Catheter infection. A comparison of two catheter maintenance techniques

Intravenously Infused Stem Cells for Cancer Treatment

Despite the recent influx of immunotherapies and small molecule drugs to treat tumors, cancer remains a leading cause of death in the United States, in large part due to the difficulties of treating metastatic cancer. Stem cells, which are inherently tumoritropic, provide a useful drug delivery vehicle to target both primary and metastatic tumors. Intravenous infusions of stem cells carrying or secreting therapeutic payloads show significant promise in the treatment of cancer. Stem cells may be engineered to secrete cytotoxic products, loaded with oncolytic viruses or nanoparticles containing small molecule drugs, or conjugated with immunotherapies. Herein we describe these preclinical and clinical studies, discuss the distribution and migration of stem cells following intravenous infusion, and examine both the limitations of and the methods to improve the migration and therapeutic efficacy of tumoritropic, therapeutic stem cells.

Practice Guidelines for Central Venous Access 2020

These practice guidelines update the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the American Society of Anesthesiologists in 2011 and published in 2012. These updated guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist and may also serve as a resource for other physicians, nurses, or healthcare providers who manage patients with central venous catheters.

Supplemental Digital Content is available in the text.

Guideline for Prevention of Intravascular-Device–Related Infections

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

Effect of Nurse Staffing and Antimicrobial-Impregnated Central Venous Catheters on the Risk for Bloodstream Infections in Intensive Care Units

Background:

Defining risk factors for central venous catheter (CVC)-associated bloodstream infections (BSIs) is critical to establishing prevention measures, especially for factors such as nurse staffing and antimicrobial-impregnated CVCs.

Methods:

We prospectively monitored CVCs, nurse staffing, and patient-related variables for CVC-associated BSIs among adults admitted to eight ICUs during 2 years.

Results:

A total of 240 CVC-associated BSIs (2.8%) were identified among 4,535 patients, representing 8,593 CVCs. Antimicrobial-impregnated CVCs reduced the risk for CVC-associated BSI only among patients whose CVC was used to administer total parenteral nutrition (TPN, 2.6 CVC-associated BSIs per 1,000 CVC-days vs no TPN, 7.5 CVC-associated BSIs per 1,000 CVC-days;P= .006). Among patients not receiving TPN, there was an increase in the risk of CVC-associated BSI in patients cared for by “float” nurses for more than 60% of the duration of the CVC. In multivariable analysis, risk factors for CVC-associated BSIs were the use of TPN in non-antimicrobial-impregnated CVCs (P= .0001), patient cared for by a float nurse for more than 60% of CVC-days (P= .0019), no antibiotics administered to the patient within 48 hours of insertion (P= .0001), and patient unarousable for 70% or more of the duration of the CVC (P= .0001). Peripherally inserted central catheters (PICCs) were associated with a lower risk for CVC-associated BSI (P= .0001).

Conclusions:

Antimicrobial-impregnated CVCs reduced the risk of CVC-associated BSI by 66% in patients receiving TPN. Limiting the use of float nurses for ICU patients with CVCs and the use of PICCs may also reduce the risk of CVC-associated BSI.

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.

The microbiological and clinical outcome of guide wire exchanged versus newly inserted antimicrobial surface treated central venous catheters

INTRODUCTION

The management of suspected central venous catheter (CVC)-related sepsis by guide wire exchange (GWX) is not recommended. However, GWX for new antimicrobial surface treated (AST) triple lumen CVCs has never been studied. We aimed to compare the microbiological outcome of triple lumen AST CVCs inserted by GWX (GWX-CVCs) with newly inserted triple lumen AST CVCs (NI-CVCs).

METHODS

We studied a cohort of 145 consecutive patients with GWX-CVCs and contemporaneous site-matched control cohort of 163 patients with NI-CVCs in a tertiary intensive care unit (ICU).

RESULTS

GWX-CVC and NI-CVC patients were similar for mean age (58.7 vs. 62.2 years), gender (88 (60.7%) vs. 98 (60.5%) male) and illness severity on admission (mean Acute Physiology and Chronic Health Evaluation (APACHE) III: 71.3 vs. 72.2). However, GWX patients had longer median ICU lengths of stay (12.2 vs. 4.4 days; P < 0.001) and median hospital lengths of stay (30.7 vs. 18.0 days; P < 0.001). There was no significant difference with regard to the number of CVC tips with bacterial or fungal pathogen colonization among GWX-CVCs vs. NI-CVCs (5 (2.5%) vs. 6 (7.4%); P = 0.90). Catheter-associated blood stream infection (CA-BSI) occurred in 2 (1.4%) GWX patients compared with 3 (1.8%) NI-CVC patients (P = 0.75). There was no significant difference in hospital mortality (35 (24.1%) vs. 48 (29.4%); P = 0.29).

CONCLUSIONS

GWX-CVCs and NI-CVCs had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk receiving AST CVCs GWX may be an acceptable initial approach to line insertion.

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

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

Central venous catheter use in the pediatric patient: mechanical and infectious complications

OBJECTIVE

Following the introduction and widespread use of central venous catheters (CVCs) in adults, these devices are being used with increasing frequency in the pediatric population. This review will focus on differences between adults and children regarding CVC use and its potential complications. Both mechanical and infectious complications will be discussed.

DATA SOURCES

Systematic review of the literature.

CONCLUSIONS

CVC-related complications in pediatric patients are closely linked to age, body size, and age-related immune status. In older children, many complications are similar to those encountered in adult patients. Because of ongoing growth and body changes, a cutoff point beyond which children can be regarded as "young adults" is difficult to define; many of our recommendations are therefore age-related. More frequently than in adults, an implanted port may be the first choice in pediatric patients when long indwelling times are expected. The optimal site of insertion also depends on factors such as the patients' age as well as the need for sedation and analgesia during the insertion procedure. In contrast to guidelines in adult patients, we recommend that a radiograph always be made following CVC insertion to check the position of the catheter. Regarding prevention of infectious complications, we recommend full sterile barrier precautions during CVC insertion and strict protocols for catheter care. CVCs should be removed as soon as possible when they are no longer needed, but there is no place for elective CVC replacement on a routine basis. New developments such as the use of impregnated catheters might help reduce infection rates; however, additional research will be required to provide more evidence of benefit in the pediatric population.

A prospective, randomized study in critically ill patients using the Oligon Vantex® catheter

Microbial colonization and the incidence of catheter-related bloodstream infections (CR-BSI) associated with Oligon Vantex silver central venous catheters (CVC) in critically ill patients were determined. A prospective, randomized, controlled 17-month trial was carried out in an intensive care unit (ICU). All patients requiring a triple-lumen CVC for four days or longer were enrolled. Patients were randomized to receive a standard polyurethane CVC or an Oligon Vantex silver CVC. Before removal of the catheter either due to discharge from the ICU or suspected infection, blood for cultures was taken via the CVC and a peripheral site. Skin and hub swabs and catheter-tips were also cultured. Two hundred and six catheters, 103 in both groups, were evaluated. In the control group (CG) 45/103 (44%) and in the silver group (SG) 30/103 (29%) were colonized or had a CR-BSI (P=0.04). The SG was less likely to be colonized than the CG when the catheter remained in situ for eight days or less (P=0.03) or over 15 days (P=0.01); a second or subsequent catheter was present in the same patient (P=0.002), or if the CVC was placed in the internal jugular vein (P=0.05). Multivariate logistic-regression showed predisposing factors for catheter colonization were jugular and femoral sites, second or subsequent catheter, and being a member of the CG. CR-BSI occurred in five cases (four in CG). Rates of CR-BSI per 1000 catheter-days in the CG were 2.8 and in the SG, 0.8 (P<0.001). The Oligon Vantex silver catheter reduced the incidence of catheter-colonization and may decrease the risk of CR-BSI.

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

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

Preventing vascular catheter-related infections: current controversies

Prevention of vascular catheter-related infection remains an important priority. This review focuses on salient controversies regarding optimal preventive methods. Intensity of surveillance for nosocomial infections was the single most important predictor of prevention in the Study of the Efficacy of Nosocomial Infection Control (SENIC). Used suboptimally by most hospitals in the SENIC study, surveillance is probably conducted even less today. There has been one randomized trial of the optimal method of aseptic insertion for central venous catheters and none comparing the 2 most frequently used sites. Scheduled replacement did not prevent infection in multiple randomized trials but, according to a recent survey, was still being used frequently. Chlorhexidine preparation of skin before and during catheterization has significantly reduced colonization of catheters in multiple randomized trials and should be used. Impregnation of catheter and/or hub surfaces with antiseptics raises less concern about fostering the development of antibiotic resistance than does the use of antibiotics for this purpose.

Reducing central venous catheter infections

This article reviews the current literature in relation to the management of central venous catheters and the prevention of catheter related infection. Sources and factors influencing catheter related infection are reviewed. In some areas of catheter management, there are clear recommendations such as the choice of skin preparation and catheter site. Other areas don't have clear guidelines; this results in varying practices and the need for further research. The latest research has been in the areas of impregnated catheters with studies showing some benefits. Recent research has also analysed the effect of the method of fluid and line changes as well as their frequency in relation to catheter related infections. A summary is given outlining interventions which have evidence supporting their practice in the reduction of catheter related infections along with interventions which may be effective in reducing catheter related infection and the need for further research.

Managing central venous catheters: a prospective randomised trial of two methods

A randomised, prospective study was conducted to evaluate the impact on central venous catheter (CVC) infection when fluids and lines connected to a CVC were changed using a 'sterile' compared to an 'aseptic, non-touch' technique. The study sought to determine whether there were any differences in CVC tip colonisation (CTC) or CVC-related bacteraemia (CRB) as a result of the technique used for fluid and line changes. In the sterile technique (control) group, fluids and tubing were changed using full sterile technique. In the aseptic, non-touch (experimental) group, fluids and tubing attached to the CVC were changed using only a small sterile drape and a 2-minute clinical hand wash. When the CVC was removed, the tip was sampled and cultured using the semi-quantitative method. Blood cultures were also collected. In all, 111 samples from 79 patients were included in the trial: 61 in the sterile technique group and 50 in the non-touch, aseptic technique group. Results showed a CTC rate of 31 per cent in the control group and 14 per cent in the experimental group, while the CRB rate was 8.2 per cent and 6 per cent respectively. The most common organisms cultured were Staphylococcus aureus and S. epidermis respectively. This study indicates that it is safe to change fluids and lines attached to CVCs using the aseptic, non-touch technique, which has resulted in significant financial savings through less use of equipment and less nursing time required to perform fluid and line changes.

Dialysis and central venous catheter infections in critically ill patients: results of a prospective study

OBJECTIVE

To determine the incidence of dialysis catheter (DC)-related infections in intensive care unit (ICU) patients, and to compare the frequency of DC and central venous catheter (CVC) infections in an ICU setting.

DESIGN

Prospective, descriptive survey.

SETTING

An adult, 10-bed medical/surgical ICU at a university hospital.

PATIENTS

A total of 151 DCs and 230 CVCs placed in 170 patients were evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Catheter colonization was defined by a quantitative catheter tip culture yielding > or =10(3) colony-forming units/mL, catheter-related bacteremia was defined as catheter colonization and blood culture positive for the same organism, and site infection was defined as the presence of pus at the insertion site. The mean duration of catheterization was 6.8+/-6 days for DCs and 5.9+/-4.6 for CVCs (p = .52). There was no difference between DCs and CVCs in catheter colonization and catheter-related bacteremia incidence rates per 1000 days of catheter use (24.2 vs. 19.8 [p = .46] and 0.96 vs. 1.5 [p = .60], respectively). Site infection was observed in one patient (CVC placement). For DCs and CVCs the duration of catheterization was associated with catheter infection (p = .0007 and p = .04, respectively), but when the catheters were examined over 5-day intervals, the incidence of catheter infections did not increase with duration of catheter use (p = .23 and p = .10, respectively).

CONCLUSIONS

DC-related infections are associated with DC longevity. As shown by the 5-day-interval analysis, the incidence of DC-related infections did not increase with DC duration, suggesting that the risk for DC-related infections remained unchanged with time. The characteristics of DC-related infections in ICU patients were comparable to those previously reported for CVC-related infections.

Catheter-Related Bloodstream Infection

Central venous catheters are associated with the vast majority of nosocomial, catheter-related bloodstream infections (CR-BSI). Despite identification of multiple effective methods for preventing CR-BSI, it remains an important clinical problem. Catheters coated with anti-infective substances, such as chlorhexidine and silver sulfadiazine or rifampin and minocycline, have shown promising results in recent clinical trials, but confirmatory studies by different investigators are still needed. Concern has also been raised about widespread use of clinically important antibiotics on catheter surfaces, which may promote the development of antibiotic resistance. More accurate and cost-effective methods of diagnosing CR-BSI are desirable. Recent studies have evaluated endoluminal brush sampling and differential blood culture growth rates, which may provide acceptable accuracy without requiring removal of long-dwelling catheters, but the accuracy of these techniques needs to be confirmed in other studies.

Central venous catheter replacement strategies: a systematic review of the literature

OBJECTIVE

To evaluate the effect of guidewire exchange and new-site replacement strategies on the frequency of catheter colonization and infection, catheter-related bacteremia, and mechanical complications in critically ill patients.

DATA SOURCES

We searched for published and unpublished research by means of MEDLINE and Science Citation Index, manual searching of Index Medicus, citation review of relevant primary and review articles, review of personal files, and contact with primary investigators.

STUDY SELECTION

From a pool of 151 randomized, controlled trials on central venous catheter management, we identified 12 relevant randomized trials of catheter replacement over a guidewire or at a new site.

DATA EXTRACTION

In duplicate and independently, we abstracted data on the population, intervention, outcome, and methodologic quality.

DATA SYNTHESIS

As compared with new-site replacement, guidewire exchange is associated with a trend toward a higher rate of catheter colonization (relative risk 1.26, 95% confidence interval 0.87 to 1.84), regardless of whether patients had a suspected infection. Guidewire exchange is also associated with trends toward a higher rate of catheter exit-site infection (relative risk 1.52, 95% confidence interval 0.34 to 6.73) and catheter-related bacteremia (relative risk 1.72, 95% confidence interval 0.89 to 3.33). However, guidewire exchange is associated with fewer mechanical complications (relative risk 0.48, 95% confidence interval 0.12 to 1.91) relative to new-site replacement. Exchanging catheters over guidewires or at new sites every 3 days is not beneficial in reducing infections, compared with catheter replacement on an as-needed basis.

CONCLUSIONS

Guidewire exchange of central venous catheters may be associated with a greater risk of catheter-related infection but fewer mechanical complications than new-site replacement. More studies on scheduled vs. as-needed replacement strategies using both techniques are warranted. If guidewire exchange is used, meticulous aseptic technique is necessary.

Thrombotic, infectious, and procedural complications of the jugular bulb catheter in the intensive care unit

OBJECTIVE

An assessment of the thrombotic, infectious, and technical complications of continuous jugular bulb catheter monitoring in the intensive care unit (ICU) was made.

METHODS

Over a 1-year period, 44 patients suffering from traumatic brain injury, subarachnoid hemorrhage, or stroke received jugular bulb catheter monitoring in the ICU. They were followed for catheter insertion complications and the development of bacteremia. In 20 patients chosen randomly, an ultrasonographic evaluation was performed after removal of the catheter for an assessment of internal jugular vein thrombosis.

RESULTS

Of the 44 patients, 1 became bacteremic; the source was identified as a thoracostomy site. Among the complications related to the 44 catheter insertions, there were 2 instances of carotid artery puncture (4.5%), 1 misplaced catheter (thoracic placement), and 1 clinically insignificant hematoma. Of the 20 patients investigated with ultrasonography, 8 (40%) had nonobstructive, subclinical internal jugular vein thrombi after jugular bulb catheter monitoring (95% confidence interval, 19-61%). The median monitoring duration was 3 days (range, 1-6 d). No clinical factor was identified to be associated with thrombus formation.

CONCLUSION

We conclude the following: 1) the risk of bacteremia related to the jugular bulb catheter was negligible; 2) complications related to catheter insertion were rare and clinically insignificant; and 3) the incidence of subclinical internal jugular vein thrombosis after jugular bulb catheter monitoring is considerable. Although it is worthy to note this complication, no patient with a thrombus became symptomatic in the present series. The risk-benefit assessment of this monitoring technique must include consideration of subclinical thrombosis.

Management of catheter-related bacteremia and fungemia in patients on total parenteral nutrition

To diminish the risk of serious complications from catheter-related bacteremias or fungemias, an optimized diagnosis and antimicrobial therapy is essential and early catheter removal should be considered. Prompt removal of the catheter and targeted antimicrobial treatment remains a common approach for febrile episodes in patients on total parenteral nutrition. However, novel tools allow diagnosis of catheter-related infections with the catheter in situ. Moreover, many of the established catheter-related infections caused by coagulase-negative staphylococci can successfully be treated with the catheter still in place. The use of these advanced management options depends widely on the resource of the microbiology laboratory as well as the type of catheter and severity of the patient's disease.

Infectious rates of central venous pressure catheters: comparison between newly placed catheters and those that have been changed

OBJECTIVE

To analyze the rate of infection of de novo, guidewire exchanged, and new site replacement catheters in a cohort of patients in whom catheters were changed on the basis of the clinical discretion of the attending physicians.

DESIGN

We conducted an observational cohort study in catheterized patients in the intensive-care unit (ICU).

MATERIAL AND METHODS

ICU patients admitted between Jan. 1, 1991, and Dec.31, 1992, were eligible for enrollment in the study. Catheter care, replacement, and duration were prospectively documented. Catheter-related infection was prospectively evaluated. Rates of catheter-related infection were determined for de novo, guidewire exchanged, and new site replacement catheters and analyzed relative to the duration of placement of individual catheters and the total duration of central venous catheterization for a specific patient.

RESULTS

Fifty catheter-related infections developed in 2,470 patients. When the rate of catheter-associated infection was determined for each type of catheterization, de novo catheters had a lower observed rate of infection than either replacement type (P < or = 0.0001). After controlling for the effect of time, we found that the rate of catheter-related infections associated with a de novo catheter was less than the rate in guidewire exchanged catheters (P = 0.035). Rates of infection were similar between guidewire exchanged catheters and catheters replaced to a new site.

CONCLUSION

In a population of ICU patients in whom catheter change was governed by clinical judgement, no differences were noted between the observed rates of infection of new site replacement catheters and guidewire exchange catheters.

Care of central venous catheters for total parenteral nutrition

This report summarizes data obtained via a mailed questionnaire from 129 Department of Veterans Affairs (VA) hospitals regarding current practices in the care of central venous catheters (CVCs) used for total parenteral nutrition (TPN). The size of VA hospitals' acute medical-surgical beds ranged from 14 to 1320 (median 168) beds. Over 6000 patients annually received CVCs for TPN. Hospitals reported using triple-lumen catheters most frequently as their CVC for TPN (80.3%). A povidone-iodine scrub was used to prepare the skin for CVC insertion by 72.6% of reporting hospitals. Sixty percent of hospitals used transparent polyurethane dressings. Care of CVCs varied among hospitals. Catheter-related infection and sepsis rates were within the national average, although < 50% of responding hospitals provided data on these outcomes. The results of this survey point to the need for a national standardized database relative to patients receiving TPN via a CVC.

Optimal interval for triple-lumen catheter changes: a decision analysis

A survey of 53 university and community hospitals revealed that 73% of the institutions had no standard policy for the replacement of triple-lumen catheters (TLCs). Since the maintenance of a TLC in place for a prolonged period may lead to infectious complications, it appeared warranted that standards of management be developed. A decision-tree model was constructed for evaluating the optimal time for changing a TLC that would minimize infection. Cost estimates and health effects at three-, five-, and ten-day change intervals were considered for catheter insertion and complications resulting from such insertion. The results suggested that prophylactic catheter changes should occur no later than every five days, provided that there are no signs of infection. However, sensitivity analysis of several variables suggested that individual institutions should establish policy timing changes based upon careful interpretation of their own data. A model was developed to assist in determining the optimal time to change a TLC based upon such data.

Central venous catheter infections: concepts and controversies

Central venous catheters (CVCs) are widely used in critically ill patients in intensive care units. However, infectious complications are common and may limit their utility. We critically review the literature to determine the impact of CVC design and composition, insertion site selection, insertion procedures, care and removal of temporary CVCs on infectious complications. Relevant articles were identified and selected for review using a database search (Medline and manual of the English language literature) based upon study design and sample size with an emphasis on prospective randomized trials. To minimize infectious complications and maintain a reasonable cost-benefit ratio, we recommend: i) use a single lumen catheter unless clear indications for a multi-lumen catheter exist; ii) insert the catheter via the subclavian vein if no relative contraindication exists (bleeding diathesis, positive pressure ventilation); iii) disinfect the insertion site employing sterile technique; iv) apply a dry, sterile dressing and change the dressing every other day; v) inspect the insertion site for signs of infection and remove the catheter if pus is present; vi) if a catheter-related infection is suspected, change the catheter over a guidewire and culture the distal segment. The replacement catheter should be removed if an original catheter segment culture is positive.

Detection and prevention of central venous catheter-related infections

Infectious complications of central venous catheterization are an important clinical problem. Although systemic infection complicates only a small fraction of cases, the prevalence of catheter-related sepsis remains high because of the widespread use of these catheters in acutely ill hospitalized patients. The major route of infection is probably by migration of microorganisms from the skin along the outer surface of the catheter and through the subcutaneous catheter tract to the bloodstream. Semi-quantitative catheter tip cultures have become a standard clinical tool for the evaluation for catheter-related infection. Despite the use of this technique and a variety of other proposed methods for evaluating catheter colonization and infection, discriminating catheter-related sepsis from sepsis originating at another site is often difficult. Prevention of these infections is important. There have been many investigations of the factors that contribute to catheter infections. These studies have shown that meticulous attention to sterile technique during catheter insertion and during routine maintenance is critical.

Value of bedside plating of semiquantitative cultures for diagnosis of central venous catheter-related infections in ICU patients

We compared semiquantitative central venous catheter tip cultures plated at the bedside with those cultured in the laboratory, to determine if bedside plating provides a significantly better yield. Paired segments of 197 catheter tips from 92 surgical and medical ICU patients were evaluated prospectively. A total of 31 catheter tip cultures were positive for > or = 15 organisms per agar plate, with 10 of these being simultaneously positive at the bedside and in the laboratory. Cultures were exclusively positive in 18 cases plated immediately at the bedside, whereas laboratory plating resulted in only 3 exclusively positive cases. This discrepancy was statistically significant (p < 0.005). Compared with bedside plating, the sensitivity and specificity of sending catheters to the laboratory were 36 percent and 98 percent, respectively. These results indicate that the practice of sending central venous catheter tips to the laboratory for routine culture should be reconsidered in favor of bedside plating.

A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters

BACKGROUND

The incidence of infection increases with the prolonged use of central vascular catheters, but it is unclear whether changing catheters every three days, as some recommend, will reduce the rate of infection, It is also unclear whether it is safer to change a catheter over a guide wire or insert it at a new site.

METHODS

We conducted a controlled trial in adult patients in intensive care units who required central venous or pulmonary-artery catheters for more than three days. Patients were assigned randomly to undergo one of four methods of catheter exchange: replacement every three days either by insertion at a new site (group 1) or by exchange over a guide wire (group 2), or replacement when clinically indicated either by insertion at a new site (group 3) or by exchange over a guide wire (group 4).

RESULTS

Of the 160 patients, 5 percent had catheter-related bloodstream infections, 16 percent had catheters that became colonized, and 9 percent had major mechanical complications. The incidence rates (per 1000 days of catheter use) of bloodstream infection were 3 in group 1, 6 in group 2, 2 in group 3, and 3 in group 4; the incidence rates of mechanical complications were 14, 4, 8, and 3, respectively. Patients randomly assigned to guide-wire-assisted exchange were more likely to have bloodstream infection after the first three days of catheterization (6 percent vs. 0, P = 0.06). Insertions at new sites were associated with more mechanical complications (5 percent vs. 1 percent, P = 0.005).

CONCLUSIONS

Routine replacement of central vascular catheters every three days does not prevent infection. Exchanging catheters with the use of a guide wire increases the risk of bloodstream infection, but replacement involving insertion of catheters at new sites increases the risk of mechanical complications.

Complications associated with central venous cannulation

Some complications, such as pneumothorax, air embolism, and arterial laceration, may occur immediately after insertion. Others, such as infection, hydrothorax, phlebitis, and thrombosis, may occur later.

Catheter infection control in parenteral nutrition

Catheter sepsis rates related to total parenteral nutrition are variable and depend on several patient-specific factors. These factors include the presence of immunosuppression or critical illness, the use of multiple intravascular catheters, and bacterial translocation. Catheter-related sepsis may present in the patient as fever, chills, change in mental status, hypotension, and leukocytosis. In patients with suspected catheter-related infection whose peripheral blood cultures do not grow the same organism as a blood culture drawn from the catheter, a guidewire exchange of the catheter has been shown to be effective. This technique should be considered a surgical procedure. Complications that are associated with guidewire exchange of central venous catheters are catheter malposition, embolism of air or septic thrombi, and cardiac arrhythmias.

Central venous catheter related sepsis: a clinical review

Central venous catheterization is one of the most common invasive vascular procedures performed in hospitals today. Though catheter related sepsis occurs only in a small percentage of catheterized patients, this complication has a tremendous impact due to the ubiquitous use of central venous catheters and consequent morbidity and even mortality. Recent studies have considerably advanced our knowledge regarding the pathogenesis, diagnosis, and prevention of catheter sepsis. In this paper, current concepts regarding catheter-related sepsis are reviewed, regarding the incidence, pathophysiology, diagnosis, prevention, and therapy of this complication. Particular emphasis is placed upon recent research and clinical advances in this field, which have clarified important question and suggested promising approaches to the prevention and treatment of catheter bacteremia. The excessive morbidity and mortality due to catheter-related sepsis can be markedly decreased, by attention to simple infection control methods, and by future implementation of new experimental techniques.

Infections related to central venous catheters

Infection is a potentially life-threatening complication of central venous catheterization. Although line-related bacteremias and sepsis are relatively uncommon, the frequent use of central lines in the intensive-care unit makes these infections a common consideration. Semiquantitative culture techniques for analysis of the catheter tip provide evidence for the diagnosis of catheter-related infections. Bacterial growth of more than 15 colony-forming units/plate is typically considered significant. Preventive measures include using sterile insertion techniques, providing meticulous care for the local site, and minimizing the duration of catheter use. The practice of changing lines over a guidewire is controversial. For treatment of most catheter-related infections, the catheter should be removed and antibiotics should be administered if associated systemic infection occurs.