A prospective, randomized evaluation of the effect of silver impregnated subcutaneous cuffs for preventing tunneled chronic venous access catheter infections in cancer patients

Optimizing Intravenous Access for Long-Term Parenteral Nutrition

PURPOSE OF REVIEW

Securing safe and effective intravenous (IV) access is of utmost importance for administering parenteral nutrition (PN). Sustaining this access can indeed pose challenges, especially when dealing with the risk of complications associated with long-term PN. This review emphasizes best practices to optimize intravenous access and reviews the current evidence-based recommendations and consensus guidelines.

RECENT FINDINGS

An individualized approach when selecting central venous catheters (CVC) is recommended, considering the estimated duration of need for IV access and the number of lumens needed. Established and novel approaches to minimize complications, including infection and thrombosis, are recognized. These include placement and positioning of the catheter tip under sonographic guidance and the use of antimicrobial lock therapies. Moreover, when possible, salvaging CVCs can reduce the risk of vascular access loss. CVC selection for patients requiring PN depends on several factors. Carefully reviewing an individual patient's clinical characteristics and discussing options is important. Given the increased infection risk, CVC lumens should be minimized. For long-term PN beyond 6 months, using CVCs with skin barriers and larger diameters should be considered.

Prophylactic antibiotics for preventing gram-positive infections associated with long-term central venous catheters in adults and children receiving treatment for cancer

BACKGROUND

This is an updated version of a Cochrane Review last published in 2013. Long-term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram-positive bacteria. Antimicrobial prevention strategies aimed at these micro-organisms could potentially decrease the majority of CVC-related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram-positive infections in people with cancer who have long-term CVCs.

OBJECTIVES

To assess the effects of administering antibiotics prior to the insertion of long-term CVCs or as a flush/lock solution, or both during long-term CVC access to prevent gram-positive CVC-related infections in adults and children receiving treatment for cancer.

SEARCH METHODS

The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long-term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non-antibiotic flush/lock solution in long-term CVCs, in adults and children receiving treatment for cancer.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram-positive catheter-related infection events and total number of CVCs and CVC days. We pooled the data using a random-effects model for meta-analyses. We used the GRADE approach to assess the certainty of the evidence.  MAIN RESULTS: For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long-term CVC. One study did not observe any CVC-related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram-positive CVC-related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate-certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low.   Antibiotics as a flushing or locking solution Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin-only solution for flushing or locking the long-term CVC after use. One study did not observe any CRS events and was not include this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long-term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram-positive CVC-related infections compared to a heparin-only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC-days; 5 studies, 443 participants; moderate-certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low.  AUTHORS' CONCLUSIONS: Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long-term CVCs to prevent gram-positive CVC-related infections. Flushing or locking long-term CVCs with an antibiotic solution likely reduces gram-positive CVC-related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high-risk people or if the baseline CVC-related infection rates are high. Further research is needed to identify high-risk groups most likely to benefit from these antibiotic flush/lock solutions.

Chlorhexidine and silver sulfadiazine coating on central venous catheters is not sufficient for protection against catheter-related infection: Simulation-based laboratory research with clinical validation

Objective The efficacy of chlorhexidine- and silver sulfadiazine-coated central venous catheters (CSS-CVC) against catheter-related infection remains controversial. We hypothesized that the loss of silver nanoparticles may reduce the antibacterial efficacy of CSS-CVCs and that this loss could be due to the frictional force between the surface of the CVC and the bloodstream. The objective of this study was to investigate whether the antimicrobial effect of CSS-CVCs decreases with increasing exposure time in a bloodstream model and quantitatively assay the antimicrobial effect of CSS-CVCs compared with polyurethane and antiseptic-impregnated CVCs. Methods Each CVC was subjected to 120 hours of saline flow and analyzed at intervals over 24 hours. The analyses included energy-dispersive X-ray spectroscopy, scanning electron microscopy, and optical density after a Staphylococcus aureus incubation test. Results The weight percentage of silver in the CSS-CVCs significantly decreased to 56.18% (44.10% ± 3.32%) with 48-hour catheterization and to 18.88% (14.82% ± 1.33%) with 120-hour catheterization compared with the initial weight percentage (78.50% ± 6.32%). In the S. aureus incubation test, the antibacterial function of CSS-CVCs was lost after 48 hours [3 (N/D) of OD]. Similar results were observed in a pilot clinical study using 18 CSS-CVCs. Conclusions We found that the efficacy of CSS-CVCs decreased over time and that the antibacterial function was lost after 48 hours of simulated wear-out. Therefore, antibiotic-impregnated CVCs may be a better option when longer (>48 hours) indwelling is needed.

Antimicrobial Treatment of Polymeric Medical Devices by Silver Nanomaterials and Related Technology

Antimicrobial biocompatible polymers form a group of highly desirable materials in medicinal technology that exhibit interesting thermal and mechanical properties, and high chemical resistance. There are numerous types of polymers with antimicrobial activity or antimicrobial properties conferred through their proper modification. In this review, we focus on the second type of polymers, especially those whose antimicrobial activity is conferred by nanotechnology. Nanotechnology processing is a developing area that exploits the antibacterial effects of broad-scale compounds, both organic and inorganic, to form value-added medical devices. This work gives an overview of nanostructured antimicrobial agents, especially silver ones, used together with biocompatible polymers as effective antimicrobial composites in healthcare. The bactericidal properties of non-conventional antimicrobial agents are compared with those of conventional ones and the advantages and disadvantages are discussed.

Antifungal Properties of Cationic Phenylene Ethynylenes and Their Impact on β-Glucan Exposure

Candida species are the cause of many bloodstream infections through contamination of indwelling medical devices. These infections account for a 40% mortality rate, posing a significant risk to immunocompromised patients. Traditional treatments against Candida infections include amphotericin B and various azole treatments. Unfortunately, these treatments are associated with high toxicity, and resistant strains have become more prevalent. As a new frontier, light-activated phenylene ethynylenes have shown promising biocidal activity against Gram-positive and -negative bacterial pathogens, as well as the environmental yeast Saccharomyces cerevisiae In this study, we monitored the viability of Candida species after treatment with a cationic conjugated polymer [poly(p-phenylene ethynylene); PPE] or oligomer ["end-only" oligo(p-phenylene ethynylene); EO-OPE] by flow cytometry in order to explore the antifungal properties of these compounds. The oligomer was found to disrupt Candida albicans yeast membrane integrity independent of light activation, while PPE is able to do so only in the presence of light, allowing for some control as to the manner in which cytotoxic effects are induced. The contrast in killing efficacy between the two compounds is likely related to their size difference and their intrinsic abilities to penetrate the fungal cell wall. Unlike EO-OPE-DABCO (where DABCO is quaternized diazabicyclo[2,2,2]octane), PPE-DABCO displayed a strong propensity to associate with soluble β-glucan, which is expected to inhibit its ability to access and perturb the inner cell membrane of Candida yeast. Furthermore, treatment with PPE-DABCO unmasked Candida albicans β-glucan and increased phagocytosis by Dectin-1-expressing HEK-293 cells. In summary, cationic phenylene ethynylenes show promising biocidal activity against pathogenic Candida yeast cells while also exhibiting immunostimulatory effects.

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.

Prophylactic antibiotics for preventing Gram positive infections associated with long-term central venous catheters in oncology patients

BACKGROUND

This is an updated version of the review which was first published in the Cochrane Database of Systematic Reviews in 2006. Long-term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating oncology patients. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infection remains a common complication. These infections are mainly caused by Gram positive bacteria. Antimicrobial prevention strategies aimed at these micro-organisms could potentially decrease the majority of CVC infections. The aim of this review was to evaluate the efficacy of antibiotics in the prevention of Gram positive infections in long-term CVCs.

OBJECTIVES

To determine the efficacy of administering antibiotics prior to the insertion of long-term CVCs, or flushing or locking long-term CVCs with a combined antibiotic and heparin solution, or both, to prevent Gram positive catheter-related infections in adults and children receiving treatment for cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (to June 2013) and the MEDLINE and EMBASE databases (1966 to 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing prophylactic antibiotics given prior to long-term CVC insertion with no antibiotics, RCTs comparing a combined antibiotic and heparin solution with a heparin-only solution to flush or lock newly inserted long-term CVCs, and RCTs comparing a combination of these interventions in adults and children receiving treatment for cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, classified them and extracted data on to a pre-designed data collection form. We pooled data using the RevMan software version 5.2 and used random-effects (RE) model methods for meta-analyses.

MAIN RESULTS

We included 11 trials with a total of 828 oncology patients (adults and children). We assessed most included studies to be at a low or unclear risk of bias. Five trials compared the use of antibiotics (vancomycin, teicoplanin or ceftazidime) given before the insertion of the long-term CVC with no antibiotics, and six trials compared antibiotics (vancomycin, amikacin or taurolidine) and heparin with a heparin-only solution for flushing or locking the long-term CVC after use. Administering an antibiotic prior to insertion of the CVC did not significantly reduce Gram positive catheter-related sepsis (CRS) (five trials, 360 adults; risk ratio (RR) 0.72, 95% confidence interval (CI) 0.33 to 1.58; I² = 5 2%; P = 0.41).Flushing and locking long-term CVCs with a combined antibiotic and heparin solution significantly reduced the risk of Gram positive catheter-related sepsis compared with a heparin-only solution (468 participants, mostly children; RR 0.47, 95% CI 0.28 to 0.80; I² = 0%; P = 0.005). For a baseline infection rate of 15%, this reduction translated into a number needed to treat (NNT) of 12 (95% CI 9 to 33) to prevent one catheter-related infection. We considered this evidence to be of a moderate quality.

AUTHORS' CONCLUSIONS

There was no benefit to administering antibiotics before the insertion of long-term CVCs to prevent Gram positive catheter-related infections. Flushing or locking long-term CVCs with a combined antibiotic and heparin solution appeared to reduce Gram positive catheter-related sepsis experienced in people at risk of neutropenia through chemotherapy or disease. Due to insufficient data it was not clear whether this applied equally to TCVCs and totally implanted devices (TIDs), or equally to adults and children. The use of a combined antibiotic and heparin solution may increase microbial antibiotic resistance, therefore it should be reserved for high risk people or where baseline CVC infection rates are high (> 15%). Further research is needed to identify high risk groups most likely to benefit.

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.

Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

PURPOSE

The aim of this study is to review the current evidence-based data regarding strategies for prevention of central venous catheter (CVC) infections at the time of catheter insertion and as a part of routine care.

METHODS

We conducted a PubMed search from January 1990 to November 2010 using the following keywords: central venous catheter, clinical trials, pediatric, infection, prevention, antibiotic, chlorhexidine, dressing, antiseptic impregnated catheters, ethanol lock, impregnated cuff, insertion site infection, and Cochrane systematic review. Seven questions, selected by the American Pediatric Surgical Association Outcomes and Clinical Trials Committee, were addressed.

RESULTS

Thirty-six studies were selected for detailed review based on the strength of their study design and relevance to our 7 questions. These studies provide evidence that (1) chlorhexidine skin prep and chlorhexidine-impregnated dressing can decrease CVC colonization and bloodstream infection, (2) use of heparin and antibiotic-impregnated CVCs can decrease CVC colonization and bloodstream infection, and (3) ethanol and vancomycin lock therapy can reduce the incidence of catheter-associated bloodstream infections.

CONCLUSION

Grade A and B recommendations can be made based on available evidence in adult and limited pediatric studies for multiple components of proper CVC insertion practices and subsequent management. These strategies can minimize the risk of CVC infections in pediatric patients.

Effectiveness of sutureless percutaneous placement of cuffed tunneled hemodialysis catheters applying StatLock attachment devices

PURPOSE

A prospective, randomized-controlled trail was conducted to evaluate the effectiveness of securing tunneled hemodialysis (HD) catheters with sutureless StatLock attachment devices (Bard Access Systems) compared to traditional suture fixation.

METHODS

At a university teaching hospital 72 patients with chronic renal failure received cuffed tunneled HD catheters. In the study group (n=36) the HD catheters were secured with a sutureless StatLock attachment device, whereas the control group HD catheters were fixated with sutures only. The intended intermediate use of the tunneled HD catheters was 42 ± 7 days until the arteriovenous fistula was sufficient. All catheters were placed by an interventional radiologist using ultrasound for the puncture of the internal jugular vein. We evaluated the success and complication rate of tunneled catheter implantation.

RESULTS

The primary success rate for implantation of HD catheters was 100%. There was an overall complication rate of 8.3% in the study group (one hematoma in the subcutaneous catheter tract and two central venous thromboses). In the control group the overall complication rate was 13.9% (two hematomas, one central venous thrombosis and two catheter displacements). The two catheter displacements required a HD catheter exchange. In addition, four local irritations at the HD catheter entry site were seen only in the control group and were rated as minor complications.

CONCLUSIONS

The sutureless placement technique is safe and effective with a low complication rate, and is superior to the traditional suture fixation of tunneled catheters.

Risk factors for early catheter-related infections in cancer patients

BACKGROUND

Early catheter-related infection is a serious complication in cancer treatment, although risk factors for its occurrence are not well established. The authors conducted a prospective study to identify the risk factors for developing early catheter-related infection.

METHODS

All consecutive patients with cancer who underwent insertion of a central venous catheter were enrolled and were followed prospectively during 1 month. The study endpoint was occurrence of early catheter-related infection.

RESULTS

Over 10,392 catheter-days of follow-up, 14 of 371 patients had early catheter-related infections (14 patients in 10,392 catheter-days or 1.34 per 1000 catheter-days). The causative pathogens were gram positive in 11 of 14 patients. In univariate analysis, the risk factors for early catheter-related infection were aged <10 years (P = .0001), difficulties during insertion (P < 10(-6)), blood product administration (P < 10(-3)), parenteral nutrition (P < 10(-4)), and use >2 days (P < 10(-6)). In multivariate analysis, 3 variables remained significantly associated with the risk of early catheter-related infection: age <10 years (odds ratio [OR], 18.4; 95% confidence interval [95% CI], 1.9-106.7), difficulties during insertion procedure (OR, 25.6; 95% CI, 4.2-106), and parenteral nutrition (OR, 28.5; 95% CI, 4.2-200).

CONCLUSIONS

On the day of insertion, 2 variables were identified that were associated with a high risk of developing an early catheter-related infection: young age and difficulties during insertion. The results from this study may be used to identify patients who are at high risk of infection who may be candidates for preventive strategies.

The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies

OBJECTIVE

To better understand the absolute and relative risks of bloodstream Infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults In which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI.

METHODS

English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremla [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream Infection AND the specific type of intravascular device (e.g., central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days.

RESULTS

Point incidence rates of IVD-related BSI were lowest with peripheral Intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the Intensive care unit. Surgically implanted long-term central venous devices--cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)--appear to have high rates of Infection when risk Is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

CONCLUSIONS

Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies In which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs In use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related Infection have focused on short-term noncuffed CVCs used in Intensive care units, Infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

Peripherally Inserted Central Venous Catheters Are Not Superior to Central Venous Catheters in the Acute Care of Surgical Patients on the Ward

BACKGROUND

Peripherally inserted central venous catheters (PICC) have supplanted central venous catheters (CVC) for the administration of intravenous antibiotics and total parenteral nutrition to patients in our hospital. From the literature, it appears that this change has occurred in a number of other surgical units. Accounting for the change are the expected advantages of low complication rates at insertion, prolonged use without complications and interruption, and cost- and time-savings.

METHODS

We have proceeded with a review of the literature to understand and justify this change in practice. Our hypothesis was that the routine adoption of PICC instead of CVC for the acute care of surgical patients has occurred in the absence of strong scientific evidence. Our aim was to compare the associated infectious, thrombotic, phlebitic, and other common complications, as well as PICC and CVC durability. Articles concerning various aspects of PICC- and CVC-related complications in the acute care of adult patients were selected from the literature. Studies were excluded when they primarily addressed the use of long-term catheters, outpatient care, and pediatric patients. Data were extracted from 48 papers published between 1979 and 2004.

RESULTS

Our results show that infectious complications do not significantly differ between PICC and CVC. Thrombotic complications appear to be more significant with PICC and to occur early after catheterization. Phlebitic complications accounted for premature catheter removal in approximately 6% of PICC. Finally, prospective data suggest that approximately 40% of PICC will have to be removed before completion of therapy, possibly more often and earlier than CVC.

CONCLUSIONS

We believe that there is no clear evidence that PICC is superior to CVC in acute care settings. Each approach offers its own advantages and a different profile of complications. Therefore, the choice of central venous access should be individualized for surgical patients on the ward. More comparative prospective studies are needed to document the advantages of PICC over CVC.

Managing peripherally inserted central catheter-related venous thrombosis: How I do it

Imaging-guided insertion of central venous catheters, either in the form of a peripherally inserted central catheter (PICC) or through a subclavian or a jugular approach, is becoming the preferred method of acquiring long-term venous access for a variety of therapeutic purposes. The most significant complication from central venous catheters is thrombosis of the catheterized vein. Venous thrombosis related to the insertion of PICC lines is conventionally treated with line removal followed by anticoagulation. Direct thrombolysis with urokinase, using the lumen of the PICC line to facilitate the insertion of the infusion catheter is a simple, safe and effective treatment option. In this article, we describe our experience with this procedure and the technique used.

Central venous catheters: the role of radiology

The insertion and management of long-term venous catheters have long been the province of anaesthetists, intensive care physicians and surgeons. Radiologists are taking an increasing role in the insertion of central venous catheters (CVCs) because of their familiarity with the imaging equipment and their ability to manipulate catheters and guide-wires. The radiological management of the complications of CVCs has also expanded as a result. This article reviews the role of radiology in central venous access, covering the detection and management of their complications.

Prophylactic antibiotics for preventing early Gram-positive central venous catheter infections in oncology patients, a Cochrane systematic review

OBJECTIVE

Long-term tunnelled central venous catheters (TCVC) are increasingly used in oncology patients. Infections are a frequent complication of TCVC, mostly caused by Gram-positive bacteria. The objective of this review is to evaluate the efficacy of antibiotics in the prevention of early Gram-positive TCVC infections, in oncology patients.

DATA SOURCES

We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Register up to July 2003.

REVIEW METHODS

We selected randomised controlled trials (RCT) evaluating prophylactic antibiotics prior to insertion of the TCVC, and the combination of an antibiotic and heparin to flush the TCVC, in paediatric and adult oncology patients. The primary outcome was documented Gram-positive bacteraemia in patients with a TCVC. All trials identified were assessed and the data extracted independently by two reviewers.

RESULTS

There were nine trials included. Four trials reported on vancomycin/teicoplanin prior to insertion of the TCVC compared to no antibiotics. There was no reduction in the number of Gram-positive TCVC infections with an Odds ratio of 0.42 (95% confidence interval 0.13-1.31). Five trials studied flushing of the TCVC with a vancomycin/heparin solution compared to heparin flushing only. This method decreased the number of TCVC infections significantly with an Odds ratio of 0.43 (95% CI 0.21-0.87).

CONCLUSION

Flushing the TCVC with a vancomycin/heparin solution reduced the incidence of Gram-positive infections.

Comparison of catheter-related infection risk in two different long-term venous devices in adult hematology-oncology patients

PURPOSE: Infection is the leading complication of long-term central venous catheters, and its incidence may vary according to catheter type. The objective of this study was to compare the frequency and probability of infection between two types of long-term intravenous devices. METHODS: Retrospective study in 96 onco-hematology patients with partially implanted catheters (n = 55) or completely implanted ones (n = 42). Demographic data and catheter care were similar in both groups. Infection incidence and infection-free survival were used for the comparison of the two devices. RESULTS: In a median follow-up time of 210 days, the catheter-related infection incidence was 0.2102/100 catheter-days for the partially implanted devices and 0.0045/100 catheter-days for the completely implanted devices; the infection incidence rate was 46.7 (CI 95% = 6.2 to 348.8). The 1-year first infection-free survival ratio was 45% versus 97%, and the 1-year removal due to infection-free survival ratio was 42% versus 97% for partially and totally implanted catheters, respectively (P <.001 for both comparisons). CONCLUSION: In the present study, the infection risk was lower in completely implanted devices than in partially implanted ones.

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.

Prevention of bloodstream infections with central venous catheters treated with anti-infective agents depends on catheter type and insertion time: evidence from a meta-analysis

OBJECTIVE

To test the evidence that the risk of infection related to central venous catheters (CVCs) is decreased by anti-infective coating or cuffing.

DESIGN

Systematic review of randomized, controlled trials comparing anti-infective with inactive (control) CVCs.

INTERVENTIONS

Average insertion times were taken as a measurement of the length of insertion. Dichotomous data were combined using a fixed effect model and expressed as odds ratio (OR) with 95% confidence interval (CI95).

RESULTS

Two trials on antibiotic coating (343 CVCs) had an average insertion time of 6 days; the risk of BSI decreased from 5.1% with control to 0% with anti-infective catheters. There were no trials with longer average insertion times. In three trials on silver collagen cuffs (422 CVCs), the average insertion time ranged from 5 to 8.2 days (median, 7 days); the risk of BSI was 5.6% with control and 3.2% with anti-infective catheters. In another trial on silver collagen cuffs (101 CVCs), the average insertion time was 38 days; the risk of BSI was 3.7% with control and 4.3% with anti-infective catheters. In five trials on chlorhexidine-silver sulfadiazine coating (1,269 CVCs), the average insertion time ranged from 5.2 to 7.5 days (median, 6 days); the risk of BSI decreased from 4.1% with control to 1.9% with anti-infective catheters. In five additional trials on chlorhexidine-silver sulfadiazine coating (1,544 CVCs), the average insertion time ranged from 7.8 to 20 days (median, 12 days); the risk of BSI was 4.5% with control and 4.2% with anti-infective catheters.

CONCLUSIONS

Antibiotic and chlorhexidine-silver sulfadiazine coatings are anti-infective for short (approximately 1 week) insertion times. For longer insertion times, there are no data on antibiotic coating, and there is evidence of lack of effect for chlorhexidine-silver sulfadiazine coating. For silver-impregnated collagen cuffs, there is evidence of lack of effect for both short- and long-term insertion.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

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 (i.e., 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.

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.

The promise of novel technology for the prevention of intravascular device-related bloodstream infection. II. Long-term devices

Intravascular devices (IVDs) are widely used for vascular access but are associated with a substantial risk of IVD-related bloodstream infection (BSI). The development of novel technologies based on our understanding of pathogenesis promises a quantum reduction in IVD-related infections in an era of growing nursing shortage. Infections of long-term IVDs (most are in place for > or =10 days), including cuffed and tunneled central venous catheters (CVCs), implanted subcutaneous central venous ports, and peripherally inserted central catheters (PICCs), are primarily due to microorganisms that gain access to the catheter hub and lumen. Novel securement devices and antibiotic lock solutions have been shown to reduce the risk of IVD-related BSI in prospective randomized trials. The challenge for the future will be to identify new preventative technologies and to begin to more-widely adapt those technologies that have already been shown to be efficacious and cost effective.

Efficacy of antiadhesive, antibiotic and antiseptic coatings in preventing catheter-related infections: review

In recent years, central venous catheters (CVCs) are increasingly used in clinical practice. However, complications such as local or systemic infections are frequent for both temporary and indwelling vascular catheters. Annually, in the United States of America there are more than 200,000 cases of nosocomial bloodstream infections (BSIs), of which 90% are related to the use of an intravascular device. These infections are associated with increased morbidity and mortality, prolonged hospitalization and growing medical costs. Technological treatments of polymer surfaces including coating the catheter with antimicrobial substances may be promising tools for prevention of catheter-associated infections. A large number of surface-treated central venous catheters are now commercially available. In this paper the features and the clinical efficacy of different antimicrobial coatings are reviewed.

Antimicrobial-coated/bonded and -impregnated intravascular catheters

OBJECTIVE

To review the literature regarding the prevention of catheter colonization and catheter-related bloodstream infections (CRBIs) with the use of antimicrobial-coated/bonded and -impregnated intravascular catheters.

DATA SOURCES

Primary and review English-language literature were identified using MEDLINE (1966-September 2000) pertaining to the key terms antibiotic, antimicrobial, antiseptic, silver, and bonded, coated, Impregnated catheters. In addition, textbooks and relevant reference lists were reviewed.

DATA EXTRACTION

All articles identified through the data sources were evaluated. Information deemed relevant to the objectives of the review was included.

DATA SYNTHESIS

Significant morbidity and mortality are associated with the development of CRBIs. Preventative measures such as modification of these catheters with antimicrobial coating/bonding have produced varying results. Trials evaluating cefazolin, teicoplanin, vancomycin, silver, and chlorhexidine-silver sulfadiazine (C-SS) used for coated/bonded intravascular catheters have not demonstrated a consistent decrease in the incidence of CRBIs. However, a meta-analysis of trials evaluating C-SS intravascular catheters demonstrated a statistically significant reduction in CRBIs. A larger reduction in CRBIs has been reported with minocycline-rifampin (M-R) versus C-SS intravascular catheters. Use of the M-R and C-SS catheters may result in a cost savings of $100 million and reduce as many as 12,000 CRBI-related deaths annually when used short term (<7 d).

CONCLUSIONS

When used for short-term catheterization, M-R catheters appear to be superior to the currently available C-SS catheters at preventing CRBIs. Significant cost savings and reduction in mortality can be anticipated with the use of M-R catheters.

[Catheter-related infection in intensive care. Physiopathology, diagnosis, treatment and prevention]

PURPOSE

To review the mechanisms, diagnosis, treatment and prophylaxis of catheter-related sepsis in intensive care unit patients.

DATA SOURCES

A Medline research of the English- or French-language reports published between 1966 and 2000 and a manual research of references of relevant papers.

STUDY SELECTION

Experimental, clinical and basic research studies related to catheter-related sepsis.

DATA EXTRACTION

Data in selected articles were reviewed, and relevant clinical information was extracted.

DATA SYNTHESIS

Infection remains the major complication related to catheter insertion. No bacteriological exam or systematic catheter change is required in the absence of infection suspicion. In the intensive care unit, and without septic shock, the surveillance of skin cultures at the catheter insertion site or the time to positivity of hub-blood versus peripheral-blood culture determination may reduce the number of unnecessary removed catheters. Catheter change over a guidewire is not recommended because of the risk of dissemination of infection. When the catheter is removed, a quantitative culture is warranted. The treatment of catheter-related sepsis is based on catheter removal. The use of antibiotics is limited to some organisms or when the infection is complicated. The persistence of fever and positive blood cultures 72 h after catheter removal require to look for dissemination of infection or septic thrombophlebitis, especially if S. aureus or Candida are incriminated. The treatment of infection without catheter removal is not recommended in the intensive care unit because of a high risk of treatment failure. Compliance with catheter care guidelines and continuing quality improvement programs are the two major procedures in reducing catheter infection.

CONCLUSIONS

Improved understanding of the pathophysiology of catheter-related sepsis has led to improved prevention. Compliance with catheter care guidelines and continuing quality improvement programs are majors procedures to reduce the risk of catheter infection.

Efficacy of silver-coated fabric to prevent bacterial colonization and subsequent device-based biofilm formation

Efficacy of silver-coated poly(ethylene terephthalate) to prevent bacterial attachment and subsequent infection was quantified in vitro, in both batch- and flowing-fluid experiments. Kinetic analysis of batch suspended cell cultures of Staphylococcus epidermidis (SE), at various growth-limiting nutrient concentrations, in the absence of any fabric, indicated a maximum culture growth rate constant micro(max) = 0.78 +/- 0.02 h(-1). Batch experiments for Control fabric samples indicated that SE cultures exhibited about the same suspended cell growth rate (0.72 +/- 0.02 h(-1)) as observed in batch suspended cultures without fabric. Suspended SE cultures in the presence of silver-coated fabric grew at a considerably lower rate, 0.15 +/- 0.01 h(-1), indicating the inhibitory effect of Ag(+2) ion released from the fabric. Growth rates of suspended SE cultures were 5-6 times higher in the fluid phase in contact with the Control fabric compared to cultures exposed to silver-coated fabric. Maximum suspended cell concentrations attained at time = 24 h were 1-2 orders of magnitude higher for Control fabrics vs. silver-coated fabric. In all batch colonization experiments, both live and dead SE bacterial cells accumulate on the surfaces of both silver-coated and Control fabrics. Adherent viable SE cells accumulated to 1-2 orders of magnitude more ( approximately 5 x 10(+8) cells/cm(2)) on Control fabric than SE cells on the silver-coated fabric ( approximately 1.1 x 10(+6) cells/cm(2)), respectively. Between 70-95% SE cells on the Control fabric were viable, while on the silver-coated fabric samples, at 24 h, viable cells were less than 10% of the adherent community (i.e., greater than 90% nonviable cells). In flow cell colonization experiments, SE cells accumulated on Control fabric to a maximum adherent cell concentration of 6 x 10(+7) - 8 x 10(+7) cells/cm(2) by 24 h with the proportion of viable cells remaining relatively constant at 76% throughout an experiment. Both noninvasive microscopic enumeration and destructive assays gave the same results for adherent cell numbers. Using silver-coated fabric, total cells numbers (live + dead) reached a level of approximately 1.1 x 10(+7) - 3.0 x 10(+7) cells/cm(2) after about 6 h and remained constant. However, while the proportion of viable cells initially on the surface was 63-75%, this fraction dropped continuously during each experiment to less than 6% viable cells at 24 h. Regardless of the criteria, the number of viable or nonviable cells attached to silver-coated fabric were significantly lower than on Control fabric.

Can we achieve consensus on central venous catheter-related infections?

Central venous catheter-related bacteraemia is a substantial and preventable source of iatrogenic morbidity and mortality. A single episode of catheter-related bacteraemia has an estimated cost of A$50,000, with an attributable mortality between 10 and 35%. Catheter colonization is diagnosed with standard culture techniques. Diagnostic criteria for catheter-related bacteraemia include the results of cultures from the catheter tip, the peripheral blood and other possible sites of infection. The presence of clinical symptoms and subsequent defervescence may assist in making the diagnosis. This review explores the existing definitions of catheter-related infections and proposes a new and more rigorous classification with criteria for definite, probable and possible catheter-related bacteraemia. The authors hope that this classification will enhance the interpretation of the literature and the planning of new investigations. Infection rates can be reduced by appropriate site selection, adequate skin preparation, sterile technique and appropriate dressings. Decreased manipulation of administration sets, with more careful technique and less frequent set replacement, may reduce hub contamination. Infection rates increase with the duration in situ of the catheter, however are not reduced by regular scheduled catheter replacement or guide-wire exchanges. A range of antimicrobial catheter materials and coatings are under investigation, some of which are effective in reducing the rate of catheter-related bacteraemia. Chorhexidine-silver sulphadiazine and rifampicin-minocycline are the best studied combinations to date. Further developments are expected, although none are likely to be as effective as not inserting or removing the central venous catheter when it is not required.

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.

Transcutaneously tunneled central venous lines in cancer patients: an analysis of device-related morbidity factors based on prospective data collection

BACKGROUND

Long-term transcutaneous tunneled central venous catheters are frequently placed in cancer patients, accounting for significant costs and morbidity. Factors influencing outcome, though, are poorly studied.

METHODS

Between June 1991 and June 1993, 923 central venous tunneled catheters were placed in 791 patients at Memorial Sloan-Kettering Cancer Center. Placement-, device-, and patient-related parameters were charted prospectively (median follow-up: 120 days) and correlated to device-specific outcome events.

RESULTS

Median patient age was 28.5 years (range: 0.025 - 84.5). Disease distribution included hematologic malignancies (64.7%), solid tumors (30.4%), and others (4.9%). Primary indications for line access included chemotherapy (72.8%), bone marrow transplantation (18.7%), total parenteral nutrition (6.4%), and drug administration (2.1%). There were 11 insertion complications (1.2%), including insertion failure (n = 6), hemorrhage (n = 4), and malposition (n = 1). Subsequent to placement, a proven or suspected device-specific complication occurred in 540 lines (58.5%). Per 10,000 catheter days, there were 17.6 infection episodes, 8.1 thrombotic complications, 6.9 instances of catheter breakage, 3.5 accidental or inadvertent cases of displacement, and 0.6 device leaks. Reasons for line removal or other termination of follow-up were patient's death (32.1%), treatment end (28%), infection (19.6%), suspected infection (6.3%), displacement (6.8%), thrombosis (3.1%), leak (1%), and others (3.1%). Median device-specific duration was 365 days, compared with a median complication-free device-specific duration of 167 days (P < 0.0001), reflecting a highly significant device salvage rate after complications. Catheter tip position emerged as the dominant independent prognostic factor for reduced device-specific duration or complication-free device-specific duration.

CONCLUSIONS

Transcutaneous tunneled central venous lines can be placed safely, with a considerable incidence of subsequent device-specific complications, but a high salvage rate. Factors determining outcome are related to device placement, as well as the patient's disease status. In this study, patients alive 90 days after catheter placement had a 37% chance for a device complication, with a 20% chance for device loss. Future analyses of intermediate-term intravenous access should employ the measurement of device-specific outcome as a reference parameter to assess clinical results.

Hemodialysis catheter placement and management

Hemodialysis catheters are an integral part of the delivery of hemodialysis. While catheters play an important role in the patient undergoing hemodialysis, catheters should be considered a bridge to more permanent forms of dialysis access in most patients. Recent advances in catheter technology, access techniques, and choice of access sites have improved outcomes associated with hemodialysis catheters. The placement and management of hemodialysis catheters by interventional radiologists have played an important role in these advances, and interventional radiologists are taking an increasingly active role in the research and development of catheters and catheter insertion techniques. The present status of hemodialysis catheters is reviewed.

Infection-resistant alloplasts

Prosthesis-related infection accounts for nearly half of nosocomial infections, resulting in significant morbidity, mortality, prolonged hospitalization, and higher healthcare costs. Although numerous antimicrobial-coated surfaces have been suggested to guard against prosthesis-related infection, only a few, such as minocylcine plus rifampin, are clinically protective. The differences in clinical efficacy can be attributed at least in part to differences in the magnitude of leaching of the antimicrobial agent off the surface. There is a pressing need to explore the clinical efficacy of antimicrobial surfaces suitable for use in devices intended for long-term use.

Direct confocal microscopy studies of the bacterial colonization in vitro of a silver-coated heart valve sewing cuff

The antimicrobial coating of prosthetic heart valve sewing cuffs has been considered a potentially effective method for preventing prosthetic valve endocarditis. Although traditional in vitro bacterial adherence studies are often useful as screening tools, they can be inadequate in examining the antiinfective efficacy of antimicrobial-coated devices. We conducted a pilot in vitro study to directly assess the antimicrobial activity of a silver-coated sewing cuff versus uncoated cuff using confocal scanning laser microscopy. Staphylococcus epidermidis adhered more to the surfaces of the silver-coated sewing cuff compared with the uncoated cuff. These pilot in vitro results cast a doubt on the antiinfective efficacy of silver-coated prosthetic heart valve sewing cuffs and suggest further assessment should be carried out using animal studies.