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

Association of Prophylactic Antibiotics With Early Infectious Complications in Children With Cancer Undergoing Central Venous Access Device Placement

OBJECTIVE

To evaluate the impact of prophylactic antibiotics on early infectious complications after central venous access device (VAD) placement in children with cancer.

BACKGROUND

Despite the frequency of VAD procedures in children, the effectiveness of prophylactic antibiotics for reducing infectious complications is unknown.

METHODS

This was a retrospective cohort study of children with cancer undergoing central VAD placement identified in the Pediatric Health Information System database between 2017 and 2021. The primary outcome was the rate of early infectious complications (composite surgical site infections, central line-associated bloodstream infections, and bacteremia). Multivariable logistic regression was used to evaluate factors associated with early infection, and heterogeneity of treatment effect of prophylactic antibiotics was compared across subgroups.

RESULTS

A total of 9216 patients were included (6058 ports and 3158 tunneled lines). Prophylactic antibiotics were associated with lower early infectious complications overall [1.3% vs 2.4%; odds ratio (OR): 0.55 (95% CI: 0.39-0.79), P < 0.001], an effect demonstrated for tunneled lines (OR: 0.59, 95% CI: 0.41-0.84) but not ports (OR: 3.01, 95% CI: 0.66-13.78). On multivariate analysis, prophylactic antibiotics (OR: 0.67, 95% CI: 0.45-0.97) and solid tumors (OR: 0.38, 95% CI: 0.22-0.64) were associated with reduced odds of early infections, whereas tunneled lines (OR: 20.78, 95% CI: 9.83-43.93) and acute myelogenous leukemia (OR: 2.37, 95% CI: 1.58-3.57) had increased odds.

CONCLUSIONS

Prophylactic antibiotics are associated with reduced early infectious complications after central VAD placement overall. Despite recommendations from multiple national organizations against prophylactic antibiotics, these findings suggest a benefit in children with malignancy undergoing tunneled line placement.

Risk factors and incidence of peripheral venous catheters-related phlebitis between 2017 and 2021: A multicentre study (Flebitis Zero Project)

BACKGROUND

The peripheral venous catheter is one of the most frequently used devices in inpatient units worldwide. The risk of complications arising from use of peripheral venous catheters is low, but phlebitis frequently develops.

METHODS

A multicentre, prospective cohort study was conducted in 65 Spanish hospitals on 10,247 inpatients who had had a total of 38,430 peripheral venous catheters inserted. Data were collected for 15 consecutive days in 2017, 2018, 2019, 2020 and 2021. Central tendency and dispersion were measured, cumulative incidence and incidence density were determined and odds ratios (OR) were also calculated using binary logistic regression.

RESULTS

The incidence density of phlebitis, during the period from 2017 to 2021, was 1.82 cases of phlebitis per 100 venous catheter-days. The difference between average cumulative incidence of phlebitis per year was statistically significant as determined by ANOVA test results (F = 10.51; df = 4; p < 0.000). Unequivocal risk factors for phlebitis were revealed to be hospitals with more than 500 beds (OR = 1.507; p < 0.001), patients suffering from neoplastic disease (OR = 1.234; p < 0.001) and the first 3-4 days after insertion (OR = 1.159; p < 0.001).

CONCLUSIONS

A correct knowledge of insertion technique and venous catheter maintenance is likely to reduce the incidence of phlebitis and other complications, and hence continuing education of nurses is essential.

Non-cuffed central venous catheter for unplanned and urgent start haemodialysis in chronic kidney disease: A multi-centre experience from India

BACKGROUND

Central Venous Catheter (CVC) is indispensable to unplanned and urgent start haemodialysis in chronic kidney disease (CKD). While cuffed CVC is preferred to non-cuffed CVC for urgent start haemodialysis, patient's clinical condition might warrant immediate insertion of non-cuffed CVC. In the resource poor setting, non-cuffed CVCs might have to be retained longer than guideline recommended limit of 2 weeks. In this multi-centre retrospective observational study, the real-world survival of non-cuffed CVC was assessed among CKD patients who initiated dialysis urgently.

METHODS

CVC survival was assessed by Kaplan-Meier survival estimate. Predictors of premature CVC loss were assessed using multi-level multi-variate Cox frailty model wherein, each centre was provided with a random intercept to account for within-centre correlation of practice patterns.

RESULTS

Among 433 non-cuffed CVCs, there were 393 removals out of which 80% were elective and 20% were premature. The median CVC survival was 37 days (95% CI: 35-41). The rate of premature CVC removal was 4.5/1000 CVC-days (95% CI: 3.6-5.6). Mechanical complications followed by central line associated blood stream infection (CLABSI) were the most common reasons for premature removal. Rate of CLABSI was 1.7/1000 CVC-days (95% CI: 1.2-2.5). Diabetic CKD significantly increased the hazard of premature CVC removal (HR 1.91, 95% CI: 1.01-3.63, p = 0.04) while right internal-jugular location decreased the hazard (HR 0.22, 95% CI: 0.13-0.38, p < 0.001).

CONCLUSION

Prolonged retention of non-cuffed CVC (median 37 days) is common in resource-poor setting. It is worrisome and calls for pre-emptive access creation.

Microbiology of catheter-associated bloodstream infection: differences according to catheter type

OBJECTIVES

Catheter-associated bloodstream infections (CABSI) cause preventable morbidity. We compared the microbiological etiology of CABSI across different types of central and peripherally-inserted catheters.

METHODS

We analyzed prospectively collected CABSI data in a 2100-bed hospital network in Switzerland between 2016 and 2022. We included: short-term non-tunneled central venous catheters (CVC); long-term catheters (tunneled, or peripherally-inserted central catheters); arterial catheters; dialysis catheters; and peripheral venous catheters (PVC). We used multivariable logistic regression models to describe the risk of Staphylococcus aureus and Gram-negative pathogens according to catheter type.

RESULTS

Overall, 416 CABSI episodes were included, including 60 episodes of S. aureus and 92 episodes of Gram-negative CABSI. Microbiological profiles differed between catheter types. Together, PVC and dialysis catheters accounted for 43/60 (72%) of all S. aureus CABSI. After adjusting for age, sex, and hematology/oncology care, the odds of S. aureus were higher for hemodialysis catheters (odds ratio [OR] 17.3, 95% confidence interval [CI] 5.75-52.2, P <0.01) and PVC (OR 2.96, 95% CI 1.22-7.20, P = 0.02) compared to short-term non-tunneled CVC. Odds of Gram-negative organism as the cause of CABSI were higher in long-term catheters versus short-term non-tunneled CVC (OR 2.70, 95% CI 1.37-5.24).

CONCLUSIONS

CABSI in catheters other than short-term non-tunneled CVC is more commonly caused by virulent organisms including S. aureus and Gram-negative bacteria. Catheter type should be considered when selecting empirical antimicrobial therapies.

The antimicrobial effectiveness of chlorhexidine and chlorhexidine-silver sulfadiazine-impregnated central venous catheters against the emerging fungal pathogen Candida auris

BACKGROUND

Candida auris is an emerging multidrug-resistant fungus associated with catheter-related bloodstream infections. In vitro efficacy of chlorhexidine (CHX) and CHX-silver sulfadiazine-impregnated (CHX-S) antimicrobial central venous catheters (CVCs) against C auris was investigated.

METHODS

Minimum inhibitory and bactericidal CHX concentrations were determined against 19 C auris isolates. To assess extraluminal efficacy, segments from CVCs impregnated externally (CHX-S1) and both externally and internally (CHX-S2) were plasma-conditioned for 1- and 6-day, and to assess intraluminal efficacy, CHX-S2 CVCs were preconditioned with saline-lock for 6days, followed by 24-hour C auris inoculation and microbial adherence determination on impregnated and nonimpregnated CVCs.

RESULTS

CHX inhibited all C auris isolates with minimum inhibitory and bactericidal concentrations range of 8 to 128 μg/mL. C auris adherence was reduced on CHX-S1 and CHX-S2 extraluminally by 100% on day 1, 86.96% to 100% on day 7, and intraluminally on CHX-S2 by 56.86% to 90.52% on day 7.

DISCUSSION

CHX and CHX-S CVC performance against C auris observed in this study is consistent with antimicrobial benefits observed in prior preclinical and randomized controlled clinical studies.

CONCLUSIONS

CHX showed strong inhibitory and cidal effects on C auris. CHX-S CVCs proved highly efficacious against this pathogen under in vitro conditions. Additional studies, however, are required to confirm clinical benefit.

Reducing central line-associated bloodstream infections (CLABSI) by improved identification of primary infection sites through preliminary blood culture notifications

Central line-associated bloodstream infections (CLABSI) pose a significant patient risk. To address incorrect classifications of infectious events as CLABSI, the surveillance process was changed from using finalized blood culture to preliminary blood culture results as trigger of timely, in-depth reviews. This improved the detection of true CLABSI events.

The epidemiology and microbiology of central venous catheter related bloodstream infections among hemodialysis patients in the Philippines: a retrospective cohort study

BACKGROUND

Despite efforts to improve the management of catheter-related bloodstream infections (CRBSI) in literature, temporary CVCs continue to be used for maintenance hemodialysis outside of acute care settings, particularly in the Philippines.

METHODS

We conducted a retrospective cohort study to investigate the incidence, outcomes, risk factors, and microbiological patterns of CRBSI among adult kidney disease patients undergoing hemodialysis at the Philippine General Hospital, the country's largest tertiary referral center. We included all adult patients who received a CVC for hemodialysis from January 1, 2018, to August 31, 2019, and followed them for six months to observe the occurrence of CRBSI and its outcomes.

RESULTS

Our study documented a CRBSI incidence rate of 6.72 episodes per 1000 catheter days, with a relapse rate of 5.08%, a reinfection rate of 15.74%, and a mortality rate of 6.09%. On multivariable regression analysis, we identified autoimmune disease, dialysis frequency of > 3 × per week, use of CVC for either blood transfusion or IV medications, renal hypoperfusion, drug-induced nephropathy, and hypertensive kidney disease as significant risk factors for CRBSI. Gram-negative bacteria, including B. cepacia complex, Enterobacter, and Acinetobacter spp, were the most common organisms causing CRBSI. Multidrug-resistant organisms (MDROs) comprised almost half of the isolates (n = 89, 44.5%), with Coagulase-negative Staphylococcus species having the highest proportion among gram-positive organisms and Acinetobacter spp. among gram-negative isolates.

CONCLUSION

Our findings emphasize the need for more stringent measures and interventions to prevent the propagation of identified pathogens, such as a review of sterile technique and adequate hygiene practices, continued surveillance, and expedited placement and utilization of long-term access for patients on maintenance hemodialysis. Furthermore, CVC use outside of hemodialysis should be discouraged, and common antibiotic regimens such as piperacillin-tazobactam and fluoroquinolones should be reviewed for their low sensitivity patterns among gram-negative isolates. Addressing these issues can improve hemodialysis patients' outcomes and reduce the CRBSI burden in our institution.

Incidence and risk factors for central venous access device failure in hospitalized adults: A multivariable analysis of 1892 catheters

BACKGROUND

Central venous access devices (CVADs) allow intravenous therapy, haemodynamic monitoring and blood sampling but many fail before therapy completion.

OBJECTIVE

To quantify CVAD failure and complications; and identify risk factors.

DESIGNS, SETTINGS, AND PARTICIPANTS

Secondary analysis of multicentre randomised controlled trial including patients aged ≥16 years with a non-tunnelled CVAD (NTCVAD), peripherally-inserted central catheter (PICC) or tunnelled CVAD (TCVAD). Primary outcome was incidence of all-cause CVAD failure (central line-associated bloodstream infection [CLABSI], occlusion, accidental dislodgement, catheter fracture, thrombosis, pain). Secondary outcomes were CLABSI, occlusion and dislodgement. Cox regression was used to report time-to-event associations.

RESULTS

In 1892 CVADs, all-cause failure occurred in 10.2% of devices: 49 NTCVADs (6.1%); 100 PICCs (13.2%); 44 TCVADs (13.4%). Failure rates for CLABSI, occlusion and dislodgement were 5.3%, 1.8%, and 1.7%, respectively. Independent CLABSI predictors were blood product administration through PICCs (hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.24-5.55); and in TCVADs, one or two lumens, compared with three to four (HR 3.36, 95%CI 1.68-6.71), intravenous chemotherapy (HR 2.96, 95%CI 1.31-6.68), and diabetes (HR 3.25, 95%CI 1.40-7.57). Independent factors protective for CLABSI include antimicrobial NTCVADs (HR 0.23, 95%CI 0.08-0.63) and lipids in TCVADs (HR 0.32, 95%CI 0.14-0.72). NTCVADs inserted at another hospital (HR 7.06, 95%CI 1.48-33.7) and baseline infection in patients with PICCs (HR 2.72, 95%CI 1.08-6.83) were predictors for dislodgement. No independent occlusion predictors were found. Modifiable risk factors were identified for CVAD failure, which occurred for 1-in-10 catheters. Strict infection prevention measures and improved CVAD securement could reduce CLABSI and dislodgement risk.

Patient safety and the COVID-19 pandemic: a qualitative study of perspectives of front-line clinicians

INTRODUCTION

Studies on the impacts of COVID-19 on patient safety are emerging. However, few studies have elicited the perspectives of front-line clinicians.

METHODS

We interviewed clinicians from 16 US hospitals who worked in the emergency department, intensive care unit or inpatient unit during the COVID-19 pandemic. We asked about their experiences with both clinician well-being and patient care throughout the pandemic. We used a rigorous thematic analysis to code the interview transcripts. This study was part of a larger randomised control trial of an intervention to improve healthcare worker well-being during the COVID-19 pandemic; the findings described here draw from clinicians who spontaneously raised issues related to patient safety.

RESULTS

11 physicians and 16 nurses in our sample raised issues related to patient safety. We identified two primary themes: (1) compromised access to healthcare and (2) impaired care delivery. First, clinicians discussed how changes in access to healthcare early in the pandemic-including a shift to telehealth and deferred care-led to delays in accurate diagnosis and patients presenting later in their disease course. Second, clinicians discussed the effects of COVID-19 on care delivery related to staffing, equipment shortages and space constraints and how they deviated from the standard of care to manage these constraints. Clinicians noted how these issues led to patient safety events such as central line infections, patient falls and serious medication administration errors.

CONCLUSIONS

Several well-intentioned interventions implemented in the early weeks of the pandemic created a unique context that affected patient safety throughout the pandemic. Future pandemic preparedness should consider planning that incorporates a patient safety lens to mitigate further harm from occurring during a public health crisis.

Impact of a 'Catheter Bundle' on Infection Rates and Economic Costs in the Intensive Care Unit: A Retrospective Cohort Study

INTRODUCTION

Catheter-related infections (CBRSIs) are a widespread problem that increase morbidity and mortality in intensive care unit (ICU) patients and management costs.

OBJECTIVE

The main aim of this study was to assess the prevalence of CBRSIs in an intensive care unit following international literature guidelines for managing vascular lines in critically ill patients. These guidelines include changing vascular lines every 7 days, using needle-free devices and port protectors, standardising closed infusion lines, employing chlorhexidine-impregnated dressings, and utilising sutureless devices for catheter securement.

MATERIALS AND METHODS

This single-centre retrospective observational study was conducted in a general Italian ICU. This study included all eligible patients aged > 1 year who were admitted between January 2018 and December 2022.

RESULTS

During the study period, 1240 patients were enrolled, of whom 9 were diagnosed with a CRBSI. The infection rate per 1000 catheters/day was as follows: femorally inserted central catheter, 1.04; centrally inserted central catheter, 0.77; pulmonary arterial catheter 0.71, arterial catheter, 0.1; and peripherally inserted central catheter and continuous veno-venous haemodialysis dialysis catheters equal to 0. No difference in CRBSI was observed between the years included in the study (p = 0.874). The multivariate analysis showed an association between the diagnosis of CBRSI and Nursing Activities Score (per single point increase β = 0.04-95%CI: -0.01-0.09, p = 0.048), reason for ICU admission-trauma (β = 0.77-95%CI: -0.03-1.49, p = 0.039), and use of therapeutic hypothermia (β = 2.06, 95%CI: 0.51-3.20, p < 0.001). Implementing the study protocol revealed a cost of EUR 130.00/patient, equivalent to a daily cost of EUR 15.20 per patient.

CONCLUSIONS

This study highlights the importance of implementing a catheter care bundle to minimise the risk of CRBSI and the associated costs in the ICU setting. A policy change for infusion set replacement every 7 days has helped to maintain the CRBSI rate below the recommended rate, resulting in significant cost reduction and reduced production of ICU waste.

Antibiotic duration and route for treatment of adults with uncomplicated streptococcal bloodstream infections: a retrospective study in a large healthcare system

Data guiding the duration and route of streptococcal bloodstream infection (BSI) treatment are lacking. We conducted a retrospective cohort study of adults hospitalized with uncomplicated streptococcal BSI in a large integrated healthcare system from 2013 to 2020. The exposures of interest were antibiotic duration (5-10 days vs. 11-15 days) and antibiotic route (oral switch vs. entirely intravenous). The primary outcome was a composite 90-day outcome comprised of all-cause mortality, recurrent streptococcal BSI, or readmission. We performed non-inferiority analyses for each exposure. Separate multivariable Cox proportional hazards regression models were constructed for each exposure. The antibiotic duration analysis included 1,407 patients (5-10 days, n = 246; 11-15 days, n = 1,161). We found that 5-10-day courses were non-inferior to 11-15-day courses (P = 0.047). The antibiotic route analysis included 1,461 patients (oral switch, n = 1,112; entirely intravenous, n = 349). Oral step-down therapy did not meet the criteria for non-inferiority (P = 0.06). In the adjusted models, no significant difference was found in the primary outcome rate by antibiotic duration or antibiotic route at discharge. We found that 5-10-day courses were non-inferior to longer courses, and thus may be a safe and effective treatment option in the treatment of uncomplicated streptococcal bacteremia. Randomized controlled trials are needed to confirm the equivalent outcomes with shorter regimens and to definitively determine the optimal antibiotic route on discharge.

Epidemiology and Clinical Insights of Catheter-Related Candidemia in Non-ICU Patients with Vascular Access Devices

INTRODUCTION

Vascular access devices (VADs), namely peripheral VADs (PVADs) and central venous VADs (CVADs), are crucial in both intensive care unit (ICU) and non-ICU settings. However, VAD placement carries risks, notably catheter-related bloodstream infections (CRBSIs). Candida spp. is a common pathogen in CRBSIs, yet its clinical and microbiological characteristics, especially in non-ICU settings, are underexplored.

METHODS

We conducted a monocentric, retrospective observational study at Luigi Sacco Hospital from 1 May 2021 to 1 September 2023. We reviewed medical records of non-ICU adult patients with CVADs and PVADs. Data on demographics, clinical and laboratory results, VAD placement, and CRBSI occurrences were collected. Statistical analysis compared Candida spp. CRBSI and bacterial CRBSI groups.

RESULTS

Out of 1802 VAD placements in 1518 patients, 54 cases of CRBSI were identified, and Candida spp. was isolated in 30.9% of episodes. The prevalence of CRBSI was 3.05%, with Candida spp. accounting for 0.94%. Incidence rates were 2.35 per 1000 catheter days for CRBSI, with Candida albicans and Candida non-albicans at 0.47 and 0.26 per 1000 catheter days, respectively-patients with Candida spp. CRBSI had more frequent SARS-CoV-2 infection, COVID-19 pneumonia, and hypoalbuminemia.

CONCLUSIONS

During the COVID-19 pandemic, Candida spp. was a notable cause of CRBSIs in our center, underscoring the importance of considering Candida spp. in suspected CRBSI cases, including those in non-ICU settings and in those with PVADs.

Nurses' attitudes, behaviours, and enablers of intravenous to oral switching (IVOS) of antibiotics: a mixed-methods survey of nursing staff in secondary care hospitals across the Midlands region of England

BACKGROUND

Intravenous (IV) antibiotic use in secondary care in England is widespread. Timely appropriate intravenous to oral switch (IVOS) has the potential to deliver significant clinical and operational benefits. To date, antimicrobial stewardship (AMS) efforts around IVOS have not focused on the nursing staff who administer antibiotics, which represents a significant gap in AMS programmes.

AIM

To determine the involvement of bedside nurses in acute trusts in the Midlands region of England in IVOS in their organizations and describe their views regarding how to improve IVOS.

METHODS

An anonymous self-administered mixed-methods online survey was developed and distributed to nursing staff in acute trusts via antimicrobial stewardship networks between March and May 2023. Quantitative data was analysed to describe participant demographics and behaviours, whereas barriers and enablers to IVOS were explored through thematic content analysis of responses to open-ended questions.

FINDINGS

A total of 545 nursing staff responded to the survey. The majority (65.3%) routinely suggested IVOS to clinicians, despite only 50.6% being aware of local IVOS policies. One-third (34.7%) did not suggest IVOS, relying on doctors, believing their patients needed IV treatment, or lacked knowledge and skills to request IVOS. Content analysis of suggestions for improving the rate of IVOS proposed three major themes (People, Process, System) and identified that education and training, improved confidence and interprofessional relationships, and prompts were important drivers.

CONCLUSION

Nursing staff suggest IVOS to other clinicians, but more education and resources are needed to enable and empower them in this role.

Hospital-Acquired Bloodstream Infections in the Adult Intensive Care Unit at Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia

Introduction Hospital-acquired infections, also called nosocomial infections, are infectious diseases acquired in healthcare facilities at least 48 hours after admission and can't be present at the time of admission. Nosocomial bloodstream infection is a serious medical complication from hospitalization, and it can be potentially preventable by taking certain precautions. Aim The aim of this study is to determine the prevalence of central line-related bloodstream infections (CLABSI) with different organisms between January 2022 and February 2024 at the intensive care unit (ICU) at Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia. Patients and methods This retrospective cross-sectional study was conducted among ICU adult patients. The data were collected from medical and infection control records. All data for intensive care patients with positive blood cultures, except for the pediatric age group, were collected. Data were tabulated and cleaned in MS Excel, and subsequent data analyses were performed in IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States). Results Data from 21 patients were collected and analyzed. The mean age of the participants was 62.9 (SD 15.1) years. Female participants (61.9% (13)) were higher than males (38.1% (8)). All patients were inserted with a non-tunneled central venous catheter (CVC). The mortality rate was 76.2% (16). Vancomycin-resistant enterococci (VRE) was the most commonly detected organism in seven cultures (33.3%), followed by Candida species in six cultures (28.6%). Candida species were prevalent in younger patients (p=0.021) and those sensitive to medication (p=0.015). Survival analyses between age, gender, and organisms yielded insignificant results (p>0.05). Conclusion The major sources of bloodstream infection among adult ICU patients were VRE and Candida species. Mortality was common in this population, particularly among patients who were resistant to medication. Hence, strategies to reduce hospital-acquired bloodstream infections are warranted.

Use of a novel configuration of ports for patients needing intermittent long-term apheresis

PURPOSE

In patients with a need for frequent but intermittent apheresis, vascular access can prove challenging. We describe the migration of the use of a Vortex LP dual lumen port (Angiodynamics, Latham, NY) to one Powerflow and one ClearVUE power injectable port (Becton Dickinson, Franklin Lakes, NJ) in a series of patients undergoing intermittent apheresis.

MATERIALS AND METHODS

All patients had a need for long-term intermittent apheresis. Eight had double lumen Vortex port (pre) and were exchanged for one Powerflow port and one conventional subcutaneous venous port with 90° needle entry (post) while 12 did not have any port in place and received the same configuration. IRB approval was granted. We recorded the treatment time, flow rate, and tissue plasminogen activator (tPA) use for five treatment sessions after placement. When available, we compared five treatments with the Vortex port and the new configuration.

RESULTS

The mean treatment time is reduced with the new configuration (P = 0.0033). The predicted mean treatment time, adjusting for gender, race, BMI and age and accounting for correlations within a patient is 91.18 min pre and 77.96 min post. The flow rate is higher with the new configuration (P < 0.0001). The predicted mean flow rate in mL/min is 61.59 for the Vortex port and 71.89 for the new configuration. tPA use was eliminated in the population converted from Vortex ports and had a 48% reduction when compared to all other configurations in the study.

CONCLUSION

The introduction of a novel device configuration of venous access ports for intermittent apheresis resulted in higher flow rates and less total time for treatment. Use of tPA was greatly reduced. These results suggest that the new configuration could result in less expense for the hospital and better throughput in a busy pheresis practice. Clinical trial registration with ClinicalTrials.gov: NCT04846374.

Best practice in the use of peripheral venous catheters: A consensus from French experts

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical devices in healthcare. While they are often perceived as innocuous because they are common, this perception does not match their risk factors. In France, 16% of intravenous device-associated bacteremia are due to PIVCs. This consensus document reports the French experience in PIVC management, issues arising from their complications, and a proposed path toward improved PIVC care.

METHODS

A panel of five French experts discussed this topic based on evidence and personal experience. A consensus process was applied to highlight the issues in need of increased awareness and to suggest possible improvements. PIVC topics were organized as General Statements, Indication, Preparation, Insertion, Maintenance, and Removal. An electronic survey was used to record agreement or disagreement; to expand the dataset, five additional French experts also answered the questions.

RESULTS

Out of 67 statements, 62 reached a consensus (the 80% agreement threshold was exceeded). Experts are increasingly aware that PIVCs are a significant source of complications, including local and bloodstream infections. Practices need to progress to improve patient outcomes, which will require better education for all personnel involved with the insertion and maintenance of PIVCs.

CONCLUSIONS

Current practice around PIVCs does not always comply with the recommendations issued. A new surveillance network targeting catheter-related healthcare-associated infections is now in place in France. Simplified, standardized, bundled solutions are needed to reduce avoidable harm from PIVCs. Healthcare practice has changed over time and new educational tools are needed to adapt to increased workload and time constraints.

Midline Catheters as an Alternative for Central Venous Catheters in Venous Oxygen Saturation Monitoring: A Single Center Experience

BACKGROUND

Central venous oxygen saturation (ScvO2) obtained from a central venous catheter (CVC) is often used to approximate oxygen delivery in critically ill patients. Despite their importance in administering medications and monitoring oxygen delivery, the use of CVCs can be associated with significant complications. Midline catheters are inserted via a peripheral vein above the antecubital fossa and provide a safe alternative to CVCs. This study aimed to determine the equivalence of ScvO2 and midline catheter oxygen saturation (SmO2) in critically ill patients.

METHODS

This was a single-center observational study of critically ill adult patients who had concurrently placed CVCs (internal jugular and subclavian) and midline catheters as part of standard ICU care. Venous oxygen saturation and lactate levels were measured from both catheters using the Abbott point-of-care i-STAT analyzer. Demographic and ICU admission data were collected. Continuous variables were compared using the paired t-test. Pearson's correlation was used to evaluate the linear correlation between ScvO2 and SmO2. The systematic error (bias) was calculated using Bland-Altman analysis. Receiver operating characteristic curves were constructed to evaluate the sensitivities and specificities for different values of SmO2 to predict ScvO2.

RESULTS

Forty-eight patients (n = 48) were enrolled in the study. The mean ScvO2 and SmO2 were 65.5% +/- 11.2% and 62.7% +/- 17.6% respectively (p = 0.1197). In the Bland-Altman analysis, the mean bias between ScvO2 and SmO2 was 2.8% +/- 12.3% with 95% limits of agreement of -21.3% to 26.9%. More than 60% of the ScvO2 and SmO2 values diverged by ≥ 5%.

CONCLUSIONS

The difference between the mean SmO2 and ScvO2 was not statistically significant and the mean bias between SmO2 and ScvO2 is low. Despite this, the substantially large standard deviation and limits of agreement preclude the use of SmO2 as a direct surrogate of ScvO2.

In vitro biocompatibility analysis of protein-resistant amphiphilic polysulfobetaines as coatings for surgical implants in contact with complex body fluids

The fouling resistance of zwitterionic coatings is conventionally explained by the strong hydrophilicity of such polymers. Here, the in vitro biocompatibility of a set of systematically varied amphiphilic, zwitterionic copolymers is investigated. Photocrosslinkable, amphiphilic copolymers containing hydrophilic sulfobetaine methacrylate (SPe) and butyl methacrylate (BMA) were systematically synthesized in different ratios (50:50, 70:30, and 90:10) with a fixed content of photo-crosslinker by free radical copolymerization. The copolymers were spin-coated onto substrates and subsequently photocured by UV irradiation. Pure pBMA and pSPe as well as the prepared amphiphilic copolymers showed BMA content-dependent wettability in the dry state, but overall hydrophilic properties a fortiori in aqueous conditions. All polysulfobetaine-containing copolymers showed high resistance against non-specific adsorption (NSA) of proteins, platelet adhesion, thrombocyte activation, and bacterial accumulation. In some cases, the amphiphilic coatings even outperformed the purely hydrophilic pSPe coatings.

Protect peripheral intravenous catheters: a study protocol for a randomised controlled trial of a novel antimicrobial dressing for peripheral intravenous catheters (ProP trial)

INTRODUCTION

Peripheral intravenous catheters (PIVCs) are the most commonly used vascular access device in hospitalised patients. Yet PIVCs may be complicated by local or systemic infections leading to increased healthcare costs. Chlorhexidine gluconate (CHG)-impregnated dressings may help reduce PIVC-related infectious complications but have not yet been evaluated. We hypothesise an impregnated CHG transparent dressing, in comparison to standard polyurethane dressing, will be safe, effective and cost-effective in protecting against PIVC-related infectious complications and phlebitis.

METHODS AND ANALYSIS

The ProP trial is a multicentre, superiority, randomised clinical and cost-effectiveness trial with internal pilot, conducted across three centres in Australia and France. Patients (adults and children aged ≥6 years) requiring one PIVC for ≥48 hours are eligible. We will exclude patients with emergent PIVCs, known CHG allergy, skin injury at site of insertion or previous trial enrolment. Patients will be randomised to 3M Tegaderm Antimicrobial IV Advanced Securement dressing or standard care group. For the internal pilot, 300 patients will be enrolled to test protocol feasibility (eligibility, recruitment, retention, protocol fidelity, missing data and satisfaction of participants and staff), primary endpoint for internal pilot, assessed by independent data safety monitoring committee. Clinical outcomes will not be reviewed. Following feasibility assessment, the remaining 2624 (1312 per trial arm) patients will be enrolled following the same methods. The primary endpoint is a composite of catheter-related infectious complications and phlebitis. Recruitment began on 3 May 2023.

ETHICS AND DISSEMINATION

The protocol was approved by Ouest I ethic committee in France and by The Queensland Children's Hospital Human Research Ethics Committee in Australia. The findings will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05741866.

Vascular access specialist teams versus standard practice for catheter insertion and prevention of failure: a systematic review

OBJECTIVE

Billions of vascular access devices (VADs) are inserted annually for intravenous therapy worldwide. However, their use is not without challenges. Facilitating the process and enhancing results, hospital authorities have created vascular access specialist teams (VASTs) with advanced competencies in the evaluation, insertion, care and management of VADs. The objective is to compare the effectiveness of VASTs versus standard practice regarding cannulation success and vascular access maintenance in hospitalised adults.

DESIGN

Systematic review, using the Mixed Methods Appraisal Tool.

DATA SOURCES

We conducted a structured data search on Cochrane Library, MEDLINE, Web of Science, Scopus and EBSCOhost up to 31 May 2023. We did not impose a time limit regarding the date of publication.

ELIGIBILITY CRITERIA

Studies were eligible for inclusion in the review if they were randomised and non-randomised trials and observational studies.

DATA EXTRACTION AND SYNTHESIS

We included studies that described or evaluated the activity of VASTs compared with clinical practitioners. The outcomes analysed were the success of the cannulation and the incidence of associated adverse effects.

RESULTS

The search strategy produced 3053 papers published between 1984 and 2020, from which 12 were selected for analysis. VASTs are heterogeneously described among these studies, which mainly focus on insertions, frequently for patients with difficult intravenous access. Some patients presented with specific needs or requirement for specific insertion technique or catheter type. Compared with usual practice, these studies indicate that the involvement of a VAST is associated with a higher effectiveness in terms of first attempt insertions and insertion success rates, and a reduction in catheter-associated adverse events. However, meta-analyses confirming this trend are not currently possible.

CONCLUSIONS

It seems apparent that VASTS contribute to improving the health of patients during the administration of intravenous. VASTs seem to increase the effectiveness of VAD insertion and care and reduce complications.

PROSPERO REGISTRATION NUMBER

CRD42021231259.

Aligning peripheral intravenous catheter quality with nursing culture-A mixed method study

AIM

To explore barriers and facilitators that influence adherence to evidence-based guidelines for peripheral intravenous catheter care in different hospital wards.

DESIGN

Sequential explanatory mixedmethod study design, with qualitative data used to elaborate on quantitative findings.

METHOD

Data were collected between March 2021 and March 2022 using the previously validated Peripheral Intravenous Catheter mini questionnaire (PIVC-miniQ) on each ward in a tertiary hospital in Norway. Survey completion was followed by individual interviews with nurses from selected wards. The Pillar Integration Process was used to integrate and analyse the quantitative and qualitative findings.

RESULTS

The PIVC-miniQ screening assessed 566 peripheral intravenous catheters in 448 patients in 41 wards, and we found variation between wards in the quality of care. Based on the quantitative variation, we interviewed 24 nurses on wards with either excellent or not as good quality. The integration of the quantitative and qualitative findings in the study enabled an understanding of factors that influence nurses' adherence to the care of peripheral venous catheters. One main theme and four subthemes emerged. The main finding was that ward culture affects education practice, and this was evident from four subthemes: (1) Deviation from best practice, (2) Gaps in education and clinical training, (3) Quality variation between wards and (4) The importance of supportive leadership.

CONCLUSION

This mixed method study is the first study to explore reasons for variability in peripheral intravenous catheter quality across hospital wards. We found that ward culture was central to catheter quality, with evidence of deviations from best practice correlating with observed catheter complications. Ward culture also impacted nursing education, with the main responsibility for learning peripheral intravenous catheter management left to students' clinical training placements. Addressing this educational gap and fostering supportive leadership, including champions, will likely improve peripheral intravenous catheter care and patient safety.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses learn good peripheral intravenous catheter care in wards with supportive leaders and champions. This implies that the quality of nursing practice and patient outcomes are situational. Nurses need a strengthened emphasis on peripheral catheter quality in the undergraduate curriculum, and nurse leaders must emphasize the quality of catheter care in their wards.

IMPACT

The study findings impact nurse leaders who must commit to quality and safety outcomes by appointing and supporting local ward champions for promoting peripheral intravenous catheter care. This also impacts nursing education providers, as the emphasis on catheter care must be strengthened in the undergraduate nursing curriculum and continually reinforced in the hospital environment, particularly when guidelines are updated.

REPORTING METHOD

The study adhered to the Good Reporting of A Mixed Method Study (GRAMM).

PATIENT OR PUBLIC CONTRIBUTION

A patient representative has been involved in planning this study.

Catheter-associated Bloodstream Infection in Children with Tunneled Central Venous Catheters: A Single-center Experience

Background

Tunnelled catheters improve venous access in haematological diseases and malignancies, but are associated with complications. We prospectively analysed the episodes of CABSI and its associated risk factors.

Aims

To study the incidence and risk factors for CABSI in children with tunnelled central venous catheters (both Hickmans and Chemoports).

Materials and Methods

This is a prospective observational study done at our institute. Children under the age of 18 who underwent insertion of a Hickman or Chemoport from March 2018 to Dec 2022 were enrolled. Episodes of CABSI were noted and its risk factors were analysed.

Results

In total, 258 catheters were inserted in 250 children. Age ranged from 1 month to 18 years (median 67 months) with 60% being boys. A total of 152 Hickmans, 106 chemoports were inserted. Indications for insertions were for requirement of BMT and chemotherapy in majority of cases. CABSI were seen in 28.6% of catheters. Younger children (< 4years), Neutropenia (counts < 1000) and use of TPN were significantly associated with CABSI(p value<0.05). Infection was more with externalized catheters (Hickman) than implantable ports (Chemoports) but was not statistical significant(p value>0.05). Almost 30% of catheters with CABSI required removal because of florid sepsis. Others could be salvaged with aggressive antibiotics.

Conclusions

CABSI is a serious complications related to tunnelled catheter. Smaller children (<4 years), neutropenia and usage of TPN is a risk factor for development of CABSI. It can be treated with appropriate antibiotics and required removal in almost a third of all the cases.

Complications after removal of totally implanted central venous access devices: A single-center retrospective study

BACKGROUND

Complications after removal of totally implanted vascular access devices. (TIVADs) have not been studied widely. The aim of this study was to assess the prevalence and risk factors of these complications.

METHODS

This was a single-center retrospective study conducted in Gustave Roussy hospital in Villejuif, Ile-de-France, France. All adult patients scheduled for TIVAD removal between January 2015 and November 2019 were eligible for the study. The record of complications was compiled by noting the reason for a surgical or emergency department consultation during the month following removal, and also by calling the patients during the week of TIVAD removal to assess whether surgical advice was needed.

RESULTS

There were 2533 included patients, representing 2583 TIVAD removals. The prevalence of complications was 1.47% (n = 38), of which 0.31% were infectious complications (n = 8). These complications required surgical or interventional radiology management in 50% of cases. In multivariate analysis, two independent risk factors were associated with these complications: the duration of the surgical procedure (p = 0.04) and the active status of the underlying malignant disease (p = 0.07).

CONCLUSIONS

Complications after TIVAD removal are uncommon (prevalence = 1.47%), but their morbidity appears to be high, with interventional procedures frequently needed. The duration of the removal procedure and the active status of cancer appear to be associated with the occurrence of complications.

Predictive model for totally implanted venous access ports‑related long‑term complications in patients with lung cancer

Totally implanted venous access ports (TIVAPs), which are typically used in oncological chemotherapy and parenteral nutritional support, are convenient and safe, and thus offer patients a higher quality of life. However, insertion or removal of the device requires a minor surgical operation. Long-term complications (>30 days post insertion), such as catheter migration, catheter-related thrombosis and infection, are major reasons for TIVAP removal and are associated with a number of factors such as body mass index and hemoglobin count. Since management of complications is typically time-consuming and costly, a predictive model of such events may be of great value. Therefore, in the present study, a predictive model for long-term complications following TIVAP implantation in patients with lung cancer was developed. After excluding patients with a large amount of missing data, 902 patients admitted to The First Affiliated Hospital with Nanjing Medical University (Nanjing, China) were ultimately included in the present study. Of the included patients, 28 had complications, indicating an incidence rate of 3.1%. Patients were randomly divided into training and test cohorts (7:3), and three machine learning-based anomaly detection algorithms, namely, the Isolation Forest, one-class Support Vector Machines (one-class SVM) and Local Outlier Factor, were used to construct a model. The performance of the model was initially evaluated by the Matthew's correlation coefficient (MCC), area under curve (AUC) and accuracy. The one-class SVM model demonstrated the highest performance in classifying the risk of complications associated with the use of the intracavitary electrocardiogram method for TIVAP implantation in patients with lung cancer (MCC, 0.078; AUC, 0.62; accuracy, 66.0%). In conclusion, the predictive model developed in the present study may be used to improve the early detection of TIVAP-related complications in patients with lung cancer, which could lead to the conservation of medical resources and the promotion of medical advances.

Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department-Convenience or necessity?

BACKGROUND

Peripheral Intravenous Cannulas (PIVCs) are frequently utilised in the Emergency Department (ED) for delivery of medication and phlebotomy. They are associated with complications and have an associated cost to departmental resources. A growing body of international research suggests many of the PIVCs inserted in the ED are unnecessary.

METHODS

The objective of this study was to determine the rates of PIVC insertion and use. This was a prospective observational study conducted in one UK ED and one Italian ED. Adult ED patients with non-immediate triage categories were included over a period of three weeks in the UK ED in August 2016 and two weeks in the Italian ED in March and August 2017. Episodes of PIVC insertion and data on PIVC utilisation in adults were recorded. PIVC use was classified as necessary, unnecessary or unused. The proportion of unnecessary and unused PIVCs was calculated. PIVCs were defined as unnecessary if they were either used for phlebotomy only, or solely for IV fluids in patients that could have potentially been hydrated orally (determined against a priori defined criteria). PIVC classified as unused were not used for any purpose.

RESULTS

A total of 1,618 patients were included amongst which 977 PIVCs were inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for IV fluids in patients that could drink.

CONCLUSIONS

More than half of PIVCs placed in the ED were unnecessary in this study. This suggests that clinical decision making about the benefits and risks of PIVC insertion is not being performed on an individual basis.

Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections

SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.

Safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions: a single-center retrospective observational study

Introduction

Metaraminol is a sympathomimetic amine vasopressor that can be administrated through a peripheral venous access. However, limited evidence restricts its application in critically ill patients. This study aimed to investigate the safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions.

Methods

Patients who received peripheral metaraminol infusion between May 2019 and April 2022 were recruited. Data on baseline characteristics, clinical parameters, and infusion-related complications were retrospectively collected and analyzed.

Results

273 patients who received metaraminol were enrolled. Of these, 35 (12.8%) patients required central venous catheter insertion due to inability in achieving hemodynamic stability following peripheral metaraminol monotherapy. In 29,574.2 hours of vasopressor infusion, metaraminol infusion resulted achievement of the target blood pressure 73.4% of the time. Meanwhile, adverse events occurred in 5 patients and resolved after local tissue treatment.

Discussion

Metaraminol could provide hemodynamic support and avoid complications associated with a central venous catheter and delay in vasopressor administration. Through careful and close monitoring, peripheral metaraminol infusion is safe and feasible for patients with neurological conditions. Future large-scale, prospective, multicenter studies are needed to evaluate the safety and efficacy of metaraminol infusion through a peripheral intravenous catheter.

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.

Teaching-Learning Programs to Prevent and Control Infections Related to Long-Term Central Venous Access Device in Cancer Patients: A Systematic Review

OBJECTIVES

To evaluate the effectiveness of teaching-learning programs for cancer patients and/or their caregivers or family in preventing and controlling infections associated with long-term central venous access devices.

DATA SOURCES

This systematic review used the CINAHL, Cochrane Library, EMBASE, LILACS, and MEDLINE via PubMed portal, Scopus, and Web of Science. Google Scholar was used for the gray literature search. The included studies were analyzed, and the obtained data were qualitatively synthesized. The risk of bias was assessed using Cochrane tools: RoB 2 and ROBINS-I. The certainty of the evidence was evaluated using the GRADE. The review protocol was registered in PROSPERO (CRD42021267530).

CONCLUSION

The teaching-learning programs were implemented through theoretical-practical and theoretical dimensions in five and two studies, respectively. The risk of bias in the studies was low, moderate, severe, and high in one, three, two, and one of them, respectively. The certainty was very low. Teaching-learning programs on central venous access devices care for cancer patients and/or their caregivers or families could be effective in reducing infection rates.

IMPLICATIONS FOR NURSING PRACTICE

This systematic review addressed the teaching-learning programs for preventing and controlling infections associated with long-term central venous access devices. We identified that the most programs were effective in reducing the infection rates. The results may influence the clinical practice of oncology nurses, and consequently, the educational strategies and methods provided not only to these patients but for caregivers and families.

Nutritional support for the trauma and emergency general surgery patient: What you need to know

ABSTRACT

Decades of research have provided insight into the benefits of nutritional optimization in the elective surgical patient. Patients who are nutritionally prepared for surgery enjoy reduced length of hospital and intensive care unit stays and suffer fewer complications. In the trauma and emergency general surgery patient populations, we are not afforded the preoperative period of optimization and patients often suffer longer lengths of hospital stay, discharge to nonhome destinations, and higher infectious and mortality rates. Nonetheless, ongoing research in this vulnerable and time critical diagnosis population has revealed significant outcomes benefits with the meticulous nutritional support of these patients. However, it is important to note that optimal nutritional support in this challenging patient population is not simply a matter of "feeding more and feeding earlier." In this review, we will address assessing nutritional needs, the provision of optimal nutrition, the timing and route of nutrition, and monitoring outcomes and discuss the management of nutrition in the complex trauma and emergency general surgery patient.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

Dressings and securement devices to prevent complications for peripheral arterial catheters

BACKGROUND

Peripheral arterial catheters (ACs) are used in anaesthesia and intensive care settings for blood sampling and monitoring. Despite their importance, ACs often fail, requiring reinsertion. Dressings and securement devices maintain AC function and prevent complications such as infection.

OBJECTIVES

To evaluate the effectiveness of peripheral AC dressing and securement devices to prevent failure and complications in hospitalised people.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus up to 16 May 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to 16 May 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different dressing and securement devices for the stabilisation of ACs in hospitalised people.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias using Cochrane's RoB 1 tool. We resolved disagreements by discussion, or by consulting a third review author when necessary. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included five RCTs with 1228 participants and 1228 ACs. All included studies had high risk of bias in one or more domains. We present the following four comparisons, with the remaining comparisons reported in the main review. Standard polyurethane (SPU) plus tissue adhesive (TA) compared with SPU: we are very uncertain whether use of SPU plus TA impacts rates of AC failure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.20 to 0.98; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Neither study (165 participants) reported catheter-related bloodstream infections (CRBSI), thus we are very uncertain whether SPU plus TA impacts on the incidence of CRBSI (very low-certainty evidence). It is very uncertain whether use of SPU plus TA impacts AC dislodgement risk (RR 0.54, 95% CI 0.03 to 9.62; I² = 44%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts AC occlusion rates (RR 1.20, 95% CI 0.37 to 3.91; I² = 3%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts rates of adverse events with few reported events across groups (RR 0.89, 95% CI 0.09 to 8.33; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Bordered polyurethane (BPU) compared to SPU: we are very uncertain whether use of BPU impacts rates of AC failure (RR 0.67, 95% CI 0.21 to 2.13; 1 study, 60 participants; very low-certainty evidence). BPU may make little or no difference to CRBSI compared to SPU (RR 3.05, 95% CI 0.12 to 74.45; I² = not applicable as 1 study (60 participants) reported 0 events; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to the risk of AC dislodgement compared with SPU (RR 0.75, 95% CI 0.17 to 3.22; I² = 0%; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to occlusion risk compared with SPU (RR 0.80, 95% CI 0.60 to 1.07; I² = 0%; 2 studies, 572 participants; low-certainty evidence). It is very uncertain whether BPU impacts on the risk of adverse events compared with SPU (RR 0.33, 95% CI 0.01 to 7.87; 1 study, 60 participants; very low-certainty evidence). SPU plus sutureless securement devices (SSD) compared to SPU: we are very uncertain whether SPU plus SSD impacts risk of AC failure compared with SPU (RR 0.78, 95% CI 0.40 to 1.52; I² = 0%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain if SPU plus SSD impacts CRBSI incidence rate with no events in both groups (2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of dislodgement (RR 0.14, 95% CI 0.01 to 2.57; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of AC occlusion (RR 1.94, 95% CI 0.50 to 7.48; I² = 38%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain whether SPU plus SSD impacts on the risk of adverse events (RR 1.94, 95% CI 0.19 to 20.24; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). Integrated securement dressings compared to SPU: integrated securement dressings may result in little or no difference in risk of AC failure compared with SPU (RR 1.96, 95% CI 0.80 to 4.84; 1 study, 105 participants; low-certainty evidence); may result in little or no difference in CRBSI incidence with no events reported (1 study, 105 participants; low-certainty evidence); may result in little or no difference in the risk of dislodgement (RR 0.33, 95% CI 0.04 to 3.04; 1 study, 105 participants; low-certainty evidence), may result in little or no difference in occlusion rates with no events reported (1 study, 105 participants; low-certainty evidence), and may result in little or no difference in the risk of adverse events (RR 0.35, 95% CI 0.01 to 8.45; 1 study, 105 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the relative clinical effectiveness of AC dressing and securement products. Limitations of current evidence include small sample size, infrequent events, and heterogeneous outcome measurements. We found no clear difference in the incidence of AC failure, CRBSI, or adverse events across AC dressing or securement products including SPU, BPU, SSD, TA, and integrated securement products. The limitations of current evidence means further rigorous RCTs are needed to reduce uncertainty around the use of dressing and securement devices for ACs.

Medical Device-Associated Biofilm Infections and Multidrug-Resistant Pathogens

Medical devices such as venous catheters (VCs) and urinary catheters (UCs) are widely used in the hospital setting. However, the implantation of these devices is often accompanied by complications. About 60 to 70% of nosocomial infections (NIs) are linked to biofilms. The main complication is the ability of microorganisms to adhere to surfaces and form biofilms which protect them and help them to persist in the host. Indeed, by crossing the skin barrier, the insertion of VC inevitably allows skin flora or accidental environmental contaminants to access the underlying tissues and cause fatal complications like bloodstream infections (BSIs). In fact, 80,000 central venous catheters-BSIs (CVC-BSIs)-mainly occur in intensive care units (ICUs) with a death rate of 12 to 25%. Similarly, catheter-associated urinary tract infections (CA-UTIs) are the most commonlyhospital-acquired infections (HAIs) worldwide.These infections represent up to 40% of NIs.In this review, we present a summary of biofilm formation steps. We provide an overview of two main and important infections in clinical settings linked to medical devices, namely the catheter-asociated bloodstream infections (CA-BSIs) and catheter-associated urinary tract infections (CA-UTIs), and highlight also the most multidrug resistant bacteria implicated in these infections. Furthermore, we draw attention toseveral useful prevention strategies, and advanced antimicrobial and antifouling approaches developed to reduce bacterial colonization on catheter surfaces and the incidence of the catheter-related infections.

The safe implementation of peripherally inserted central catheters by nurse practitioners for patients with gastroenterological diseases in Japan: a single-center retrospective study

PURPOSE

As a safe and reliable alternative to central venous catheters (CVCs), peripherally inserted central catheters (PICCs) are commonly used in clinical practice. However, the insertion of PICCs by nurse practitioners (NPs), especially in Japan, has not been reported extensively. Thus, we investigated the safety and efficiency of PICC insertions by NPs.

METHODS

The participants were 1322 patients who underwent PICC insertion by NPs at Fujita Health University Hospital (FNPs). The basilic vein in the brachium was the preferred vein for insertion; the brachial vein was the alternative. Patients were monitored from the time of PICC insertion until its removal. Ultrasonography-guided puncture was used for all catheter insertions, and the catheter tip was replaced into the superior vena cava under fluoroscopic imaging with maximal sterile barrier precautions. The outcomes of the PICC insertions by the FNPs were evaluated retrospectively.

RESULTS

Overall, 23 FNPs inserted a collective total of 1322 PICCs, which remained in place for a collective total of 23,619 catheter days. The rate of successful PICC insertion was 99% (1310 patients). The median time taken for PICC insertion was 12 min (interquartile range, 10-15 min). Intraoperative complications occurred in two patients (0.2%). The confirmed incidence of central line-associated bloodstream infection was 3.4% (45 patients), and these infections occurred on 1.9 per 1000 catheter days. The median duration of PICC placement was 15 days (range, 10-23 days).

CONCLUSION

PICC insertion by NPs is safe and a potential alternative to CVC insertion by surgeons.

Soft and Hard Tissue Integration around Percutaneous Bone-Anchored Titanium Prostheses: Toward Achieving Holistic Biointegration

A holistic biointegration of percutaneous bone-anchored metallic prostheses with both hard and soft tissues dictates their longevity in the human body. While titanium (Ti) has nearly solved osseointegration, soft tissue integration of percutaneous metallic prostheses is a perennial problem. Unlike the firm soft tissue sealing in biological percutaneous structures (fingernails and teeth), foreign body response of the skin to titanium (Ti) leads to inflammation, epidermal downgrowth and inferior peri-implant soft tissue sealing. This review discusses various implant surface treatments/texturing and coatings for osseointegration, soft tissue integration, and against bacterial attachment. While surface microroughness by SLA (sandblasting with large grit and acid etched) and porous calcium phosphate (CaP) coatings improve Ti osseointegration, smooth and textured titania nanopores, nanotubes, microgrooves, and biomolecular coatings encourage soft tissue attachment. However, the inferior peri-implant soft tissue sealing compared to natural teeth can lead to peri-implantitis. Toward this end, the application of smart multifunctional bioadhesives with strong adhesion to soft tissues, mechanical resilience, durability, antibacterial, and immunomodulatory properties for soft tissue attachment to metallic prostheses is proposed.

Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis

BACKGROUND

Peripheral intravenous catheters are the most frequently used invasive device in nursing practice, yet are commonly associated with complications. We performed a systematic review to determine the prevalence of peripheral intravenous catheter infection and all-cause failure.

METHODS

The Cochrane Library, PubMed, CINAHL, and EMBASE were searched for observational studies and randomised controlled trials that reported peripheral intravenous catheter related infections or failure. The review was limited to English language and articles published from the year 2000. Pooled estimates were calculated with random-effects models. Meta-analysis of observation studies in epidemiology guidelines and the Cochrane process for randomised controlled trials were used to guide the review. Prospero registration number: CRD42022349956.

FINDINGS

Our search retrieved 34,725 studies. Of these, 41 observational studies and 28 randomised controlled trials (478,586 peripheral intravenous catheters) met inclusion criteria. The pooled proportion of catheter-associated bloodstream infections was 0.028 % (95 % confidence interval (CI): 0.009-0.081; 38 studies), or 4.40 catheter-associated bloodstream infections per 100,000 catheter-days (20 studies, 95 % CI: 3.47-5.58). Local infection was reported in 0.150 % of peripheral intravenous catheters (95 % CI: 0.047-0.479, 30 studies) with an incidence rate of 65.1 per 100,000 catheter-days (16 studies; 95 % CI: 49.2-86.2). All cause peripheral intravenous catheter failure before treatment completion occurred in 36.4 % of catheters (95 % CI: 31.7-41.3, 53 studies) with an overall incidence rate of 4.42 per 100 catheter days (78,891 catheter days; 19 studies; 95 % CI: 4.27-4.57).

INTERPRETATION

Peripheral intravenous catheter failure is a significant worldwide problem, affecting one in three catheters. Per peripheral intravenous catheter, infection occurrence was low, however, with over two billion catheters used globally each year, the absolute number of infections and associated burden remains high. Substantial and systemwide efforts are needed to address peripheral intravenous catheter infection and failure and the sequelae of treatment disruption, increased health costs and poor patient outcomes.

Safety and Efficacy of Midline vs Peripherally Inserted Central Catheters Among Adults Receiving IV Therapy: A Randomized Clinical Trial

Importance

Midline catheters (MCs) are widely used, but safety and efficacy compared with peripherally inserted central catheters (PICCs) has not been adequately evaluated.

Objective

To compare the safety and efficacy of MCs with PICCs among adult patients with an anticipated intravenous therapy lasting from 5 to 28 days.

Design, Setting, and Participants

This parallel, 2-group, open-label, randomized clinical trial (RCT) was conducted in Denmark from October 2018 to February 2022 at a single academic tertiary care center. Adult inpatients and outpatients were consecutively randomized.

Intervention

Patients were randomized in a 1:1 ratio to either the MC group or the PICC control group.

Main Outcomes and Measures

The primary outcome was catheter-related bloodstream infection (CRBSI), analyzed using the Fisher exact test. Secondary outcomes were symptomatic catheter-related thrombosis and catheter failure, including mechanical cause, phlebitis, infiltration, pain in relation to drug or fluid administration, and leaking from the puncture site. Incidence rate ratios (IRRs) were calculated to assess between-group failure rates over device dwell time using Poisson regression. An intention-to-treat analysis was performed.

Results

A total of 304 patients (mean [SD] age, 64.6 [13.5] years; 130 [42.8%] female) were included in the analysis, and 152 patients were allocated to each catheter group. The incidence of CRBSI was low, with 0 in the MC group and 1 in the PICC control group (P > .99). The MC group had a higher catheter-related complication rate (20 [13.2%] vs 11 [7.2%]), and an IRR of 2.37 (95% CI, 1.12-5.02; P = .02) for complications compared with the PICC control group. In a post hoc analysis stratified by catheter dwell time, no significant difference in complication rate (IRR, 1.16; 95% CI, 0.50-2.68; P = .73) was found between the 2 groups for catheters used less than 16 days.

Conclusions and Relevance

In this RCT with patients who received medium- to long-term intravenous therapy, the incidence of CRBSI was low, with no difference between MCs and PICCs. The use of MCs resulted in a higher incidence of catheter-related complications compared with use of PICCs. This finding should be balanced in the decision of type of catheter used at the individual patient level.

Trial Registration

ClinicalTrials.gov Identifier: NCT04140916.

Microbial Profile, Antimicrobial Susceptibility, and Prevalence of MDR/XDR Pathogens Causing Medical Device Associated Infections: A Single Center Study

Background

There is a scarcity of studies evaluating the microbial profile, antimicrobial susceptibility, and prevalence of MDR/XDR pathogens causing medical device-associated infections (MDAIs). The present study was sought in this regard.

Materials and methods

An ambispective-observational, site-specific, surveillance-based study was performed for a period of 2 years in the intensive care unit (ICU) and high dependency unit (HDU) (medicine/surgery) of a Tertiary-care University Hospital. Three commonly encountered MDAIs including central-line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated pneumonia (VAP), were targeted.

Results and conclusion

Of the total 90 patients, 46 (51.1%) were admitted to the ICU (medicine/surgery), and the remaining 44 (48.8%) were admitted to the HDU (medicine/surgery). The median (P25-P75) age of the total patients was 55 (43.1-62.3) years. Male 61 (67.8%) preponderance was observed. Sixty-two of 90 (68.9%) were immunocompromised. A total of 104 pathogens causing MDAIs were isolated. Staphylococcus epidermidis (CoNS), and Staphylococcus capitis were commonly isolated multi-drug resistant (MDR) gram-positive pathogens causing MDAIs. Similarly, carba-resistant Klebsiella pneumoniae, Stenotrophomonas maltophilia, and carba-resistant Acinetobacter baumanni were commonly isolated MDR gram-negative pathogens causing MDAIs. Five of 9 (55.5%) K. pneumoniae and three of 9 (33.3%) S. maltophilia isolates were found to be extensively drug resistant. Among Candida, C. parapsilosis was the most prevalent fungal pathogen causing CLABSI and CAUTI in patients admitted to ICU/HDU.

How to cite this article

Suryawanshi VR, Pawar A, Purandare B, Vijayvargiya N, Sancheti S, Philip S, et al. Microbial Profile, Antimicrobial Susceptibility, and Prevalence of MDR/XDR Pathogens Causing Medical Device Associated Infections: A Single Center Study. Indian J Crit Care Med 2024;28(2):152-164.

Care bundles and peripheral arterial catheters

HIGHLIGHTS

What we know about the topic: Recommendations for the use of vascular access care bundles to reduce infection are followed for different devices. The risk of arterial catheter-related infection is comparable with short-term, non-cuffed central venous catheters. There are practice concerns for clinicians inserting and caring for peripheral arterial catheters. What this paper adds: The selected studies had a theme of decreased infection after using bundled strategies for all devices. Few studies addressed use of bundles for care of peripheral arterial catheters. High-quality research should be performed about using care bundles for insertion and care of arterial catheters.

INTRODUCTION

A scoping review of the literature was performed.

AIMS/OBJECTIVES

To find information on the use of care bundles for care of arterial, central, and peripherally inserted venous catheters.

METHODS

Data was extracted by 2 independent researchers using standardized methodology.

RESULTS

Results of 84 studies included 2 (2.4%) randomized controlled trials, 38 (45.2%) observational studies, 29 (34.5%) quality projects, and 15 (17.9%) reviews. Populations had more adults than pediatric patients. All studies had the most prominent theme of decreased infection in all devices after using bundle strategies.

DISCUSSION AND CONCLUSIONS

The mapping of available evidence strongly supports the use of care bundles to reduce infection in the care of all intravascular devices. However, deficiencies regarding practice concerns about insertion and care of arterial catheters highlight areas for future research with the aim to eliminate the gap in the evidence of studies of care bundles for peripheral arterial catheters.

Central Venous Catheters versus Peripherally Inserted Central Catheters: A Comparison of Indwelling Time Resulting in Colonization by Multidrug-Resistant Pathogens

BACKGROUND

The use of peripherally inserted central catheters (PICCs) as an alternative to central venous catheters (CVCs) has steadily risen over the last two decades. However, there is an ongoing debate regarding research evidence that supports any clear advantages or disadvantages of them compared to traditional central venous lines. The present study was conducted to compare the indwelling time of CVC and PICC placements leading to microbial colonization by multidrug-resistant microorganisms (MDROs) in critically ill patients.

METHODS

A single-center retrospective descriptive study was performed that reviewed the medical records of critically ill patients with colonized CVCs and PICCs who were hospitalized during a 24-month period (May 2019-May 2021). To evaluate the association between indwelling time of catheter placement and colonization rates, events were categorized into three groups, each representing a one-week time interval of catheter indwelling time: group 1: ≤7 days, group 2: 8-14 days, and group 3: >14 days.

RESULTS

A total of 207 hospitalized patients with colonized PICCs or CVCs were included in the study. Of these, 144 (69.5%) had a CVC placement and 63 (30.5%) had a PICC placement. The overall colonization rate (per 1.000 catheter/days) was 14.73 in the CVC and 5.67 in the PICC cohort (p = 0.003). In the group of PICCs, 12/63 (19%) of the pathogens were MDROs and 51/63 (81%) were non-MDROs, while in the group of CVCs, 86/144 (59.7%) were MDROs and 58/144 (40.3%) were non-MDROs (p < 0.001). The colonization rate in the CVC cohort, was 6.98 for group 1, 21.57 for group 2, and 21.6 for group 3 (p = 0.019). The colonization rate of MDROs was 3.27 for group 1, 14.47 for group 2, and 12.96 for group 3 (p = 0.025). Regarding the PICC cohort, the colonization rate was 1.49 for group 1, 3.19 for group 2, and 8.99 for group 3 (p = 0.047). No significant difference existed between the three groups in terms of MDRO pathogens, with the colonization rate being 0 for group 1, 0.8 for group 2, and 1.69 for group 3 (p = 0.78). Within the CVC cohort, the most common isolated microorganism was MDR Acinetobacter baumannii (n = 44; 30.6%), followed by MDR Klebsiella pneumoniae (n = 27; 18.7%). In the PICC cohort, the predominant isolated microorganism was Candida non-albicans (n = 15; 23.8%), followed by Candida albicans, coagulase-negative staphylococci, and MDR Klebsiella pneumoniae in equal numbers (n = 6; 9.5%).

CONCLUSIONS

Our findings show that while the indwelling time of PICC placement was longer compared to CVCs, its colonization rate was considerably lower. Furthermore, high colonization rates by microorganisms, especially MDROs, arose later during catheterization in PICCs compared to CVCs, suggesting that in terms of vascular infections, PICCs may be a safer alternative to conventional CVCs for long-term intravenous access.

Implementation of a vascular access team and an intravenous therapy programme: A first-year activity analysis

BACKGROUND

Creating Vascular Access Teams (VAT) provides an expert nursing role that contributes to the training and continuous improvement of healthcare personnel. They can offer greater clinical safety, reducing complications and costs. Peripherally inserted central catheters (PICCs) and midline catheters (ML) can be safe and cost-effective alternatives to other types of venous access (VA). The aim of the study was to analyse our centre's VAT first 12 months of activity. The primary outcome was reported complications. Secondary outcomes were cause of catheter removal, consultancy activity and economic impact of VAT implantation.

METHODOLOGY

A longitudinal, descriptive study was carried out from March 2019 to March 2020. Using consecutive sampling, all VA inserted, and all consults received were included. Patients under 18 years of age were excluded.

RESULTS

The VAT inserted 1257 catheters into 1056 patients (291 MLs, 966 PICCs). The mean dwell time was 14.9 days for MLs and 59.07 days for PICCs. The main reason for removing VA was end of treatment (80.7%). During VA follow-up confirmed infection was detected in 1 ML (0.3%) and nine PICCs (0.9%). Symptomatic thrombosis was reported in 2 MLs (0.7%) and 16 PICCs (1.7%). The VAT received 367 consultations, and the main reason for consultation was to resolve doubts regarding the management of VA (80.9%). The insertion of ML and PICC catheters represented annual estimated economic savings of €867,688.44€.

CONCLUSIONS

Our study provides a detailed analysis of VAT's activity, its relevance to clinical safety, and to efficient resource management within our hospital. It demonstrates how VAT establishment can be a safe and efficient intervention that enhances care quality.

Technical Feasibility and Safety of Central Venous Ports for Intravenous Chemotherapy in Infants With Retinoblastoma: A Retrospective Study

PURPOSE

The central venous port (CVP) is widely used for intravenous chemotherapy (IVC) in adult patients because of its lower infection rates and easier management than that of a central venous catheter. However, the feasibility and safety of the CVP for IVC in infants remain unknown. This study evaluated the usefulness of CVP for IVC in infants with retinoblastoma.

METHODS

The usefulness of CVP was retrospectively evaluated using technical success rates, the safety of CVP placement, and postoperative procedure-related complications in 18 infants with retinoblastoma. This study was conducted at the National Cancer Center Hospital, Chuo-Ku, Tokyo, Japan.

RESULTS

The technical success rate was 100% (18/18) without any procedure-related complications. The sum duration of CVP implantation was 12,836 days (mean: 713 ± 453 days, range: 10-1,639 days). Postoperative complications were observed in two cases; one was a port reversal after 20 days, which was reversed by incisional surgery, and another was a catheter-related bloodstream infection after eight days, resulting in CVP removal. The total incidence of CVP-related infections was 5.6% (1/18) and 0.08/1000 catheter days. No other CVP-related complications were noted.

CONCLUSION

The use of the CVP for IVC in infants with retinoblastoma was feasible with few complications.

Metastatic spondylodiscitis in central venous catheter related bloodstream infections in hemodialysis patients: Risk factors and prognosis

BACKGROUND

Infection is one of the most common causes of death in hemodialysis patients. Catheter infections are among the most common infections in this patient group. Spondylodiscitis which has a high incidence in ESRD is more commonly encountered in patients with CVCs compared to AVF. In this study, we aimed to evaluate the frequency and risk factors of spondylodiscitis in catheter-related bloodstream infections in hemodialysis patients.

METHODS

In total, 1620 patients were screened and 42 male and 35 female patients with central catheter infection with a mean age of 65.8 ± 14.9 years were included in this study. Patients with metastatic infections secondary to CVC related bloodstream infections were determined. The diagnosis of spondylodiscitis was based on clinical information, computed tomography (CT) and magnetic resonance imaging (MRI), and vertebral cultures.

RESULTS

Metastatic infection due to catheter infection was observed in 15 patients (19.5%). In the regression analysis, CRP level and RRT time were found to be significantly correlated with the development of metastatic infection. Spondylodiscitis was the most common subtype of metastatic infections (8/15). The presence of lumbar hernia was associated with increased risk of metastatic spondylodiscitis in case of catheter infection in hemodialysis patients. The only factor associated with resistance to medical treatment was the time from admission to diagnosis.

CONCLUSION

Patients with long RRT time and high blood CRP levels on admission should be closely monitored for metastatic infection in patients with CVC related bloodstream infections. Screening for spondylodiscitis with CT or MRI should be performed in patients with symptoms, since early diagnosis may prevent the development of possible neurological deficits and treatment resistance.

The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: A systematic review and meta-analysis

BACKGROUND

Central venous catheters are commonly used in healthcare, but they come with a range of potential complications. Over the last 15 years, an influx of securement and dressing products has been released, with unknown overall effectiveness to prevent these complications.

OBJECTIVE

To compare the effects of dressings and securement devices for central venous catheters on a range of common complications including catheter-related bloodstream infection, catheter tip colonisation, entry/exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing durability and mortality.

DESIGN

Systematic review with meta-analysis.

METHODS

Following standard Cochrane methods, a systematic search of Cochrane Wounds Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, EBSCO CINAHL, and multiple clinical trial registries was completed in November 2022. Randomised controlled trials evaluating the effectiveness of dressing and securement devices for all CVC types were included. A random-effects model was used during the meta-analysis. Results were expressed using risk ratio (RR), rate ratio, or mean difference (MD), with 95 % confidence intervals (CIs). Methodological quality and bias were assessed.

RESULTS

We included 46 studies involving 10,054 participants. All studies had either an unclear or high-performance bias. The blinding of outcome assessment was unclear in most studies. Chlorhexidine gluconate-impregnated dressings, compared with standard polyurethane dressings, may reduce the incidence (7 studies; N = 5816; RR 0.60, 95 % CI 0.44-0.83; low certainty evidence) and rate (4 studies; N = 4447; RR 0.51, 95 % CI 0.32-0.79; moderate certainty evidence) of catheter-related bloodstream infection and catheter tip colonisation (8 studies; N = 4788; RR 0.70, 95 % CI 0.52-0.95; very low certainty evidence). Medication-impregnated dressings may reduce the incidence of catheter-related bloodstream infection (6 studies; N = 5687; RR 0.60, 95 % CI 0.39-0.93; low certainty evidence) and catheter-tip colonisation (7 studies; N = 4769; RR 0.60, 95 % CI 0.47-0.76; low certainty evidence) relative to non-impregnated dressing types. Tissue adhesive may increase the risk of skin irritation or damage compared with integrated securement dressings (3 studies; N = 166; RR 1.88, 95 % CI 1.09-3.24; low certainty evidence) or sutureless securement devices (4 studies; N = 241; RR 1.64, 95 % CI 1.10-2.44; moderate certainty evidence). Tissue adhesive increased dressing durability compared with integrated securement dressings (MD 43.03 h, 95 % CI 4.88-81.18; moderate certainty evidence) and sutureless securement devices (MD 42.90 h, 4.64-81.16; moderate certainty evidence). Tissue adhesive increased failed catheter securement rate compared with suture (2 studies; N = 103; RR 9.33, 95 % CI 1.10-79.21; moderate certainty evidence).

CONCLUSIONS

The findings of the review provide insights and guidance for clinicians in selecting the appropriate dressings and securements for catheters. Findings should be interpreted with caution due to heterogeneity in catheters and patient types.

REGISTRATION

#CD010367.

TWEETABLE ABSTRACT

Time to implement chlorhexidine gluconate-impregnated dressings to prevent catheter-related bloodstream infections; a meta-analysis by @GraceNP and team.

Defaulting peripherally inserted central catheter (PICC) orders to single lumen: A quality improvement initiative at a Midwestern academic center 2022-2023

Defaulting the order for peripherally inserted central catheters (PICCs) placement to single lumen increased proportion of single-lumen insertions over total insertions from 42/126 (33%) to 57/104 (51)%. Single-lumen PICCs had a nonsignificant lower rate of central line-associated bloodstream infection compared to double-lumen PICCs.

Understanding the diagnosis of catheter-related bloodstream infection: real-time monitoring of biofilm growth dynamics using time-lapse optical microscopy

Background

The differential time to positivity (DTTP) technique is recommended for the conservative diagnosis of catheter-related bloodstream infection (C-RBSI). The technique is based on a 120-minute difference between microbial growth in blood drawn through the catheter and blood drawn through a peripheral vein. However, this cut-off has failed to confirm C-RBSI caused by Candida spp. and Staphylococcus aureus.

Objective

We hypothesized that the biofilm of both microorganisms disperses faster than that of other microorganisms and that microbial load is rapidly equalized between catheter and peripheral blood. Therefore, our aim was to compare the biofilm dynamics of various microorganisms.

Methods

Biofilm of ATCC strains of methicillin-resistant Staphylococcus epidermidis, methicillin-susceptible S. aureus, Enterococcus faecalis, Escherichia coli and Candida albicans was grown on silicon disks and analyzed using time-lapse optical microscopy. The time-lapse images of biofilms were processed using ImageJ2 software. Cell dispersal time and biofilm thickness were calculated.

Results

The mean (standard deviation) dispersal time in C. albicans and S. aureus biofilms was at least nearly 3 hours lower than in biofilm of S. epidermidis, and at least 15 minutes than in E. faecalis and E. coli biofilms.

Conclusion

Our findings could explain why early dissemination of cells in C. albicans and S. aureus prevents us from confirming or ruling out the catheter as the source of the bloodstream infection using the cut-off of 120 minutes in the DTTP technique. In addition, DTTP may not be sufficiently reliable for E. coli since their dispersion time is less than the cut-off of 120 minutes.

Interventions to reduce peripheral intravenous catheter failure: An international e-Delphi consensus on relevance and feasibility of implementation

BACKGROUND

Around 1 billion peripheral intravenous catheters (PIVC) fail annually worldwide before prescribed intravenous therapy is completed, resulting in avoidable complications, dissatisfaction, and avoidable costs surging to ∼€4bn. We aimed to provide an international consensus on relevance and feasibility of clinical practice guideline recommendations to reduce PIVC failure.

METHODS

e-Delphi study with three rounds through an online questionnaire from March-September 2020 recruiting a multispecialty panel formed by clinicians, managers, academic researchers, and experts in implementation from seven developed and three developing countries, reflecting on experience in PIVC care and implementation of evidence. Further, we included a panel of chronic patients with previous experience in the insert, maintenance, and management of PIVC and intravenous therapy from Ireland and Spain as public and patient involvement (PPI) panel. All experts and patients scored each item on a 4-point Likert scale to assess the relevance and feasibility. We considered consensus descriptor in which the median was 4 with less than or equal to 1,5 interquartile intervals.

FINDINGS

Over 90% participants (16 experts) completed the questionnaire on all rounds and 100% PPI (5 patients) completed round 1 due to high consensus they achieved. Our Delphi approach included 49 descriptors, which resulted in an agreed 30 across six domains emerged from the related to (i) general asepsis and cutaneous antisepsis (n = 4), (ii) catheter adequacy and insertion (n = 3), (iii) catheter and catheter site care (n = 6), (iv) catheter removal and replacement strategies (n = 4), (v) general principles for catheter management (n = 10), and (vi) organisational environment (n = 3).

CONCLUSION

We provide an international consensus of relevant recommendations for PIVC, deemed feasible to implement in clinical settings. In addition, this methodological approach included substantial representation from clinical experts, academic experts, patient and public expertise, mitigating uncertainty during the implementation process with high-value recommendations to prevent PIVC failure based contextual and individual features, and economic resources worldwide.

Effectiveness of short peripheral intravenous catheter educational programmes to improve clinical outcomes protocol for a systematic review

The placement of a short peripheral intravenous catheter (sPIVC) is the most common invasive clinical procedure for patients requiring fluid infusion and multiple blood draws. Phlebitis and infiltration represent the most common catheter-related complications. Occlusions, dislocations, and infections are less frequent. Insufficient knowledge and skills may increase the risk of these complications. This review aims to evaluate the effectiveness of training programmes to reduce sPIVC failure amongst hospitalised patients. We will search PubMed, Embase, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Vascular Specialized Register through the Cochrane Register of Studies, and Google Scholar. We defined the search query using the PICO framework (Participants: health professionals; Intervention: training programme; Comparison: No training programme; Outcomes: all-cause catheter failure). We will include experimental studies evaluating an educational programme to reduce early sPIVC failure amongst hospitalised patients. Two reviewers will independently screen studies for inclusion, extract data, and perform the risk of bias assessment using the Cochrane Effective Practice and Organisation of Care Risk of Bias tool for randomised controlled trials. This review will highlight important perspectives for future studies on the effectiveness of educational programmes focused on reducing the rate of sPIVC complications.