Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device

The impact of central line bundles on the timing of catheter-associated bloodstream infections and their microbiological distribution in critically ill children

Catheter-associated bloodstream infection, also known as CLABSI, is the most serious consequence of central venous access devices. These infections increase the risk of mortality and morbidity. The use of central line bundles in clinical settings is increasing worldwide with the purpose of lowering the risk of catheter-associated bloodstream infections. In this study, we investigated the effect of implementing a central line bundle for the prevention of CLABSIs, the distribution of pathogens, and the duration of time it took for CLABSIs to develop in patients who had subclavian-inserted central venous catheters. This research project was a cross-sectional study investigation carried out in a pediatric tertiary teaching hospital. Participants consisted of children who had been admitted to the pediatric critical care unit with subclavian catheters during a period of 13 years. We compared the prebundle period with the bundle period for CLABSI specifically focusing on the time to infection, the number of polymicrobial infections, the proportion of Candida parapsilosis, and the percentage of Coagulase-negative staphylococci (CoNS). The "prebundle period" included the period from May 2007 to May 2013, and the "bundle period" included the period from June 2013 to June 2020. Throughout the course of the study, a total of 286 cases of CLABSI were documented. Among these patients, 141 (49.3%) had CLABSIs associated with subclavian catheters. During the prebundle period, 55 CLABSIs were diagnosed in 5235 central line days, with an overall rate of 10.5 CLABSIs per 1000 central line days; after the implementation of central line bundle, 86 CLABSIs were diagnosed in 12,450 CL days, with an overall rate of 3.6 CLABSIs per 1000 CL days. This showed a statistically significantly lower rate in the bundle period (p = 0.0126). In the prebundle period, the mean time to develop CLABSI was 15 days, whereas during the bundle period, the mean time to develop CLABSI was 27.9 days, a significantly longer time to onset (p = 0.001). While the percentage of other microorganisms was not statistically different between the prebundle and bundle periods (p > 0.05), the percentage of C. parapsilosis was significantly higher in the prebundle period (p = 0.001).   Conclusion: The results of this study imply that the use of central line bundles not only reduces the incidence of CLABSI but also delays the time to which CLABSI patients acquire an infection. In addition, as a direct consequence of the CLB, the number of CLABSIs caused by gram-positive cocci did not increase, while the proportion of CLABSIs caused by C. parapsilosis decreased. What is Known: • The most significant negative consequence of central venous access devices is catheter-associated bloodstream infections. • "Care bundles" for CLABSI prevention have been reported to reduce the CLABSI rate. What is New: • Consider what would happen if the "Care bundle" failed to prevent CLABSI. • The findings of this study imply that using central line bundles not only reduces the risk of CLABSI but also extends the time it takes for patients to develop CLABSI. While the number of CLABSIs caused by gram-positive cocci did not increase as a direct result of CLB, the rate of CLABSIs caused by C. parapsilosis, which has recently become a major problem, has decreased.

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.

Medical device-associated infections in the long-term care setting

Indwelling medical devices are increasingly used in long-term care facilities (LTCFs). These devices place residents at a heightened risk for infection and colonization and infection with multidrug-resistant organisms. Understanding the risk and pathogenesis of infection associated with commonly used medical devices can help facilitate appropriate therapy. Programs to minimize unnecessary use of indwelling medical devices in residents and maximize staff adherence to infection control and maintenance procedures are essential features of a LTCF infection prevention program. LTCFs that provide care for large numbers of residents with indwelling medical devices should routinely perform surveillance for device-related infections and develop systems for assessing the safety and efficacy of newly introduced device-related technology.

Health care-associated infection outbreak investigations by the Centers for Disease Control and Prevention, 1946-2005

Since 1946, Centers for Disease Control and Prevention (CDC) personnel have investigated outbreaks of infections and adverse events associated with delivery of health care. CDC Epidemic Intelligence Service officers have led onsite investigations of these outbreaks by systematically applying epidemiology, statistics, and laboratory science. During 1946-2005, CDC Epidemic Intelligence Service officers conducted 531 outbreak investigations in facilities across the United States and abroad. Initially, the majority of outbreaks involved gastrointestinal tract infections; however, in later years, bloodstream, respiratory tract, and surgical wound infections predominated. Among pathogens implicated in CDC outbreak investigations, Staphylococcus aureus, Enterococcus species, Enterobacteriaceae, nonfermentative Gram-negative bacteria, or yeasts predominated, but unusual organisms (e.g., the atypical mycobacteria) were often included. Outbreak types varied and often were linked to transfer of colonized patients or health care personnel between facilities (multihospital outbreaks), national distribution of contaminated products, use of invasive medical devices, or variances in practices and procedures in health care environments (e.g., intensive care units, water reservoirs, or hemodialysis units). Through partnerships with health care facilities and local and state health departments, outbreaks were terminated and lives saved. Data from investigations invariably contributed to CDC-generated guidelines for prevention and control of health care-associated infections.

A prospective clinical trial on prevention of catheter contamination using the hub protection cap for needleless injection device

BACKGROUND

Catheter hub contamination has been recognized as a source of catheter-related bloodstream infections. We have investigated the efficacy of a protection cap for a needleless injection device in preventing intraluminal catheter contamination, compared with a conventional 3-way stopcock.

METHODS

Adult patients requiring an intravascular catheter placement for at least 48 hours in an intensive care unit were randomly assigned to receive either the needleless injection device with protection cap (test group, n = 31, number of devices = 151) or with a conventional 3-way stopcock (comparator group, n = 33, number of devices = 179). To evaluate intraluminal contamination, we examined the bacteria isolated in the inline bacterial filters, which were attached downstream of the injection ports.

RESULTS

The incidence of bacterial contamination was significantly different between the groups (test group 2/151 (1.3%) vs comparator group 11/179 (6.2%), P = .04). There was no correlation between the microbial contamination rate and the in situ time of catheter or numbers of injections.

CONCLUSION

The protection cap for needleless injection devices decreased microbial transfer from the injection port to the intraluminal fluid pathway and lowered the risk of catheter-related bloodstream infections.

Blood drawn through valved catheter hub connectors carries a significant risk of contamination

Infection Control became concerned when bloodstream infection (BSI) rates increased after implementing a needleless valved hub connector. During a 21-month period three different needleless catheter hub connectors were evaluated by quantitatively culturing blood drawn through hub connectors that would have ordinarily been discarded (DBC). DBC drawn through Clearlink™ catheter hub connectors were found to be twice as likely to be positive as DBC drawn through Clave® or Q-syte™ hub connectors (P < 0.04). DBC grew pathogens 46% of the time and skin organisms 54% of the time. Patients with positive DBC were three times more likely to meet Centers for Disease Control (CDC) BSI criteria by DBC cultures than by physician-ordered blood cultures (CBC; P < 0.001). For patients growing pathogens in DBC, 64% had no CBC drawn, the average temperature was lower than for patients with pathogens in CBC (99.3 ± 1.5 ve 100.6 ± 1.9, P = 0.015), and 92% of discharged patients (11 out of 12) were not treated with an antibiotic active against the DBC pathogen. Drawing BC through a catheter hub connector carries a risk of false-positives that could increase BSI rates by up to 3-fold. Further work is necessary to evaluate this concern.

The effects of needleless connectors on catheter-related bloodstream infections

Needleless connectors, including the standard split septum and the luer-activated mechanical valve connectors, have been introduced into clinical practice to eliminate the risk of needlestick injuries by avoiding the use of needles when accessing the intravascular catheters. Negative and positive displacement mechanical valves have been associated with increased rates of catheter-related bloodstream infections as compared with split septum connectors. Based on available data, split septum connectors should be preferentially used instead of mechanical valves. Adequate disinfection by scrubbing the access port preferably with chlorhexidine is recommended to minimize the risk of catheter microbial contamination along with proper infection control practices. Large prospective randomized clinical trials are needed to evaluate further the possible causes and effects of different types of mechanical valve needleless connectors on bloodstream infections.

Decreasing central line associated bloodstream infection in neonatal intensive care

Central Line Associated Bloodstream Infections (CLABSIs) have come to be recognized as preventable adverse events that result from lapses in technique at multiple levels of care. CLABSIs are associated with increased mortality and adverse outcomes that may have lifelong consequences. This review provides a summary of evidence-based strategies to reduce CLABSI in the newborn intensive care unit that have been described in the literature over the past decades. Implementation of these strategies in "bundles" is also discussed, citing examples of successful quality improvement collaboratives. The methods of implementation require an understanding of the scientific data and technical developments, as well as knowledge of how to influence change within the unique and complicated milieu of the newborn intensive care unit.

Gram-negative bloodstream infections in hematopoietic stem cell transplant patients: the roles of needleless device use, bathing practices, and catheter care

BACKGROUND

Between August 1 and October 30, 1998 (outbreak period), an increased incidence of central venous catheter (CVC)-associated gram-negative bacterial bloodstream infection (GN-BSI) was detected in hematopoietic stem cell transplantation (HSCT) candidates and recipients in an outpatient HSCT unit. The objectives of the present study were to determine strategies for controlling the outbreak and identify risk factors for GN-BSI.

METHODS

Two case-control studies, an assessment of infection control practices, microbiologic studies, and water quality analysis were conducted. A case was defined as any outpatient with a CVC and a primary GN-BSI during the outbreak period.

RESULTS

All of the 31 case patients identified had needleless intravenous (IV) access devices. Independent risk factors for CVC-associated GN-BSI were self-administered IV infusion (odds ratio [OR] = 6.2; P = .02), lower frequency of needleless device changes (OR = 15.2; P = .03), and more frequent baths (OR = 1.4; P = .05). Interventions included increased frequency of needleless device change, recommending showers rather than baths, and use of CVC protection during showering/bathing. After these interventions, the CVC-associated GN-BSI rate declined to below the preoutbreak period rate (2.1/1000 vs 0.3/1000 CVC-days; P < .01).

CONCLUSIONS

This study demonstrated an increased risk of CVC-associated GN-BSIs related to self-IV infusion, bathing habits, and frequency of needleless device change. Infection control practices associated with the use of needleless devices may expose susceptible patients to increased risk for BSI.

Preventing central venous catheter-associated bloodstream infections: development of an antiseptic barrier cap for needleless connectors

BACKGROUND

Reports of outbreaks associated with the use of needle-free valve connectors suggest 2 common risk factors: (1) poor adherence to disinfection practices before use and (2) a design that allows contamination when not in use. Swabbing a membranous septum with 70% isopropyl alcohol may not eliminate septal surface contamination. Frequent access through and handling of needle-free connectors also puts patients at increased risk of central venous catheter-related bloodstream infections (CR-BSIs). A novel antiseptic barrier cap has been designed to maintain health care worker safety and eliminate the vulnerabilities of existing systems to contamination and CR-BSIs for patients at risk.

METHODS

A prospective in vitro study compared the effectiveness of standard disinfection of needleless luer-activated valve connectors with 70% isopropyl alcohol and the effectiveness of an antiseptic barrier cap that, when threaded onto a luer-activated connector, rapidly sterilizes a heavily contaminated surface. Standard disinfection was done by 3- to 5-second swabbing using a sterile commercial pledget of 70% isopropyl alcohol. The antiseptic barrier cap comprises an outer cap with internal female threads and a spike inside the closed end, a capsule containing 0.25 mL of 2% chlorhexidine gluconate in 70% isopropyl alcohol, and a sponge between the septum and the capsule. When the cap is threaded onto a luer-adaptable needleless connector, the spike ruptures the capsule, saturating the sponge with the antiseptic.

RESULTS

All 15 (100%) of the precontaminated positive control connectors not disinfected before entry showed transmission of Enterococcus faecalis across the membranous septum (4500-28,000 colony-forming units), and 20 (67%) of 30 connectors disinfected with 70% alcohol showed transmission (442-25,000 colony-forming units). Of 60 needle-free connectors disinfected with the antiseptic barrier cap, 1 (1.6%) showed transmission (P < .001).

CONCLUSION

An antiseptic barrier cap was highly effective in sterilizing the septum of a needle-free valve connector and preventing entry of any microorganisms, even with heavy contamination of the septum. This new technology should now be evaluated in a clinical trial with CR-BSI as the primary outcome measure.

Clinical use of disinfectable needle-free connectors

BACKGROUND

In 1992, the United States Food and Drug Administration required health care services to adopt needle-free devices to prevent health care workers' exposure to bloodborne pathogens resulting from needlestick injuries, and several systems of disinfectable needle-free connectors (DNC) were introduced.

STUDIES

MICROBIAL COLONIZATION: Experimental studies showed that DNCs designed with a split septum (SS-DNCs) and mechanical valve systems (MLV-DNC) prevented endoluminal colonization as effectively as needles or conventional caps. A comparison of the microbiologic barrier effect of SS-DNCs, MLV-DNCs, and passive positive-pressure (PPV)-DNCs found that PPV-DNCs were least effective in providing protection under experimental conditions of poor handling practices and high microorganism concentrations. PREVENTION OF CATHETER-RELATED BLOODSTREAM INFECTIONS: Some randomized trials show a positive or neutral effect of DNC use on the prevention of catheter-related bloodstream infections (CR-BSIs); however, some investigators have reported outbreaks of CR-BSIs following the introductions of DNCs that could be related to noncompliance with DNC handling recommendations or the use of PPV-DNCs.

CONCLUSION

Strategies focused in the implication of the nurse staff in CRBSI surveillance increase compliance with DNC handling recommendations and minimize the risk of developing a CR-BSI. DNCs can be used safely if staff complies with recommendations for use.

Safety of positive-pressure valve connectors in arterial catheters inserted into critically ill patients

Needleless valve connectors were introduced to avoid needlestick injuries in healthcare workers but some concerns exist about their microbiological safety. A randomised controlled trial was performed to assess hub colonisation affecting positive-pressure valve connectors (PPVCs) compared to conventional caps used for radial arterial catheters inserted into critically ill patients. Patients were randomly assigned either to the PPVC (Smartsite Plus positive bolus valve) or to the conventional cap group. Only catheters inserted for >24h were analysed. Of 100 consecutive arterial lines, 80 were inserted for >24h (mean insertion duration 5.8 days), 41 in the PPVC group and 39 in the conventional cap group. Catheter hubs were colonised in eight cases in the control group (20.5%) and in one case in the PPVC group (2.4%). Hub colonisation was caused by coagulase-negative staphylococci in all cases. No attributable bacteraemia was observed. In multivariate analysis, PPVC (odds ratio: 0.09; 95% confidence interval: 0.1-0.79; P=0.03) and use of the line for continuous haemodynamic monitoring (0.16; 0.03-0.89; P=0.037) were independently associated with a lower incidence of hub colonisation.

Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve

BACKGROUND

Needleless intravascular catheter connector valves have been introduced into clinical practice to minimize the risk of needlestick injury. However, infection-control risks associated with these valves may be underappreciated. In March 2005, a dramatic increase in bloodstream infections was noted in multiple patient care units of a hospital in temporal association with the introduction of a needleless valve into use.

METHODS

Surveillance for primary bloodstream infection was conducted using standard methods throughout the hospital. Blood culture contamination rates were monitored. Cultures were performed using samples obtained from intravascular catheter connector valves.

RESULTS

The relative risk of bloodstream infection for the time period in which the suspect connector valve was in use, compared with baseline, was 2.79 (95% confidence interval, 2.27-3.43). In critical care units, the rate of primary bloodstream infection increased with the introduction of the valve from 3.87 infections per 1000 catheter-days to 10.64 infections per 1000 catheter-days (P<.001), and it decreased to 5.59 infections per 1000 catheter-days (P=.02) in the 6 months following removal of the device from use. Similarly, in inpatient nursing units, the rate of bloodstream infection increased from 3.47 infections per 1000 catheter-days to 7.3 infections per 1000 catheter-days (P=.02) following introduction of the device, and it decreased to 2.88 infections per 1000 catheter-days (P=.57) following removal of the device from use. Similar events occurred in the cooperative care units. The rate of blood culture contamination did not substantially change over the course of the study. Of 37 valves that were subjected to microbiological sample testing, 24.3% yielded microbes, predominantly coagulase-negative staphylococci.

CONCLUSION

A significant association between primary bloodstream infection and a needleless connector valve was observed. Evaluation of needleless connector valves should include a thorough assessment of infection risks in prospective randomized trials prior to their introduction to the market.

Clinical review: new technologies for prevention of intravascular catheter-related infections

Intravascular catheters have become essential devices for the management of critically and chronically ill patients. However, their use is often associated with serious infectious complications, mostly catheter-related bloodstream infection (CRBSI), resulting in significant morbidity, increased duration of hospitalization, and additional medical costs. The majority of CRBSIs are associated with central venous catheters (CVCs), and the relative risk for CRBSI is significantly greater with CVCs than with peripheral venous catheters. However, most CVC-related infections are preventable, and different measures have been implemented to reduce the risk for CRBSI, including maximal barrier precautions during catheter insertion, catheter site maintenance, and hub handling. The focus of the present review is on new technologies for preventing infections that are directed at CVCs. New preventive strategies that have been shown to be effective in reducing risk for CRBSI, including the use of catheters and dressings impregnated with antiseptics or antibiotics, the use of new hub models, and the use of antibiotic lock solutions, are briefly described.

A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study

Hub colonization and subsequent intraluminal progression due to frequent opening and manipulation of intravenous systems is the cause of many catheter-related infections (CRI). A prospective, comparative, randomized study was performed to assess a new closed-needleless hub device (CLAVE) compared with conventional open systems (COS). End-points were hub and skin colonization, catheter tip colonization, catheter-related bloodstream infection (CRBSI) and number of accidental needlesticks. All cultures were processed following standard semiquantitative microbiological techniques. The study involved patients who underwent heart surgery over an 11-month period in a post-surgical ICU. During the study period, 352 patients underwent major heart surgery and 1774 catheters were inserted. Overall, 865 catheters in 178 patients were allocated to the CLAVE system and 909 catheters in 174 patients to COS. The groups were similar regarding underlying conditions and risk factors for infection. Comparison of endpoint results in CLAVE and COS groups was as follows: incidence density per 1000 catheter-days of tip colonization: 59.2 versus 83.6 (P=0.003); of hub colonization: 7.56 versus 24.66 (P=0.0017); of skin colonization: 41.5 versus 58.9 (P=0.038); and of CRBSI 3.78 versus 5.89 (P=0.4). There was one accidental needlestick and one catheter-related prosthetic endocarditis in the COS group. Multivariate analysis showed that CLAVE use was an independent protective factor for tip colonization. CLAVE offered significant protection from catheter-tip and hub colonization.

A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector

The microbial contamination rate of luers of central venous catheters (CVCs) with either PosiFlow needleless connectors or standard caps attached was investigated. The efficacy of 70% (v/v) isopropyl alcohol, 0.5% (w/v) chlorhexidine in gluconate 70% (v/v) isopropyl alcohol and 10% (w/v) aqueous povidone-iodine to disinfect the intravenous connections was also assessed. Seventy-seven patients undergoing cardiac surgery who required a CVC as part of their clinical management were randomly allocated either needleless connectors or standard caps. Patients were also designated to receive chlorhexidine/alcohol, isopropyl alcohol or povidone-iodine for pre-CVC insertion skin preparation and disinfection of the connections. After 72 h in situ the microbial contamination rate of 580 luers, 306 with standard caps and 274 with needleless connectors attached, was determined. The microbial contamination rate of the external compression seals of 274 needleless connectors was also assessed to compare the efficacy of the three disinfectants. The internal surfaces of 55 out of 306 (18%) luers with standard caps were contaminated with micro-organisms, whilst only 18 out of 274 (6.6%) luers with needleless connectors were contaminated (P<0.0001). Of those needleless connectors disinfected with isopropyl alcohol, 69.2% were externally contaminated with micro-organisms compared with 30.8% disinfected with chlorhexidine/alcohol (P<0.0001) and 41.6% with povidone-iodine (P<0.0001). These results suggest that the use of needleless connectors may reduce the microbial contamination rate of CVC luers compared with the standard cap. Furthermore, disinfection of needleless connectors with either chlorhexidine/alcohol or povidone-iodine significantly reduced external microbial contamination. Both these strategies may reduce the risk of catheter-related infections acquired via the intraluminal route.

Comparison of US and non-US central venous catheter infection rates: evaluation of processes and indicators in infection control study

OBJECTIVE

We sought to identify the presence or absence of international variation in central venous catheter-associated bloodstream infection (BSI) rates and to examine associated infection control practices that might underlie the differences.

DESIGN

The Evaluation of Processes and Indicators in Infection Control (EPIC) study was conducted as a prospective surveillance study.

SETTINGS

The study took place in intensive care units (ICUs) from 14 countries, which were from the Asian Pacific (3), Europe (7), Middle East (2), and South America (2), in addition to 41 US hospitals.

METHODS

We compared the National Nosocomial Infections Surveillance catheter-associated BSI rate between the non-US and US units. We also compared the following organization factors between the 2 groups: hospital factors (ownership, average daily census of patients); ICU type (medical vs surgical); number of beds; and infection control-related factors (number of staff, number of hours spent on study ICU surveillance, years of experience, number of inservice sessions on line infection, number of blood cultures drawn/1000 patients).

RESULTS

We found no significant difference in catheter-associated BSI rates between non-US and US hospitals (5.02 +/- 0.75 vs 3.82 +/- 0.42/1000 days, respectively; P =.27). Non-US hospitals were more likely to be government-owned (10/14 vs 7/41;P <.001) and to have larger daily patient census (795 +/- 84 vs 276 +/- 47 patients; P <.001). There was no difference in ICU type or number of beds. Infection control committees were present in all US and non-US hospitals. No significant differences were found in the number of staff involved in surveillance in the study ICU, years of experience, hours spent on surveillance, or the provision of inservices on line care. The use of barriers during line insertion also did not differ.

CONCLUSIONS

Catheter-associated BSIs in patients in the ICU were not significantly different between non-US and US hospitals. All hospitals had infection control committees, and there were no significant differences in time spent and numbers of persons involved in ICU surveillance activities. These findings suggest that many aspects of the standards of care do not differ between the 2 groups.

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

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