheter locks in children with cancer: a prospective randomized trial of taurolidine versus heparin

BACKGROUND

To determine if the catheter lock taurolidine can reduce the number of catheter-related bloodstream infections (CRBSI) in pediatric cancer patients with tunneled central venous catheters (CVC).

PROCEDURE

During a study period of 34 months, 129 newly placed tunneled CVCs in 112 patients were randomly assigned to standard lock with heparin solution or experimental lock with a taurolidine solution (ClinicalTrials.gov Identifier NCT00735813).

RESULTS

Sixty-five CVCs were included in the standard group and 64 CVCs in the experimental group. The groups were comparable regarding patients' characteristics. A total number of 72 bloodstream infections of which 33 were CRBSIs were observed during 39,127 CVC-days. A lower rate of CRBSI (0.4 per 1,000 CVC-days) was observed in the experimental arm compared with the standard arm (1.4 per 1,000 CVC-days, incidence rate ratio (IRR) = 0.26; 95% confidence interval (CI) 0.09-0.61; P = 0.001). A lower rate of total bloodstream infections (1.2 per 1,000 CVC-days) was also observed in the experimental arm compared with the standard arm (2.5 per 1,000 CVC-days, IRR = 0.49; 95% CI 0.29-0.82; P = 0.004). Median interval from catheter insertion until first CRBSI was significantly lower in the standard group (156 days, range 12-602) compared with the experimental group (300 days, range 12-1,176; P = 0.02). Premature removal of the CVC due to infection and overall CVC survival were similar in the two study groups.

CONCLUSION

Locking of long-term tunneled CVC with taurolidine significantly reduces catheter-related bloodstream infections in children with cancer.

[Indications, technique and complications of port implantation]

Implanted central venous access devices are becoming increasingly more important in oncology as an important tool for therapists and patients. As an intracorporeal system with reduced risk of infection compared to percutaneous tunnelled catheters they ensure a permanent and safe access to the central venous system. However, they can be associated with risks and sometimes severe complications which should not be underestimated so that planning and performance of the implantation require a high level of care and attention. Postoperative care and the correct allocation of all groups of persons involved in the therapy can reduce complication rates and are thus of prognostic relevance.

Antibiotic and other lock treatments for tunnelled central venous catheter-related infections in children with cancer

BACKGROUND

The risk of developing a tunnelled central venous catheter (CVC)-related infection ranges between 0.1 and 2.3 per 1000 catheter days for children with cancer. These infections are difficult to treat with systemic antibiotics (salvage rate 24% - 66%) due to biofilm formation in the CVC. Lock treatments can achieve 100 - 1000 times higher concentrations locally without exposure to high systemic concentrations.

OBJECTIVES

Our objective was to investigate the efficacy of antibiotic and other lock treatments in the treatment of CVC-related infections in children with cancer compared to a control intervention. We also assessed adverse events of lock treatments.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 3, 2011), MEDLINE/PubMed (1945 to August 2011) and EMBASE/Ovid (1980 to August 2011). In addition we searched reference lists from relevant articles and the conference proceedings of the International Society for Paediatric Oncology (SIOP) (from 2006 to 2010), American Society of Clinical Oncology (ASCO) (from 2006 to 2010), the Multinational Association of Supportive Care in Cancer (MASCC) (from 2006 to 2011), the American Society of Hematology (ASH) (from 2006 to 2010) and the International Society of Thrombosis and Haematology (ISTH) (from 2006 to 2011). We scanned the ISRCTN Register and the National Institute of Health Register for ongoing trials (www.controlled-trials.com) (August 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing an antibiotic lock or other lock treatment (with or without concomitant systemic antibiotics) with a control intervention (other lock treatment with or without concomitant systemic antibiotics or systemic antibiotics alone) for the treatment of CVC-related infections in children with cancer. For the description of adverse events, cohort studies were also eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and performed 'Risk of bias' assessments of included studies. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Two RCTs evaluated urokinase lock treatment with concomitant systemic antibiotics (n = 56) versus systemic antibiotics alone (n = 48), and one CCT evaluated ethanol lock treatment with concomitant systemic antibiotics (n = 15) versus systemic antibiotics alone (n = 13). No RCTs or CCTs evaluating antibiotic lock treatments were identified. All studies had methodological limitations and clinical heterogeneity between studies was present. We found no evidence of significant difference between ethanol or urokinase lock treatments with concomitant systemic antibiotics and systemic antibiotics alone regarding the number of participants cured, the number of recurrent CVC-related infections, the number of days until the first negative blood culture, the number of CVCs prematurely removed, ICU admission and sepsis. Not all studies were included in all analyses. No adverse events occurred in the five publications of cohort studies (one cohort was included in two publications) assessing this outcome; CVC malfunctioning occurred in three out of five publications of cohort studies assessing this outcome.

AUTHORS' CONCLUSIONS

No significant effect of urokinase or ethanol lock in addition to systemic antibiotics was found. However, this could be due to low power or a too-short follow-up. The cohort studies identified no adverse events; some cohort studies reported CVC malfunctioning. No RCTs or CCTs were published on antibiotic lock treatment alone. More well-designed RCTs are needed to further explore the effect of antibiotic or other lock treatments in the treatment of CVC-related infections in children with cancer.

Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline

PURPOSE

To develop an evidence-based guideline on central venous catheter (CVC) care for patients with cancer that addresses catheter type, insertion site, and placement as well as prophylaxis and management of both catheter-related infection and thrombosis.

METHODS

A systematic search of MEDLINE and the Cochrane Library (1980 to July 2012) identified relevant articles published in English.

RESULTS

The overall quality of the randomized controlled trial evidence was rated as good. There is consistency among meta-analyses and guidelines compiled by other groups as well.

RECOMMENDATIONS

There is insufficient evidence to recommend one CVC type or insertion site; femoral catheterization should be avoided. CVC should be placed by well-trained providers, and the use of a CVC clinical care bundle is recommended. The use of antimicrobial/antiseptic-impregnated and/or heparin-impregnated CVCs is recommended to decrease the risk of catheter-related infections for short-term CVCs, particularly in high-risk groups; more research is needed. The prophylactic use of systemic antibiotics is not recommended before insertion. Data are not sufficient to recommend for or against routine use of antibiotic flush/lock therapy; more research is needed. Before starting antibiotic therapy, cultures should be obtained. Some life-threatening infections require immediate catheter removal, but most can be treated with antimicrobial therapy while the CVC remains in place. Routine flushing with saline is recommended. Prophylactic use of warfarin or low-molecular weight heparin is not recommended, although a tissue plasminogen activator (t-PA) is recommended to restore patency to occluded catheters. CVC removal is recommended when the catheter is no longer needed or if there is a radiologically confirmed thrombosis that worsens despite anticoagulation therapy.

Predictors of bloodstream infection associated with permanently implantable venous port in solid cancer patients

BACKGROUND

The purpose of this study is to characterize the risk factors of bloodstream infection (BSI) associated with the use of permanent implantable venous ports (Port-A) in solid cancer patients.

METHODS

Solid cancer patients implanted with a Port-A were prospectively observed for the occurrence of Port-A-associated BSI (PABSI), defined as BSI without other identifiable infection foci. A PABSI risk score was developed using the Cox proportional hazards model.

RESULTS

A total of 415 patients were registered; 88 PABSI episodes occurred in 58 patients (incidence1.05 per 1000 catheter-days). All but one patient had stage IV cancer. Independent predictors of PABSI occurrence included neutropenia, total parenteral nutrition (TPN), chronic steroid use, invasive procedures, postoperative antibiotics, and preoperative antibiotics. A PABSI risk score with a cut-off value of 0 (sensitivity 88.5%, specificity 64.3%) was defined for stage IV cancer patients as follows: neutropenia, +1.350; TPN, +1.256; chronic steroid use, +1.947; preoperative antibiotics, -0.970; postoperative antibiotics, +0.959; and invasive procedures, +1.098. The median PABSI-free survival was 4.47 months for patients with scores ≥ 0 but not reached for patients with scores <0 (P < 0.0001).

CONCLUSION

The PABSI risk score can assist in identifying high-risk solid cancer patients and may assist in designing future preventive strategies.

Sepsis syndrome, bloodstream infections, and device-related infections

The diagnosis of sepsis is challenging given the lack of appropriate diagnostic methods and the inaccuracy of diagnostic criteria. Early resuscitation, intravenous antibiotics, and source control are crucial in the management of septic patients. The treatment of catheter-related bloodstream infection (CRBSI) often comprises 1 to 2 weeks of intravenous antibiotics plus catheter removal. Infections related to surgical devices are more difficult to manage because they require longer duration of therapy and possibly multiple surgical procedures. This review represents an update on the diagnosis and management of sepsis, catheter-related blood stream infections and some clinically important device-related infections.

Central venous port-related infection in patients with malignant tumors: an observational study

PURPOSE

We evaluated the characteristics of central venous port (CVP)-related infection with microbiological assessments in patients with malignant tumors.

MATERIALS AND METHODS

In a prospective setting, patients with CVP for the treatment of malignant tumors were enrolled in this study. The incidence of CVP-related infection during three months was determined. Microbiological surveillance from skin swab was performed before and after CVP placement.

RESULTS

Fifty-nine patients were enrolled in this study, and 60 CVPs were implanted. Thirty-six (61%) patients had head and neck malignancies. Access route was subclavian vein in 43 (71.7%) CVPs and forearm vein in 17 (28.3%). CVP-related infection was observed in three (5.1%) patients: port-pocket infection in one and probable CVP-related infection in two patients, respectively. No definitive CVP-related bloodstream infection was observed. Before the placement of CVP, colonization at the insertion site was observed in ten subclavian CVP patients, while no colonization was observed in the forearm CVP patients. At 1 and 4 weeks, detection rates of colonization were also higher in subclavian CVP patients. No definitive relationship was demonstrated between skin colonization and clinical development of CVP-related infection.

CONCLUSION

The rate of CVP-related infection in this prospective evaluation in patients with malignant tumors was comparable to previous studies. Colonization of the skin was more prominent in the subclavian site than in the forearm site. Although skin colonization was not proven to be a risk factor of infection, these results may draw attention to the adequate maintenance of CVP. (

TRIAL REGISTRATION

UMIN000003664).

Prevention of bacterial infection in pediatric oncology: what do we know, what can we learn?

Bacterial sepsis continues to be a leading cause of morbidity and toxic death in children receiving intensive therapy for cancer. Empiric therapy for suspected infections and treatment of documented infections are well-established standards of care. The routine use of prophylactic strategies is much less common in pediatric oncology. This paper will review the current literature on the use and risks of antimicrobial prophylaxis as well as non-pharmacological methods for infection prevention and will address areas in need of further research.

Control of vascular access device associated bloodstream infection in a large London teaching hospital

We describe a quality improvement programme used in a large teaching hospital trust to reduce the number of hospital acquired blood stream infections (HA-BSI) relating to vascular devices. Our strategy included the appointment of a lead nurse whose role was to engage with clinicians, to develop guidelines, to standardise and facilitate good practice, to train to uniform standards, and to retain local ownership, while working to avoid risk compensation. Information was gathered using our laboratory data search system, as well as observation and audit of vascular access device practice. Vascular access device training became part of all induction and update programmes for clinical staff.The results showed a significant and sustained decline in frequency of patient episodes of HA-BSI. The numbers of patients from whom coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp., Klebsiella and Enterobacter spp. were isolated in any given month all declined significantly. The numbers of patients with positive blood cultures with Escherichia coli did not decline. The improvement has been sustained for more than 3.5 years. This study shows that when standardisation, facilitation and education are developed with stakeholder involvement, it is possible to achieve a sustained reduction in the incidence of vascular device associated infections.