Quantifying exposure to chlorhexidine from decontamination of peripheral intravenous injection ports

BACKGROUND

Annually, almost 2 billion peripheral intravenous cannulas (PIVCs) are placed worldwide. In response to concerns of infectious complications, chlorhexidine is increasingly utilised for maintenance decontamination of PIVC injection ports. Concomitantly, the allergenic potential of chlorhexidine exposures has been highlighted by several case reports, implicating it as a trigger when used for this seemingly innocuous process. Given how widespread this application is, elucidating potential chlorhexidine exposure is needed to gauge its risks and benefits.

OBJECTIVE

To examine and quantify if chlorhexidine is entrained when used for PIVC injection port cleaning.

METHODS

Twenty benchtop PIVC set-ups were cleaned with 2% chlorhexidine and 70% alcohol wipes, following three different pragmatic protocols. Each set-up was injected with 10 ml ultrapure water, and samples tested by liquid chromatography-electrospray tandem mass spectrometry for entrained chlorhexidine.

RESULTS

Chlorhexidine was detected in every sample. Mean concentrations and standard deviations from each protocol were 41.47 ppb (4.08), 54.76 ppb (17.46), and 65.84 ppb (7.01). One-way ANOVA indicated a statistical difference between at least two groups (df = 2, F = 24.11, p < .00001), with Tukey's testing verifying significantly different mean concentrations between all groups (p < .01).

CONCLUSIONS

Using 2% chlorhexidine and 70% alcohol swabs to decontaminate PIVC injection ports resulted in consistent entrainment of chlorhexidine, with varying amounts correlated to how it was applied. These results validate case reports attributing anaphylactic/allergic reactions to suspected intravenous chlorhexidine entrainment and should factor into future risk-benefit assessments for its use in PIVC maintenance antisepsis policies and protocols.

Desinfecção de hubs e conectores de cateteres intravenosos

Objetivo: identificar métodos de desinfecção de hubs e conectores sem agulha dos cateteres intravenosos em pacientes hospitalizados e verificar a efetividade das intervenções para a prevenção de infecções de corrente sanguínea associada a cateter intravenoso. Método: revisão de escopo seguindo as recomendações de Joanna Briggs Institute. Busca realizada em bases de dados eletrônicas Pubmed, Embase, Cochrane Library, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Base de Dados Enfermagem e Bibliografía Nacional en Ciencias de la Salud Argentina, e estudos indicados por experts. A busca foi atemporal até setembro de 2020. Protocolo registrado na Open Science Framework. Resultados: foram incluídos 27 estudos, sendo que cinco foram Guidelines e 22 foram artigos publicados em periódicos. Existe grande variedade de métodos de desinfecção de hubs e de conectores. Para a desinfecção ativa, foram indicados Gluconato de Clorexedina, Isopropanol e Iodopovedina; para a desinfecção passiva, Gluconato de Clorexedina e Isopropanol. A quantidade do agente desinfetante variou de 0,25 mL a 0,6 mL. O tempo de fricção na desinfecção ativa variou de cinco segundos a 30 segundos, e o tempo de contato na desinfecção passiva variou de três minutos a sete dias. O tempo de secagem de agentes desinfetantes foi superior a cinco segundos. Conclusão: verifica-se variedade de métodos de desinfecção; no entanto, não há consenso sobre a melhor indicação. Necessita-se de estudos que evidenciem a quantidade de desinfetante, a pressão e o tempo de fricção e o tempo de secagem. Pesquisas com práticas de desinfecção utilizadas no Brasil e ensaios clínicos randomizados são necessários. 

Preclinical evaluation of passive disinfection caps with a long-term catheter for the prevention of catheter-related bloodstream infection in pediatric cancer patients

The use of passive disinfection devices (disinfection caps) may be a beneficial part of a maintenance care bundle, aiming at the prevention of catheter-related bloodstream infections in pediatric cancer patients. This preclinical in vitro investigation tested the visual and mechanical integrity of a Broviac™ catheter hub after simulation testing with 122 3M™ CurosTM Stopper Disinfection Caps for Open Female Luers repeatedly attached and removed over 6 months. We found that these catheter hubs were compatible, fully operational, and airtight with use of 3M Curos stopper caps after 6 months of use with 122 caps per catheter hub.

Minimising Blood Stream Infection: Developing New Materials for Intravascular Catheters

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

Ethanol locks for the prevention of catheter-related bloodstream infection: a meta-analysis of randomized control trials

Background

Current evidence regarding the efficacy of ethanol locks in preventing catheter-related bloodstream infection (CRBI) is inconclusive.

Methods

Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library (until April 2018),were systematically searched for relevant studies. Two reviewers independently screened the retrieved records and identified RCTs that met the inclusion criteria. Relevant data were extracted for pooled analyses using Review Manager 5.3 software. Subgroup analysis was performed according to the study quality, duration of the ethanol lock, disease type and CRBI definition. Eggs’ method was applied to detect publication bias. Sensitivity analysis was conducted to check the stability of the meta-analysis results.

Results

Ten RCTs involving 2760 patients were included in the analysis. The overall pooled result indicated that ethanol locks significantly reduced the incidence of CRBI (RR 0.66, 95% CI 0.51–0.86). Subgroup analysis suggested that an ethanol lock significantly decreased the incidence of CRBI in patients with hematological diseases (RR 0.50, 95% CI 0.31–0.80). An ethanol lock significantly reduced the incidence of CRBI in a2-hour ethanol lock group (RR 0.49, 95% CI 0.33–0.73). The meta-analysis showed that an ethanol lock significantly reduced the incidence of CRBI according to analysis of high-(RR 0.66, 95% CI 0.47–0.94) or low-(RR 0.66, 95% CI 0.46–0.95) quality studies. Meta-analysis of studies with a strict CRBI definition showed that an ethanol lock can significantly prevent CRBI (RR 0.61, 95% CI 0.42–0.89). The results of sensitivity analysis suggested that the pooled result was stable. Meta-analysis of adverse events showed that an ethanol lock did not increase the incidence of thrombosis (RR 1.05, 95% CI 0.51–2.18) or mortality (RR 0.99, 95% CI 0.90–1.08) but did result in increased nausea (RR 1.54, 95% CI 1.01–2.35), dizziness (RR 4.21, 95% CI 2.40–7.39),elevated blushing rates (RR 3.27, 95% CI 2.05–5.22) and altered taste rates (RR 2.61, 95% CI 1.93–3.54).

Conclusions

An ethanol lock may play a role in the prevention of CRBI, especially in immunocompromised patients with hematological diseases.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0548-y) contains supplementary material, which is available to authorized users.

Rate of Catheter-Related Bloodstream Infections Between Tunneled Central Venous Catheters Versus Peripherally Inserted Central Catheters in Adult Home Parenteral Nutrition: A Meta-analysis

BACKGROUND

Tunneled central venous catheters (TCVCs) and peripherally inserted central catheters (PICC) are often used for the provision of home parenteral nutrition (HPN). There is no formal comparison being made to study the rate of catheter-related bloodstream infection (CRBSI) between TCVCs and PICC in HPN to recommend the use of 1 over the other.

METHODS

An online MEDLINE, PubMed, and Scopus search was conducted. Studies reporting the rate of CRBSI in HPN patients were included. DerSimonian and Laird random effects meta-analyses were used to analyze comparative studies, whereas Begg and Pilote's random effects meta-analysis was used to pool and analyze single-arm studies.

RESULTS

Seventeen studies (12 single-arm studies and 5 comparative studies) were included for analysis. Meta-analysis of comparative studies showed that PICC use was associated with a significantly lower rate of CRBSI (relative risk (RR) 0.40, 95% CI 0.19-0.83), whereas meta-analysis of single-arm studies revealed that the relative risk for CRBSI was not statistically significantly different from unity.

CONCLUSION

TCVC is more commonly used in long-term HPN. Our analysis of comparative studies showed a lower rate of CRBSI in HPN patients using PICC compared with TCVC; however, analysis of single-arm studies showed that the rate of CRBSI was comparable in PICC and TCVC use. The decision to which type of catheter is most suited for HPN patients should hence be based on the duration of treatment, level of care, patients' dexterity, as well patients' underlying comorbidities that may potentially contribute to other catheter-related complications.

Blood Contamination of the Small Bore Peripheral Intravenous Catheter in Neonates

INTRODUCTION

Peripheral Intravenous Catheters (PIV) are extensively used in sick neonates for administration of medicines and nutrition. When these PIVs are used on intermittent basis, they are flushed with saline in order to keep the hub of the catheter free from blood. Presence of blood in the hub of the catheter can be potentially dangerous as it could facilitate infection.

AIM

The aim of this study was to find the magnitude of blood contamination of PIV catheter hub after routine flushing.

MATERIALS AND METHODS

We measured the volume of 24 g PIV by filling it with saline and thereby measuring its volume. The PIVs which were in situ for at least 6 hours and removed were used for this study. These catheters were flushed with 0.2 ml of saline and the RBC count was calculated.

RESULTS

A total of 94 PIVs were studied, out of which 84% showed blood tinged residual flush and 15% of them had visible blood clot. All (100%) of the catheter studied showed RBCs on microscopic examination. The median RBC count was 36960/cu mm and the interquartile range was 10000 - 113920/cu mm. The highest RBC count was 2080000/cu mm.

CONCLUSION

Blood contamination of the small bore PIVs after flushing is universal in neonates.

Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review

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