Draft Guideline for Prevention of Intravascular Device-Related Infections: Part 1. ``Intravascular Device-Related Infections: An Overview'' and Part 2. Recommendations for Prevention of Intravascular Device-Related Infections; Notice of Comment Period

SUMMARY: This notice is a request for review and comment of the draft

Guideline for Prevention of Intravascular Device-related Infections.

The Guideline consists of two parts: Part 1. ``Intravascular Device-

related Infections: An Overview'' and Part 2. ``Recommendations for

Prevention of Intravascular Device-related Infections,'' and was

prepared by the Hospital Infection Control Practices Advisory Committee

(HICPAC) and the National Center for Infectious Diseases (NCID), CDC.

DATES: Written comments on the draft document must be received on or

before October 30, 1995.

ADDRESSES: Comments on this document should be submitted in writing to

the CDC, Attention: IV Guideline Information Center, Mailstop E-69,

1600 Clifton Road, NE., Atlanta, Georgia 30333. To order copies of the

Federal Register containing the document, contact the U.S. Government

Printing Office, Order and Information Desk, Washington, DC 20402-9329,

telephone (202) 512-1800. Specify the date of the issue requested and

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Register containing this draft document may be viewed and photocopied

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FOR FURTHER INFORMATION CONTACT: The IV Guideline Information Center,

telephone (404) 332-2569.

SUPPLEMENTARY INFORMATION: This 2-part document updates and replaces

the previously published CDC Guideline for Prevention of Intravascular

Infections (Am J Infect Control 1983;11:183-199). Part 1,

``Intravascular Device-related Infections: An Overview,'' reviews

issues relevant to intravascular device-related infections and serves

as the background for the consensus recommendations of the Hospital

Infection Control Practices Advisory Committee (HICPAC) that are

contained in Part 2, ``Recommendations for Prevention of Intravascular

Device-related Infection.''

HICPAC was established in 1991 to provide advice and guidance to

the Secretary and the Assistant Secretary for Health, DHHS; the

Director, CDC; and the Director, NCID regarding the practice of

hospital infection control and strategies for surveillance, prevention,

and control of nosocomial infections in U.S. hospitals. The committee

also advises CDC on periodic updating of guidelines and other policy

statements regarding prevention of nosocomial infections.

The Guideline for Prevention of Intravascular Device-related

Infections is the third in a series of CDC guidelines being revised by

HICPAC and NCID, CDC.

Dated: September 14, 1995.

Claire V. Broome,

Deputy Director, Centers for Disease Control and Prevention (CDC).

Guideline for Prevention of Intravascular Device-Related Infections

Executive Summary

The revised guideline is designed to reduce the incidence of

intravascular device-related infections and provides an overview of the

evidence for recommendations considered prudent by consensus of HICPAC

members. A working draft of the guideline was reviewed by experts in

hospital infection control, internal medicine, pediatrics, and

intravenous therapy; however, all recommendations contained in the

guideline may not reflect the opinion of all reviewers.

This document focuses largely on the epidemiology, pathogenesis and

diagnosis of, and preventive strategies for, infections associated with

the intravascular devices most commonly used in health care settings

and for which there is adequate scientific data on which to base

recommendations for device use and care. Such devices include

peripheral venous and arterial catheters, central venous and arterial

catheters, peripherally inserted central venous catheters, and pressure

monitoring systems. Newer devices (e.g., antimicrobial-impregnated

catheters, needleless infusion systems) are also discussed. However,

intraaortic balloon pumps, cardiac catheters, pacemakers, and

extracorporeal membrane oxygenators are not addressed in this document

because there is insufficient scientific data on which to base

recommendations for use and care.

The unique circumstances and special considerations related to

intravascular device-related infections in pediatric patients and

infections associated with parenteral nutrition and hemodialysis will

be addressed in separate sections.

Introduction

Intravascular devices are indispensable in modern-day medical

practice. However, the use of intravascular devices is frequently

complicated by a variety of local and/or systemic infectious

complications. Infections related to the use of intravascular devices,

particularly catheter-related bloodstream infections, are associated

with increased morbidity and mortality, prolonged hospitalization, and

increased medical costs.

Part 1, ``Intravascular Device-related Infections: An Overview''

addresses many of the issues and controversies in intravascular-device

use and maintenance. These issues include definitions and diagnosis of

catheter-related infection, barrier precautions during catheter

insertion, changes of catheters and administration sets, catheter-site

care, and the use of prophylactic antimicrobials, flush solutions and

anticoagulants. Part 2, ``Recommendations for Prevention of

Intravascular Device-related Infections'' provides consensus

recommendations of the HICPAC for the prevention and control of

infections related to the use of intravascular devices.

The Guideline for Prevention of Intravascular Device-related

Infections is intended for use by personnel who are responsible for

surveillance and control of infections in the acute-care, hospital-

based setting, but many of the recommendations may be adaptable for use

in the outpatient or home-care setting.

Part 1. Intravascular Device-Related Infections: An Overview

Contents

I. Background

II. Epidemiology

Devices Used for Short-term Vascular Access

Peripheral venous catheters

Peripheral arterial catheters

Midline catheters

Nontunneled central venous catheters (CVCs)

[[Page 49979]]

Central arterial catheters

Pressure monitoring systems

Peripherally Inserted CVCs

Devices Used for Long-term Vascular Access

Tunneled CVCs

Totally implantable intravascular devices

III. Microbiology

IV. Pathogenesis

V. Definitions and Diagnosis of Catheter-Related Infections

Infections Associated with Short-term Catheters

Infections Associated with Long-term Catheters

Catheter-related Bloodstream Infection

Infusate-related Bloodstream Infection

VI. Strategies for Prevention of Catheter-Related Infections

Site of Catheter Insertion

Type of Catheter Material

Barrier Precautions during Catheter Insertion

Changing Catheters and Administration Sets

Intravenous administration set changes

Intravenous catheter changes

Catheter-site Care

Cutaneous antiseptics and antimicrobial ointments

Catheter-site dressing regimens

In-line Filters

Silver-chelated Collagen Cuffs

Antimicrobial-Impregnated (Coated) Catheters

Intravenous Therapy Personnel

Prophylactic Antimicrobials

Flush Solutions, Anticoagulants, and Other Intravenous Additives

Needleless Intravascular Devices

Multidose Parenteral Medication Vials

VII. Intravascular Device-Related Infections Associated with Total

Parenteral Nutrition

Risk Factors

Surveillance and Diagnosis

Strategies for Prevention

Infusate preparation

Cutaneous antisepsis

Selection of catheter

Catheter-site dressings

Catheter changes

Specialized personnel

VIII. Intravascular Device-Related Infections Associated with

Hemodialysis Catheters

Epidemiology

Microbiology

Strategies for Prevention of Hemodialysis Catheter-related

Infections

Cutaneous antisepsis

Catheter changes

Prophylactic antimicrobials

IX. Intravascular Device-Related Infections in Pediatric Patients

Microbiology

Epidemiology

Peripheral venous catheters

Peripheral arterial catheters

Umbilical catheters

CVCs

Table 1. Definitions for Catheter-related Infection

Table 2. Factors Associated with Infusion-related Phlebitis among

Patients with Peripheral Venous Catheters

Figure 1. Potential Sources for Contamination of Intravascular

Devices

I. Background

Intravascular devices are indispensable in modern-day medical

practice. They are used to administer intravenous fluids, medications,

blood products, and parenteral nutrition fluids, and to monitor the

hemodynamic status of critically ill patients. However, the use of

intravascular-devices is frequently complicated by a variety of local

and/or systemic infectious complications (see definitions in Table 1),

including septic thrombophlebitis, endocarditis, bloodstream infection

(BSI), and metastatic infection (e.g., osteomyelitis, endophthalmitis,

arthritis) resulting from hematogenous seeding of another body site by

a colonized catheter. Catheter-related infections (CRIs), particularly

catheter-related BSIs (CR-BSIs), are associated with increased

morbidity; mortality of 10%-20%; prolonged hospitalization (mean of 7

days); and increased medical costs, in excess of $6,000 (1988 dollars)

per hospitalization.1-5

II. Epidemiology

An estimated 200,000 nosocomial BSIs occur each year.6 During

1980-1989, significant increases were detected in the rates of

nosocomial BSI reported from the National Nosocomial Infection

Surveillance (NNIS) System hospitals where hospital-wide surveillance

was conducted.7 Reported rates increased by 70%-279%, depending on

hospital size and affiliation.

Most nosocomial BSIs are related to the use of an intravascular

device, with BSI rates being substantially higher among patients with

intravascular devices than among those without such devices.8 As

with overall rates of nosocomial BSI, rates of device-related BSI vary

considerably by hospital size, hospital unit/service, and type of

device. During the years 1986-1990, NNIS hospitals conducting intensive

care unit (ICU) surveillance reported rates of central catheter-related

BSI ranging from 2.1 (respiratory ICU) to 30.2 (burn ICU) BSIs per

1,000 central catheter days. Rates of noncentral catheter-related BSI

were substantially lower, ranging from 0 (coronary, medical, and

medical/surgical ICU) to 2.0 (trauma ICU) BSIs per 1,000 noncentral

catheter-days.8

The incidence of and potential risk factors for intravascular-

device related infections may vary considerably with the type and

intended use of the device, and these factors should be considered when

selecting a device for use.

In general, intravascular devices can be divided into two broad

categories, those used for short-term, or temporary, vascular access

and those used for long-term vascular access. Long-term (indwelling)

vascular devices usually require surgical insertion, while short-term

devices can be inserted percutaneously.

Devices Used for Short-Term Vascular Access

Peripheral venous catheters. Of all intravascular devices, the

peripheral venous catheter is the most commonly used. Phlebitis,

largely a physicochemical or mechanical rather than infectious

phenomenon, remains the most important complication associated with the

use of peripheral venous catheters. A number of factors, including type

of infusate and catheter material and size, influence a patient's risk

for developing phlebitis (Table 2); when phlebitis does occur, the risk

of local CRI may be increased.9-13 However, peripheral venous

catheters have rarely been associated with BSI; 9 14-17 this may

reflect the short duration of catheterization with these devices.

Peripheral arterial catheters. Peripheral arterial catheters are

commonly used in acute-care settings to monitor the hemodynamic status

of critically ill patients. Data suggest that peripheral arterial

catheters may be associated with a substantially lower risk of local

CRI and CR-BSI than are peripheral venous catheters left in place for a

comparable length of time.18 Although the reasons for the

differences in rates of CRI associated with these two types of

catheters are not clear, arterial catheters may be less prone to

colonization than are venous catheters because they are exposed to

higher vascular pressures.19 Factors shown to predispose patients

with peripheral arterial catheters to CRI are inflammation at the

catheter insertion site, catheterization >4 days, or catheter insertion

by cutdown.20 21 In contrast to peripheral venous catheters,

peripheral arterial catheters inserted in the lower extremities,

specifically the femoral area, do not clearly pose a greater risk of

infection than do peripheral arterial catheters inserted in upper

extremities or brachial areas.22

In addition to monitoring hemodynamic status, arterial catheters

may also be used to administer local intraarterial chemotherapy.

Although this is a well-established method for treating metastatic or

unresectable tumors, very little has been published on the infectious

complications associated with this form of therapy. Maki et al.

conducted an epidemiologic investigation of endarteritis associated

[[Page 49980]]

with intraarterial chemotherapy administration and identified several

risk factors for infection: leukopenia, hypoalbuminemia, prior

radiation therapy, difficult catheterization, and repeated manipulation

of the catheter.23

Midline catheters. Midline catheters are peripherally inserted

(into antecubital veins), six-inch elastomer catheters that do not

enter central veins, but have recently been used as an alternative to

central venous catheterization. Presently, there is little published

scientific data on which to assess the infectious risks posed by these

newer devices.

Nontunneled central venous catheters (CVCs). CVCs account for an

estimated 90% of all catheter-related bloodstream infections 6 and

nontunneled (percutaneously-inserted) CVCs are the most commonly used

central catheters. Among the factors that influence the risk of

infection associated with the use of CVCs are the number of catheter

lumens and the site at which the catheter is inserted.

Multilumen CVCs are often preferred by clinicians, because they

permit the concurrent administration of various fluids/medications and

hemodynamic monitoring among critically ill patients. In nonrandomized

trials, multilumen catheters have been associated with a higher risk of

infection than have their single-lumen counterparts.24-26 In two

of three randomized trials multilumen catheters were associated with an

increased risk of infection.27-29 Multilumen catheter insertion

sites may be particularly prone to infection because of increased

trauma at the insertion site and/or because multiple ports increase the

frequency of CVC manipulation.25 26 Although patients with

multilumen catheters tend to be more ill, the infection risk found with

the use of these catheters may be independent of the patient's

underlying disease severity.28

In addition to the number of lumens, the site at which a CVC is

inserted may play a major role in CVC-related infections. Five of six

studies have shown a significantly higher colonization or infection

rate with catheters inserted into the internal jugular vein compared

with those inserted into the subclavian vein, with a risk ratio as high

as 2.7.30-35 Other risk factors for CVC-related infections include

repeated catheterization, presence of a septic focus elsewhere in the

body, exposure of the catheter to bacteremia, absence of systemic

antimicrobial therapy,31 duration of catheterization, and type of

dressing.33

Central arterial catheters. Pulmonary artery catheters (PACs)

(i.e., Swan Ganz 1 catheters) differ from CVCs in that they are

inserted through a Teflon introducer and typically remain in place an

average of only 3 days. However, they carry many of the same risks and

have similar rates of BSI as do other central catheters. Risk factors

reported for CRI in patients with PACs include duration of

catheterization >3 days,36 >5 days,37 or >7 days;21

colonization of the skin insertion site;36 38 and catheter

insertion in the operating room using submaximal barrier precautions

(i.e., gloves, small-fenestrated drape).36 Site of insertion may

also influence the risk of infection associated with PACs. Two studies

suggest that PACs inserted into jugular veins have a higher rate of

infection compared with those inserted into subclavian veins;36,

39 three other studies found no difference in infection rates

associated with the two insertion sites.37 38 40

\1\ 1Use of trade names is for identification only and does not

imply endorsement by the U.S. Public Health Service or the U.S.

Department of Health and Human Services.

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Pressure monitoring systems. Pressure monitoring systems used in

conjunction with arterial catheters have been associated with both

epidemic and endemic nosocomial BSIs.41 42 The first outbreak of

infections due to contamination of pressure monitoring systems was

reported in 1971;43 subsequently, 26 such outbreaks have been

reported.44-48 The final common pathway for microorganisms that

enter the bloodstream of patients and cause bacteremia is the fluid

column in the tubing between the patient's intravascular catheter and

the pressure monitoring apparatus. Microorganisms in a fluid filled

system may move from the pressure monitoring apparatus to the patient

or from the patient to the pressure monitoring system.42

The earliest outbreaks related to pressure monitoring were due to

contaminated infusate 43 or failure to sterilize the fluid pathway

in reusable transducers, particularly the chamber domes.49, 50

Because of the difficulties in sterilizing reusable transducers,

sterile disposable plastic chamber domes were developed. These domes

have a plastic membrane that makes contact with the sensor diaphragm on

the head of the transducer and isolates the sterile fluid pathway from

the transducer. However, systems containing these disposable domes have

also been associated with outbreaks.45 46 51 52 While

resterilization of disposable domes may damage the membrane and permit

ingress of microorganisms into the sterile fluid pathway,53 in

most outbreaks the membranes in the disposable domes remained

intact.46, 51 A study in 1979 showed that fluid used to fill the

space between the transducer head and the membrane of the disposable

dome frequently contaminated the hands of the operator and that the

system was inoculated by touch contamination during the subsequent

assembly of the pressure monitoring system.52 This mode of

contamination is most likely to occur when glucose solutions are used

between the transducer head and the chamber dome membrane and when

transducers are not effectively decontaminated between uses.54

Most outbreaks that have occurred since the introduction of the

disposable chamber dome have been due to this type of

contamination.54

Other mechanisms by which pressure monitoring systems have been

contaminated include contamination of infusate, 41 in-use

contamination of the system by nonsterile calibrating devices,55

contamination of the system by ice used to chill syringes,56

introduction of microorganisms into the system by contaminated

disinfectant 49 and in-use contamination of the system related to

blind, stagnant columns of fluid between the transducer and infusion

system.42 The importance of the latter mechanism in contamination

was shown by a substantial drop in contamination of the system after

introduction of a continuous flush device that eliminated the stagnant

column of fluid.57

To date, no outbreaks have been reported with the use of disposable

pressure transducers. A prospective study of disposable transducers has

shown a very low rate of associated infection (one case of bacteremia

in 157 courses of pressure monitoring).58 This study also showed

that disposable transducers can be safely used for 4 days.58

Disposable transducers were used as a control measure in one reported

outbreak caused by contaminated reusable transducers.45

Peripherally Inserted CVCs

Peripherally inserted CVCs (PICCs) are inserted into the right

atrium by way of the cephalic and basilar veins of the antecubital

space and provide an alternative to subclavian or jugular vein

catheterization and, because they do not require surgical insertion,

cost much less to insert than tunneled subclavian catheters or

subcutaneous ports. PICCs have been used for a variety of purposes,

including total parenteral nutrition (TPN) administration, and their

use appears to be associated with a rate of infection similar to that

reported with other percutaneously inserted CVCs.59 Further

studies are

[[Page 49981]]

needed to adequately determine how long PICCs can safely be left in

place 59 60 and to determine the epidemiology and microbiology of

associated infections.

Devices Used for Long-Term Vascular Access

Tunneled central venous catheters. Surgically implanted right

atrial catheters, including Hickmans, Broviacs, Groshongs, and

Quintons, are commonly used to provide vascular access to patients

requiring prolonged intravenous therapy (e.g., chemotherapy or home-

infusion therapy, hemodialysis). In contrast to percutaneously inserted

(nontunneled) CVCs, these catheters have a tunneled portion exiting the

skin and a Dacron cuff just inside the exit site. The cuff inhibits

migration of organisms into the catheter tract by stimulating growth of

the surrounding tissue, thus sealing the catheter tract and providing a

natural anchor for the catheter. In general, the rates of infections

reported with the use of tunneled catheters have been significantly

lower than those reported with the use of nontunneled CVCs;61-69

however, two recent studies, one randomized, found no significant

difference in the rates of infection among tunneled and nontunneled

catheters.59 70

Totally implantable intravascular devices (TIDs). TIDs are also

tunneled beneath the skin, but have a subcutaneous port or reservoir

with a self-sealing septum that is accessed by needle puncture through

intact skin. TIDs offer the advantage of improved patient image and

obviate the need for routine catheter-site care. Among devices used for

long-term vascular access, TIDs have the lowest reported rates of

catheter-related BSI,71-81 possibly because they are located

beneath the skin with no orifice for ingress of microorganisms.

Recently, several investigators have attempted to compare the

infectious morbidity associated with TIDs and other tunneled catheters.

In one randomized study, TIDs and Hickman catheters had comparable

rates of infection.78 In another randomized study, TIDs had lower

rates of infection compared with other tunneled catheters.79

Groeger et al. conducted one of the largest comparisons of the

infectious complications associated with long-term vascular access

devices to date. In this prospective examination of 1431 devices in

patients with cancer, TIDs (0.21 infections per 1,000 device-days) had

a significantly lower rate of infectious complications compared with

other tunneled catheters (2.77 infections per 1,000 device days,

p0.001).80 However, the devices in Groeger's study were

not randomly assigned, thus the differences observed may be due to

factors other than those inherent to the devices. Existing data suggest

that either of the indwelling devices can be safely used with a low

risk of infection. The selection of a given device depends on the

intended use, patient population, and patient/practitioner preference.

III. Microbiology

Over the past two decades, there has been a marked change in the

distribution of pathogens reported to cause nosocomial BSIs.7 82

83 Since the mid-1980's, an increasing proportion of nosocomial BSIs

reported to NNIS have been due to gram-positive, rather than gram-

negative, species. Moreover, a major portion of the overall increase in

nosocomial BSIs reported to NNIS during the past decade was due to

significant increases in four pathogens: coagulase-negative

staphylococci (CoNS), Candida spp., enterococci, and Staphyloccocus

aureus. The distribution of these pathogens varied by hospital size and

affiliation (i.e., teaching, nonteaching).7

CoNS, particularly S. epidermidis, have become the most frequently

isolated pathogens in CRIs and accounted for an estimated 28% of all

nosocomial BSIs reported to NNIS during 1986-89.7 84 The emergence

of CoNS as the primary pathogen causing CRIs can be attributed to

several factors: (1) increased use of prosthetic/indwelling devices

(e.g., intravascular catheters);85 (2) improved survival of low

birthweight neonates and increased use of intralipids in these

patients;86 and (3) recognition of CoNS as true nosocomial

pathogens rather than harmless commensals.7 The prevalence of

these pathogens also shows that the hands of healthcare workers (HCWs)

and the flora of patients' skin are likely the predominant sources of

pathogens for most CRIs.

Prior to 1986, S. aureus was the most frequently reported pathogen

causing nosocomial BSIs.84 Now, S. aureus accounts for an

estimated 16% of reported nosocomial BSIs.87 S. aureus BSIs may be

complicated by metastatic foci of infection (e.g., vertebral

osteomyelitis) and endocarditis.88-90

Enterococci, another emerging nosocomial bloodstream pathogen,

accounted for 8% of nosocomial BSIs reported to NNIS during 1986-

1989.84 More alarming, has been the emergence of vancomycin-

resistant enterococci (VRE). During 1989-1993, 3.8% of the blood

isolates from BSIs reported to NNIS were vancomycin resistant. Although

data were not available to adequately assess the attributable mortality

of either the BSI or the antimicrobial resistance of the isolate,

mortality was significantly higher among patients whose isolates were

vancomycin resistant (36.6%) than among those whose isolates were

vancomycin susceptible (16.4%).91 Risk factors associated with VRE

BSIs include receipt of antimicrobials (including vancomycin),

gastrointestinal colonization with VRE, underlying disease severity

(e.g., in oncology or transplant patients), abdominal or cardiac

surgical procedures, use of indwelling devices, and prolonged hospital

stay.92-99 Although enterococcal BSIs may arise from the patients'

endogenous flora, nosocomial transmission of VRE via the hands of

HCWs,93 patient-care equipment,100 and contaminated

environmental surfaces 92 93 has also been suggested by the

findings of recent outbreak investigations. The emergence of

enterococci as significant nosocomial bloodstream pathogens is likely

due, in part, to the increased use of invasive devices and the

injudicious use of broad-spectrum antimicrobials for treatment and

prophylaxis of infections.101-105

Fungal pathogens represent an increasing proportion of nosocomial

BSIs. During 1980-1990, NNIS hospitals reported a nearly fivefold

increase in the rate of nosocomial fungal BSIs (1.0 to 4.9/10,000

discharges) and a nearly twofold increase in the proportion of BSIs due

to fungal pathogens (5.4 to 9.9%).106 Such increases were detected

for hospitals of all sizes and affiliations and on all major hospital

services. Candida spp., particularly C. albicans, accounted for >75% of

all nosocomial fungal infections reported to NNIS during this period.

Candidemia has traditionally been thought to arise from the endogenous

flora of colonized patients,107-109 but recent epidemiologic

studies, assisted by the use of molecular typing, show that exogenous

infection due to administration of contaminated fluids,110 111 use

of contaminated equipment,112 cross-infection,113-117 and the

colonized hands of HCWs 118-122 are also important contributors to

candidemia among hospitalized patients.

Although less commonly implicated than either gram-positive

bacterial or fungal species as a cause of BSI, gram-negative

microorganisms account for the majority of CRIs associated with the use

of arterial catheters. Moreover, it has been suggested that clusters of

infections caused by certain gram-negative species, such as

Enterobacter

[[Page 49982]]

spp., Acinetobacter spp., S. marcescens or non-aeruginosa pseudomonads,

should automatically raise suspicion of a common source, such as a

contaminated pressure monitoring device. The predominance of gram-

negative microorganisms in infections associated with pressure

monitoring devices may be due to concomitant receipt of broad-spectrum

antimicrobials by patients undergoing hemodynamic monitoring.

IV. Pathogenesis

The pathogenesis of CRIs is multifactorial and complex (Figure 1),

but available scientific data show most CRIs appear to result from

migration of skin organisms at the insertion site into the cutaneous

catheter tract with eventual colonization of the catheter tip.123-

126 However, there is a smaller, but growing, body of data to suggest

that hub contamination can be an important contributor to intraluminal

colonization of catheters, particularly long-term catheters.127-

130

The relative importance of these two mechanisms of catheter

contamination is the source of continuing debate. Recent findings

suggest that duration of catheterization influences which of the two

mechanisms predominates. Using electron microscopy, Raad demonstrated

that hub contamination was the more likely mechanism of infection for

long-term catheters (i.e., in place >30 days), while skin contamination

was the more likely mechanism for short-term catheters (i.e., 130 Although much less common than either of these two

mechanisms, hematogenous seeding of the catheter tip from a distant

focus of infection or administration of contaminated infusate may also

cause CRIs.128 131-134

Two other important pathogenic determinants of CRI are (1) the

material of which the device is made, and (2) the intrinsic properties

of the infecting organism. In vitro studies show that catheters made of

polyvinyl chloride or polyethylene appear to be less resistant to the

adherence of microorganisms than are newer catheters made of Teflon,

silicone elastomer, or polyurethane.135-137 Some catheter

materials also have surface irregularities that may further enhance the

microbial adherence of certain species (e.g., CoNS, Acinetobacter

calcoaceticus, and Pseudomonas aeruginosa).138 139 Thus, catheters

made of certain materials may be more prone to microbial colonization

and subsequent infection. Additionally, certain catheter materials are

more thrombogenic than others, a characteristic that also may

predispose to catheter colonization and catheter-related

infection.140

The adherence properties of a given microorganism are also

important in the pathogenesis of CRI. For example, S. aureus can adhere

to host proteins (e.g., fibronectin) commonly present on

catheters,141 142 and CoNS, the most frequent etiologic agents in

CRIs, adhere to polymer surfaces more readily than do other common

nosocomial pathogens such as E. coli or S. aureus.143

Additionally, certain strains of CoNS produce an extracellular

polysaccharide often referred to as ``slime.'' In the presence of

catheters, this slime potentiates the pathogenicity of CoNS by allowing

them to withstand host defense mechanisms 144 145 (e.g., acting as

a barrier to engulfment and killing by polymorphonuclear leukocytes) or

by making them less susceptible to antimicrobial agents 146 (e.g.,

forming a matrix that binds antimicrobials before their contact with

the organism cell wall). More recent studies suggest that certain

Candida spp., in the presence of glucose-containing fluids, may produce

``slime'' similar to that of their bacterial counterparts, potentially

explaining the increased proportion of BSIs due to fungal pathogens

among patients receiving parenteral nutrition fluids.147

V. Definitions and Diagnosis of Catheter-Related Infections

Establishing a clinical diagnosis of CRI, especially catheter-

related BSI, is often difficult. Diagnosis is typically based on

clinical and/or laboratory criteria, with each having significant

diagnostic limitations. The introduction of semiquantitative methods

for culturing catheters has greatly enhanced our ability to diagnose

CRIs. Both semiquantitative and quantitative methods have greater

specificity in identifying CRI than do traditional broth cultures,

where a clinically insignificant inocula of microorganisms can result

in a positive catheter culture.31 148

However, interpretation of the results of these culture methods may

vary depending on the type and location of the catheter and the culture

methodology used. The use of varying definitions in studies of CRI have

made it difficult to compare existing studies of these infections.

The predictive values of semiquantitative and quantitative methods

may vary, depending on the source of catheter colonization.\130\ For

example, if the skin is the primary source of catheter colonization,

methods that culture the external surface of the catheter may be

preferable. Conversely, if hub contamination is the primary mechanism

for catheter colonization, methods that culture both the external and

internal surfaces may have greater yield.\130\ As the use of

antimicrobial-coated catheters becomes more prevalent, existing

definitions of catheter colonization and CRI may need to be modified.

Infections Associated with Short-Term Catheters

The most widely used laboratory technique for diagnosis of CRI is

the roll-plate method described by Maki et al.\148\ This method

cultures a segment of the catheter after it has been removed from the

patient by rolling the catheter segment across the surface of an agar

plate and determining the number of bacterial colonies present after

overnight incubation. Growth of 15 colony forming units

(cfus) from a proximal or distal catheter segment by semiquantitative

culture in the absence of accompanying signs of inflammation at the

catheter site is considered indicative of catheter colonization. Growth

of 15 cfus from a catheter by semiquantitative culture with

accompanying signs of inflammation (e.g., erythema, warmth, swelling,

or tenderness) at the device site is indicative of local CRI. In the

absence of semiquantitative culture, CRI may be diagnosed when there is

purulent drainage from the skin-catheter junction. Limitations of the

roll plate method are that it requires removal of the catheter and

overnight incubation before results become available.

Cooper et al. proposed direct gram-staining of catheters on removal

as a rapid way to diagnose catheter infection and as a complement to

semiquantitative culture.\126\ However, this method appears to be

considerably more time-consuming than semiquantitative culture and,

thus, may be impractical for routine diagnostic use.

Acridine-orange staining of catheters has been proposed as a

modification of the gram-staining technique.\149\ Although similar to

gram-staining, acridine-orange staining is a single-step procedure that

uses a fluorescent dye to enhance detection of microorganisms in

clinical specimens. This procedure avoids many of the technical

shortcomings encountered with the direct gram-staining technique, but

confirmatory studies documenting its quantitative test performance are

needed before it can be recommended.

The most sensitive technique for diagnosis of CRI is quantitative

culture. To culture a catheter quantitatively, the catheter segment is

either flushed with and then immersed in broth \150\ or placed in broth

and sonicated; 151 152 the

[[Page 49983]]

broth recovered from these procedures is cultured quantitatively.

Sonication releases microorganisms from both the luminal and external

surfaces of the catheter and thus may have greater sensitivity for

diagnosing CRIs, especially those associated with central venous and

arterial catheters, than do methods that only culture the external

surface of the catheter.\152\

All semiquantitative and quantitative catheter culture methods

require removal of the implicated catheter, but the venous access site

can be preserved by removing the catheter over a guidewire and

inserting a new catheter over the guidewire. The proximal and distal

segments of the catheter removed over the guidewire are cultured using

the semiquantitative technique.\153\ If a catheter is removed over a

guidewire and has a negative culture, the catheter inserted over the

guidewire may be left in place. If the catheter removed over a

guidewire has a culture result suggesting colonization/infection, the

second catheter should be removed, and a new catheter inserted at a new

site.59 131 153

Quantitative blood culturing techniques have been developed for

diagnosis of CR-BSI in patients where catheter removal is undesirable

because of limited vascular access. These techniques rely on

quantitative culture of paired blood samples, one obtained through the

central catheter and the other from a peripheral venipuncture site. In

most studies, a colony count from the blood obtained from the catheter

that is five to tenfold greater than the colony count from the blood

obtained from a peripheral vein has been predictive of CR-BSI.154-

156

Infections Associated With Long-Term Catheters

The use of these indwelling catheters may be complicated by a

variety of local infectious complications: exit-site, tunnel, or pocket

infections, as defined in Table 1.\69\ However, clinical diagnosis of

CRI involving the intravascular portion of indwelling catheters is

particularly difficult; thus, laboratory diagnosis is important. The

utility of the roll-plate method for diagnosis of infection associated

with long-term vascular access devices has not been evaluated, but

recovery of 15 cfus on semiquantitative culture of a

catheter segment may be diagnostic of colonization of the intravascular

segment. BSI resulting from a colonized intravascular segment may also

be suspected if 10-fold higher concentration of

microorganisms on quantitative culture of blood obtained from the

catheter compared with the concentration of microorganisms in blood

obtained from a peripheral venous site.157-159

Catheter-Related Bloodstream Infection

CR-BSI is most stringently defined as isolation of the same

organism (i.e., identical species, antibiogram) from semiquantitative

or quantitative cultures of both a catheter segment and the blood

(preferably drawn from a peripheral vein) of a patient with

accompanying clinical symptoms of BSI and no other apparent source of

infection. In the absence of laboratory confirmation, defervescence

after removal of an implicated catheter from a patient with BSI is also

considered indirect evidence of CR-BSI.

Infusate-Related Bloodstream Infection

Since BSI may result from the administration of contaminated

intravenous fluids, culturing intravenous fluids should be part of an

investigation of potential sources of infection. Infusate-related BSI

is usually defined as the isolation of the same organism from both

infusate and separate percutaneous blood cultures, with no other

identifiable source of infection.

VI. Strategies for Prevention of Catheter-Related Infections

Strict adherence to handwashing and aseptic technique remains the

cornerstone of prevention of CRIs; however, other measures may confer

additional protection and must be considered when formulating

preventive strategies. These measures include the selection of an

appropriate site of catheter insertion, selection of appropriate

catheter material(s), use of barrier precautions during catheter

insertion, change of catheters and administration sets at appropriate

intervals, catheter-site care, and the use of filters, flush solutions,

prophylactic antimicrobials, and newer intravascular devices (e.g.,

impregnated catheters, needleless infusion systems).

Site of Catheter Insertion

The site at which a catheter is placed may influence the subsequent

risk of CRI. For peripheral venous catheters, lower extremity

insertions pose a greater risk of phlebitis than do those inserted in

the upper extremity, and upper extremity sites differ in their risk for

phlebitis.160-164 Peripheral venous catheters inserted into hand

veins have a lower risk of phlebitis than do those inserted in upper

arm or wrist veins.\6\

Among CVCs, catheters inserted into subclavian veins have a lower

risk for infection than do those inserted in either jugular or femoral

veins. 31-36 39 Internal jugular insertion sites may pose a

greater risk for infection because of their proximity to oropharyngeal

secretions, and because catheters at internal jugular sites are

difficult to immobilize. However, mechanical complications associated

with insertion are less common with internal jugular vein insertion

than with subclavian venous catheterization.

Type of Catheter Material

The relationship between catheter material and infectious morbidity

has been largely examined by the study of peripheral venous catheters.

The majority of peripheral venous catheters in the U.S. are made of

Teflon or polyurethane, and these catheters appear to be associated

with fewer infectious complications than are catheters made of

polyvinyl chloride or polyethylene.17 135 165 In one large,

randomized prospective study of Teflon and polyurethane catheters, the

two types of catheters had comparable rates of local infection, 5.4%

and 6.9%, respectively,\17\ but polyurethane catheters were associated

with a nearly 30% lower risk of phlebitis when compared with Teflon

catheters. In this trial, neither the Teflon nor polyurethane catheter

was associated with BSI.\17\ By contrast, polyvinyl chloride or

polyethylene catheters have been associated with BSI rates ranging from

0%-5%.166 167

Steel needles, used as an alternative to synthetic catheters for

peripheral venous access, have the same rate of infectious

complications as do Teflon catheters. 168 169

However, the use of steel needles is frequently complicated by

infiltration of intravenous fluids into the subcutaneous tissues, a

potentially serious complication if the infused fluid is a

vesicant.\169\ In view of the low rates of BSI seen with newer Teflon

and polyurethane catheters, the relative risks and benefits of using

steel needles must be evaluated on an individual patient basis.

Catheter material seems to also be an important determinant in the

risk of infection associated with CVCs. Most CVCs used in the U.S. are

made of polyurethane, polyvinyl chloride, polyethylene, or silicone. In

one small, prospective trial comparing silicone with polyvinyl TPN

catheters, silicone catheters had a significantly lower rate of CR-BSI

than did polyvinyl chloride catheters, 0.83 and 19 per 1,000 catheter

days, respectively; however, the silicone catheters were tunneled, and

the polyvinyl chloride catheters were largely nontunneled. The

polyvinyl

[[Page 49984]]

chloride catheters also were associated with a higher risk of

mechanical complications (i.e., breakage, blockage, displacement, and

thrombosis).\170\ Because of the potential confounding caused by the

different types of catheters in this comparison (i.e., tunneled vs.

nontunneled), appropriate conclusions about the contribution of

catheter material to CVC-related infections can not be drawn.

Barrier Precautions During Catheter Insertion

It is generally accepted that good handwashing before and attention

to aseptic technique during insertion of peripheral venous catheters

provide adequate protection against infection. Central venous

catheterization, however, carries a significantly greater risk of

infection, and the level of barrier precautions needed to prevent

infection during insertion of CVCs has been a source of debate.

Until recently, it was assumed that catheters inserted in the

operating room posed a lower risk of infection than did those inserted

on inpatient wards or other patient-care areas. However, data from two

recent prospective studies suggest that the difference in risk of

infection depends largely on the magnitude of barrier protection used

during catheter insertion, rather than the sterility of the surrounding

environment (i.e., ward vs. operating room) 36 171; CVCs or PACs

inserted in the operating room using submaximal barrier precautions

(i.e., gloves, small fenestrated drape) were more likely to become

colonized and to be associated with subsequent BSI than were those

inserted on the ward or in the ICU using maximal barrier precautions

(i.e., gloves, gown, large drape, masks). These data suggest that if

maximal barrier precautions are used during CVC insertion, catheter

contamination and subsequent CVC-related infections can be minimized,

irrespective of whether the catheter is inserted in the operating room

or at the patient's bedside.171 172

Changing Catheters and Administration Sets

Intravenous administration set changes. The optimal interval for

routinely changing intravenous administration sets used for patient

care has been examined in three well- controlled studies. Data from

each of these studies show that changing administration sets

72-hours after initiation of use is not only safe, but cost-

beneficial.173-175 However, because certain fluids (i.e., blood,

blood products, TPN, and lipid emulsions) are more likely than other

parenteral fluids to support microbial growth if contaminated, 132

176-179 more frequent tubing changes may be required when such fluids

are administered.

A common component of intravenous administration sets is the

stopcock. Stopcocks are used for injection of medications,

administration of intravenous infusions, or collection of blood samples

and, thus, represent a potential portal of entry for microorganisms

into vascular catheters or intravenous fluids. Although stopcock

contamination is common, ranging between 45% and 50% in most series,

the relative contribution of stopcock contamination to intravascular

catheter or intravenous fluid contamination is unclear. Few studies

have been able to demonstrate that the organism(s) colonizing stopcocks

is the same one responsible for CRI.180 181 Data suggest that the

use of a closed-needle sampling system can significantly reduce

sampling-port and intravenous fluid contamination.182 183

``Piggyback'' systems may be used as an alternative to stopcocks.

However, they also pose a risk for contamination of the intravascular

fluid if the needle entering the rubber membrane of an injection port

is partially exposed to air, or comes into direct contact with the tape

used to fix the needle to the port. A recently described ``piggyback''

system appears to prevent contamination at these sites and reduces the

incidence of CR-BSI sixfold compared with conventional stopcock and

``piggyback'' systems.182

Intravenous catheter changes. Routine or scheduled change of

intravascular catheters has been advocated as a method to reduce CRIs.

Studies of peripheral venous catheters show that the incidences of

thrombophlebitis and bacterial colonization of catheters seem to

increase dramatically when catheters are left in place >72

hours.12 168 Both phlebitis and catheter colonization have been

associated with an increased risk of CRI. Because of the increased risk

of infection, as well as patient discomfort associated with phlebitis,

peripheral catheter sites are commonly rotated at 48-72 hour intervals

to reduce the risk of phlebitis.

In the maintenance of CVCs, decisions regarding the frequency of

catheter change are substantially more complicated. Some investigators

have shown duration of catheterization to be a risk factor for

infection, 33 35 184 185 and routine change of CVCs at specified

intervals has been advocated as a measure to reduce infection. However,

more recent data suggest that the daily risk of infection remains

constant and show that routine changes of CVCs, without a clinical

indication, do not reduce the rate of catheter colonization or the rate

of catheter-related BSI. 186, 187

The method of replacing CVCs has also been a topic of controversy

and intensive study. CVCs can be changed by placing a new catheter over

a guidewire at the existing site or by inserting the new catheter at

another site. Catheter replacement over a guidewire has become an

accepted technique for changing a malfunctioning catheter or exchanging

a PAC for a CVC when invasive monitoring is no longer needed. Catheters

inserted over a guidewire are associated with less discomfort and a

significantly lower rate of mechanical complications than are those

percutaneously inserted at a new site.131 186 188 189 Guidewire-

assisted exchange may, however, be accompanied by complications, most

notably bleeding at the site, hydrothorax, and subsequent infection of

the newly placed catheter.131 189

Studies examining the infectious risks associated with guidewire

insertions have yielded conflicting results. Three prospective studies

(two randomized) have shown no significant difference in infection

rates between catheters inserted percutaneously and those inserted over

a guidewire.153 187 190 One prospective randomized study has shown

a significantly higher rate of BSIs associated with catheters changed

over a guidewire compared with catheters inserted

percutaneously.186 Most investigators agree that if guidewire-

assisted catheter change occurs in the setting of an CRI, the newly

placed catheter should be removed (131,153,187,188).

Catheter-Site Care

Cutaneous antiseptics and antimicrobial ointments. Skin cleansing/

antisepsis of the insertion site is regarded as one of the most

important measures for preventing CRI, but comparative studies of

cutaneous antisepsis have largely examined its efficacy in eradicating

bacterial flora from the hands of hospital personnel.191 192

However, in one trial, the effectiveness of 2% chlorhexidine, 10%

povidone-iodine, and 70% alcohol 193 as cutaneous antiseptics were

compared in preventing central venous and arterial CRIs. The rate of

catheter-related BSI when chlorhexidine was used for catheter site

preparation was 84% lower than the rates when the other two antiseptic

regimens were used; however, the 2% chlorhexidine preparation used in

this trial is not currently available in the U.S. More recently, a

sustained-release chlorhexidine gluconate patch (250 mu/

[[Page 49985]]

mg dressing) has been introduced as a dressing for catheter insertion

sites. In one randomized trial of epidural catheters, the use of these

patches significantly reduced the incidence of catheter

colonization.194 However, the efficacy of the chlorhexidine patch

in reducing intravascular device-related infection still needs to be

determined.

Tincture of iodine also has been widely used in hospitals for skin

antisepsis before catheter insertion, but its efficacy in reducing

catheter colonization and infection have not been thoroughly evaluated.

Data derived from examining its use as an antiseptic prior to blood

culturing suggest that it, like 70% alcohol and 10% povidone iodine,

may be an effective cutaneous antiseptic for preparation of the skin

prior to insertion of intravascular catheters.195 However,

tincture of iodine may cause skin irritation.195

The application of antimicrobial ointments to the catheter site at

the time of catheter insertion and/or during routine dressing changes

has also been used to reduce microbial contamination of catheter-

insertion sites. Studies of the efficacy of this practice in preventing

CRIs have yielded contradictory findings.30 196-200 Moreover, the

use of polyantibiotic ointments that are not fungicidal may

significantly increase the rate of colonization of the catheter by

Candida spp.198 200 201

Recently, topical mupirocin, a nonsystemic anti-staphylococcal

antimicrobial with documented efficacy in reducing nasal staphylococcal

spp. carriage,202 has been used for cutaneous antisepsis in

conjunction with 2.5% tincture of iodine prior to catheter insertion.

Used in this way, mupirocin was reported to reduce the incidence of

internal jugular catheter colonization among cardiac surgery patients.

However, the utility of mupirocin in reducing the rate of colonization

of peripheral or arterial catheters has not been demonstrated 203

and its use on catheter sites has not been approved. Moreover,

mupirocin resistance has been reported (204-206). Controlled studies

are needed to fully evaluate the effectiveness and potential adverse

effects of mupirocin use for catheter-site maintenance.

Catheter-site dressing regimens. Transparent, semipermeable,

polyurethane dressings have become a popular means of dressing

catheter-insertion sites. These transparent dressings reliably secure

the device, permit continuous visual inspection of the catheter site,

permit patients to bathe and shower without saturating the dressing,

and require less frequent changes than do standard gauze and tape

dressings, thus saving personnel time. Nevertheless, the use of

transparent dressings remains one of the most actively researched, and

controversial, areas of catheter site care. Some studies suggest that

their use increases both microbial colonization of the catheter site

and the risk of subsequent CRI,15 207-210 while other studies have

shown no difference in catheter colonization and infection rates

between the use of transparent dressings and gauze and tape

dressings.10 165 211 The potential risk of infection posed by

transparent dressings appears to vary with the type of catheter

(peripheral or central venous catheter) they are used to dress and,

perhaps, with the season of the year.10 15 209

In the largest controlled trial of dressing regimens to date, Maki

et al. examined the infectious morbidity associated with the use of

transparent dressings on >2,000 peripheral catheters.165 Their

findings suggest that the rate of catheter colonization among catheters

dressed with transparent dressings (5.7%) is comparable to that of

those dressed with gauze (4.6%) and that there are no clinically

important differences in either the incidences of catheter-site

colonization or phlebitis between the two groups. Further, these data

suggest that transparent dressings can be safely left on peripheral

venous catheters for the duration of catheter insertion without

increasing the risk of thrombophlebitis.165

Studies of the use of transparent dressings on CVCs have also

yielded contradictory findings. Some investigators have found an

increased risk of CRI among CVCs with a transparent dressing compared

with those gauze; 209 210 others have found the risk of infection

posed by these two types of dressings to be comparable.211 212

Most of the data on the use of transparent dressings on CVCs are

derived from studies of short-term nontunneled devices and little data

have been published regarding the use of transparent dressings on long-

term, tunneled CVCs.213 In a metaanalysis of catheter dressing

regimens, CVCs on which a transparent dressing was used had a

significantly higher incidence of catheter tip colonization, but a

nonsignificant increase in the incidence of CR-BSI.214 Preliminary

data suggest that newer transparent dressings that permit the escape of

moisture from beneath the dressing may be associated with lower rates

of skin colonization and CRI,213 215 but the length of time that a

transparent dressing can be safely left on a CVC catheter site is

unknown.

Collodion has also been evaluated for use as a potential dressing

for catheter sites. One small (n=34), retrospective study of its use on

CVCs reported a low incidence of CRIs, despite catheters remaining in

place an average of 16.5 days.216 However, before collodion can be

recommended for routine use as a catheter site dressing, randomized

trials comparing collodion to existing dressings should be done.

In-Line Filters

In-line filters may reduce the incidence of infusion-related

phlebitis (217-220), but there are no data to support their efficacy in

preventing infections associated with intravascular devices and

infusion systems. Proponents of the use of filters cite a number of

potential benefits: (1) reducing the risk of infection from

contaminated infusate or proximal contamination (i.e., introduced

proximal to the filter); (2) reducing the risk of phlebitis in patients

who require high doses of medication (e.g., antimicrobials) or in those

in whom infusion-related phlebitis has already occurred; (3) removing

particulate matter that may contaminate intravenous fluids; 221

and (4) filtering endotoxin produced by gram-negative organisms in

contaminated infusates.222 These theoretical advantages must be

tempered by the knowledge that infusate-related BSI rarely occurs and

that pre-use filtration in the pharmacy is a more practical, and less

costly, way to remove particulates from infusates. Furthermore, in-line

filters may become blocked, especially with certain solutions (dextran,

lipids, mannitol), and consequently increase line manipulations and/or

decrease the availability of administered drugs.223 Because of

these potential untoward effects, the routine use of in-line filters

may increase cost, personnel time, and possible infections.224

Silver-Chelated Collagen Cuffs

Since 1987, a silver-chelated, collagen cuff that is attachable to

percutaneously inserted CVCs has been commercially available. Similar

to the cuff used on Hickman and Broviac catheters, this cuff is

designed to form a mechanical barrier to skin microorganisms migrating

into the cutaneous catheter tract; 201 225 the silver provides an

additional antimicrobial barrier.201 225 Two randomized controlled

trials examining the efficacy of silver-chelated collagen cuffs have

been published. In the first trial, cuffed CVCs were associated with a

threefold lower risk of catheter colonization and a nearly fourfold

lower risk of CR-BSI compared with traditional noncuffed CVCs.225

In the second trial, a 78% reduction in

[[Page 49986]]

catheter colonization and a 100% reduction in CR-BSI were observed with

these devices.201 The relative contribution of the cuff versus the

antimicrobial properties of the silver preventing CRI is uncertain. No

controlled trials examining the efficacy of cuffs without antiseptic or

antimicrobial coating have been published.

The protective effect of these cuffed CVCs appears to be immediate

and exceeds that seen with the use of antimicrobial ointment

alone.201 However, cuffs appear to be most beneficial with

catheters left in place for >4 days.225 Studies on the efficacy of

these cuffs in preventing infection with longer-term CVCs (i.e., >20

days) have not been published.

Antimicrobial-Impregnated (Coated) Catheters

In animal models, antimicrobial or antiseptic impregnation of

catheters appears to reduce bacterial adherence and biofilm

formation,226 227 but the utility of these impregnated catheters

in clinical settings has only recently been evaluated. Kamal et al.

conducted a large, randomized, prospective trial among SICU patients to

evaluate a CVC bonded with cefazolin for the entire length of its

external and luminal surfaces.228 The authors found a sevenfold

reduction in the incidence of catheter colonization (2% vs 14%), but no

difference in catheter-site inflammation (i.e., culture-negative

inflammation of the insertion site). No bacteremias occurred in either

group. The authors suggest that antimicrobial coating of the luminal

surfaces of catheters may be particularly beneficial in reducing the

risk of infection resulting from hub contamination.

Data supporting the utility of antimicrobial coating for peripheral

catheters are much less conclusive. Kamal et al. also studied a small

number of peripheral arterial catheters as part of their evaluation of

the cefazolin-impregnated catheter.228 Although impregnated

peripheral arterial catheters had a fivefold lower incidence of CRI

compared with noncoated catheters (3% vs 15%), this difference was not

statistically significant. The lack of demonstrable efficacy of

antimicrobial coating of peripheral arterial catheters in reducing CRI

may be due, in part, to the inherently low incidence of CRI associated

with the use of peripheral arterial catheters.

Of the studies reported to date, antimicrobial-coated catheters do

not appear to pose any greater risk of adverse effects than do

noncoated catheters, but additional controlled trials need to be done

to fully evaluate their efficacy, determine the appropriate situations

for their use, and assess the risk of emergence of resistant

bloodstream pathogens.

Intravenous Therapy Personnel

Because insertion and maintenance of intravascular catheters by

inexperienced staff may increase the risk of catheter colonization

153 and CR-BSI, many institutions have established infusion

therapy teams. Available data suggest that trained personnel designated

with the responsibility for insertion and maintenance of intravascular

devices provide a service that effectively reduces CRIs and overall

costs.229-231

Prophylactic Antimicrobials

Prophylactic administration of antimicrobials has been used to

reduce the incidence of CR-BSIs, but scientific studies on the efficacy

of this practice are inconclusive. Two published studies, one

randomized 232 and one nonrandomized,233 suggest that

antimicrobials administered systemically at the time of (or immediately

after) insertion of a CVC may reduce the incidence of CR-BSI. Two

randomized trials of systemically administered antibiotics demonstrated

no benefit of such prophylaxis.234 235 One randomized controlled

trial showed a significant protective effect of a heparin-vancomycin

flush solution used daily in immunocompromised patients with tunneled

CVCs.236 Two other randomized controlled trials have examined the

effect of continuous low dose (25g) vancomycin, added to TPN

fluids, in reducing the incidence of CoNS BSI in low birthweight

infants.237 238 In one of these trials, the incidence of CoNS BSI

decreased from 34% to 1.4% (P237 However, 4/71 (5.6%) treated neonates developed a BSI due

to gram-positive cocci after vancomycin prophylaxis was completed. The

other trial studied neonates weighing 238 Although prophylactic administration of

vancomycin decreased the incidence of CoNS BSI, it did not decrease

overall mortality among low birth weight infants in either study.

Further studies are needed to assess the additional benefit afforded by

prophylactic antimicrobials in reducing CRIs when standard infection

control measures are adhered to and to assess the concern that such

prophylaxis may select for resistant microorganisms, particularly those

resistant to vancomycin.

Flush Solutions, Anticoagulants, and Other Intravenous Additives

Flush solutions are designed to prevent thrombosis, rather than

infection, but thrombi and fibrin deposits on catheters may serve as a

nidus for microbial colonization of the intravascular devices.

Furthermore, catheter thrombosis appears to be one of the most

important factors associated with infection of long-term

catheters.69 239 Thus, the use of anticoagulants (e.g., heparin)

or thrombolytic agents may have a role in the prevention of CR-BSI.

However, several recent studies suggest that 0.9% saline is as

effective as heparin in maintaining catheter patency and reducing

phlebitis among peripheral catheters.137 240 241 Furthermore,

recent in vitro studies suggest that the growth of CoNS on catheters

may be enhanced in the presence of heparin. In contrast, the growth of

CoNS on catheters can be inhibited by edetic acid (EDTA),242

suggesting that EDTA, rather than heparin, may decrease the incidence

of CoNS CR-BSIs. Also, the routine use of heparin to maintain catheter

patency, even at doses as low as 250-500 units/day, has been associated

with thrombocytopenia and thromboembolic and hemorrhagic

complications.243-246 Clinical trials are needed to further assess

the relative efficacy, risks, and benefits of the routine use of

various anticoagulants (e.g., EDTA) in preventing CRI.

The risk of phlebitis associated with the infusion of certain

fluids (e.g., potassium chloride,247 lidocaine,247 248

antimicrobials,247 also may be reduced by the use of certain

intravenous additives, such as hydrocortisone.247 Bassan et al. in

a prospective, controlled trial of patients being evaluated for

possible myocardial infarction found that heparin and/or hydrocortisone

significantly reduced the incidence of phlebitis in veins infused with

lidocaine.248 In other trials, topical application of

venodialators such as glycerol trinitate,249 250 or anti-

inflammatory agents such as cortisone near the catheter site,251

has effectively reduced the incidence of infusion-related

thrombophlebitis and increased the life span of the catheters.251

252 Larger, controlled trials are needed to assess the advisability of

the routine use of these agents to reduce phlebitis.

Needleless Intravascular Devices

Attempts to reduce the incidence of sharps injuries and the

resultant risk of transmission of bloodborne infections to

[[Page 49987]]

HCWs have led to the design and introduction of needleless intravenous

systems. However, there are limited data by which to assess the

potential risk of contamination of the catheter and infusate and

subsequent CRI that may be associated with the use of these devices. In

one trial where conventional and needleless heparin-lock systems were

compared, the rates of infection were comparable.\253\ However, in

another investigation, the combined use of a needleless infusion system

and TPN was associated with an increased rate of BSIs among patients

receiving home infusion therapy.\254\ As the use of these systems

becomes more widespread, the potential infectious risks associated with

their use can be more fully evaluated.

Multidose Parenteral Medication Vials (MDVs)

Parenteral medications are commonly dispensed in MDVs that may be

used for prolonged periods for one or more patients. Although the

overall risk of extrinsic contamination of MDVs appears to be small, an

estimated 0.5 per 1,000 vials,\255\ the consequences of contamination

may be serious. Contamination of MDVs due to breaks in aseptic

technique have resulted in several nosocomial outbreaks. The implicated

vehicles in these outbreaks have been lipids infused intravenously from

multidose containers\177\ and medications used for intra-articular

injections.256 257 However, when bacteria or yeasts were

inoculated into some commonly used medications, such as heparin,

potassium chloride, procainamide, methohexital, succinylcholine

chloride, and sodium thiopental, and left at room temperature, no

microorganisms could be cultured from these medications after 96 hours,

with rare exceptions, irrespective of whether they contained a

preservative.\258\ Microorganisms could proliferate in lidocaine and

insulin only if the inocula were prepared in peptone water (with one

exception), which allowed for transfer of nutrients to the vials. Even

under these conditions, when vials were kept at 4 deg.C (the

recommended storage temperature), microorganisms did not proliferate in

the insulin. There is one report of hepatitis B virus transmission

related to the use of a contaminated vial of bupivacaine in a

hemodialysis unit.\259\

VII. Intravascular Device-Related Infections Associated With Total

Parenteral Nutrition

Catheter-related BSI remains one of the most important

complications of TPN therapy and reported rates of infection during TPN

vary widely depending on the population studied and the definitions

used. Because TPN solutions commonly contain dextrose, amino acids,

and/or lipid emulsions, they are more likely than conventional

intravenous fluids to support microbial growth if contaminated.177

179 260-263 Lipid emulsions are particularly suited for the growth of

specific bacteria and yeasts,176 177 with microbial growth

occurring as early as 6 hours after inoculation of a lipid emulsion and

reaching clinically significant levels (>10\6\ CFU/ml) within 24

hours.178 Newer combined TPN solutions (e.g., 3-in-1 system) which

use glucose, amino acids, lipid emulsion, and additives in one

multiliter administration bag, may increase the risk of infection

associated with TPN, but data on which to assess this risk are not

available.

Although TPN solutions are particularly suited for microbial

growth, most infections that occur during the administration of TPN

result from contamination of the catheter. TPN- related CRI result much

less commonly from infusion of contaminated fluids or from hematogenous

seeding of the catheter.

The microbiology of TPN-related CR-BSIs is similar to that of other

CR-BSIs, with gram-positive species, particularly CoNS or S. aureus,

being the predominant pathogens. However, the proportion of BSIs due to

fungal pathogens, particularly Candida spp., are significantly greater

in patients receiving TPN.\106\

Risk Factors

A number of factors have been associated with the development of

CRI during TPN therapy, including catheter-site colonization,123

125 155 method and site of catheter insertion, the experience of the

personnel inserting the catheter,\153\ the use of the TPN line for

purposes other than administration of parenteral nutrition fluids,\264\

breaks in the protocol for aseptic maintenance of the infusion

systems,167 223 264 265 and the use of triple-lumen

catheters.24 25 27 28

Surveillance and Diagnosis

Surveillance for CRI during TPN administration should be the same

as during the administration of other types of infusion therapy.

Although culturing the skin adjacent to the catheter insertion site may

help predict BSI in patients who are receiving TPN,123 125 155

routine microbiologic surveillance can not be advocated. As with other

suspected CRIs, semiquantitative and quantitative catheter cultures may

also be useful for the diagnosis of TPN-related CRIs. Vanhuynegem et

al. evaluated the efficacy of semiquantitative cultures of blood drawn

through in place TPN catheters in febrile patients for diagnosing CR-

BSI.\266\ Comparing their methodology to the semiquantitative culture

technique of Maki, they found that such cultures had a positive

predictive value of 60%, and a negative predictive value of 100%.

Moreover, using this technique, they were able to prevent unnecessary

removal of 87% of the catheters in which infection was suspected.

Strategies for Prevention

The strategies previously outlined for the prevention of CRIs are

also effective in reducing the risk of infections associated with TPN,

and rigorous aseptic nursing care has been shown to greatly reduce the

incidence for TPN-related infection.265 267 268 Nevertheless, a

number of supplemental preventive measures that have been proposed to

reduce the risk for TPN-related CRIs bear discussion, including special

precautions for infusate preparation, cutaneous antisepsis, and

catheter selection and care.

Infusate preparation. Since TPN solutions are prone to microbial

growth if contaminated, strict attention must be given to asepsis

during the compounding of TPN solutions. Although controlled trials

have not been done, centralized preparation of TPN solutions in

hospital pharmacies, using a laminar flow hood, has generally been

regarded as the safest method of preparation.

Cutaneous antisepsis. Findings on the efficacy of various

antiseptic skin preparations on decreasing the incidence of CRI during

TPN suggest that tincture of iodine and chlorhexidine in ethyl alcohol

are superior to povidone-iodine as a skin antiseptic during TPN

catheter care.\269\ Furthermore, in one prospective randomized study,

the application of povidone-iodine ointment to the insertion sites of

subclavian catheters used for TPN was not associated with a decrease in

CRIs when compared with catheters on which povidone-iodine was not

used.\268\

The application of organic solvents, such as acetone or ether, to

``defat'' (remove skin lipids) the skin prior to catheter insertion and

during routine dressing changes has been a standard component of many

hyperalimentation protocols. However, these agents appear neither to

confer additional protection against skin colonization nor

significantly decrease the incidence of CRI. Moreover, their use can

greatly increase local inflammation and patient discomfort.\270\

[[Page 49988]]

Selection of catheter. Tunnelling of TPN catheters has been

proposed for three reasons: (1) to prevent dislodgement of the

catheter; (2) to reduce the incidence of CR-BSI by increasing the

distance between the sites where the catheter exits the skin and where

it enters the subclavian vein; and (3) to protect the catheter from

potentially contaminated sites such as tracheostomies. However, few

prospective randomized studies have been done to evaluate the efficacy

of this practice. When Koehane et al. assessed the risk of BSI among

patients with short-term, noncuffed, tunneled and nontunneled TPN

catheters, they demonstrated a reduction in the incidence of CR-BSI

among tunneled catheters as compared with nontunneled catheters.\267\

However, this reduction was greatest when a designated nutrition nurse

was used to maintain the catheter; after improved adherence to the

infection control protocol, short-term, noncuffed, tunneled and

nontunneled catheters were associated with a similar rate of BSI. The

only other controlled trial of short-term, noncuffed, tunneled and

nontunneled catheters similarly failed to demonstrate a beneficial

effect of tunnelling after rigorous attention to infection

control,\127\ suggesting that if strict infection control practices are

adhered to, short-term, noncuffed, tunneled and nontunneled TPN

catheters have a similar risk of infection.

Catheter-site dressings. The use of occlusive dressings on

catheters used for TPN has been a continuing source of debate. Two

controlled studies suggest that, with adherence to strict infection

control protocols, semipermeable, transparent dressings are a safe,

cost- effective alternative to gauze and tape for dressing TPN

catheter-insertion sites.212 268 Moreover, data suggest that

transparent dressings used on TPN catheter sites can be safely changed

at 7-day intervals.212 268 271

Catheter changes. Prospective, randomized trials examining the

frequency of TPN catheter changes have not been published. However,

data from a study in 1974 suggest that the rate of infection (6.2%) for

TPN catheters in place for >30 days is similar to the rate of infection

(7%) for all catheters.\265\

Specialized personnel. Many institutions have protocols and a

nutritional support team for insertion and maintenance of catheters

used for TPN. As with vascular devices used for other purposes, the use

of specially trained personnel to insert and maintain the catheters

appears to reduce the rate of infection in patients receiving

TPN.230, 231, 267

VIII. Intravascular Device-Related Infections Associated With

Hemodialysis Catheters

Epidemiology

Each year approximately 150,000 patients undergo maintenance

hemodialysis for chronic renal failure. Since 1979, when the Uldall

subclavian catheter was introduced, CVCs have gained popularity as a

convenient, rapid way of establishing temporary vascular hemodialysis

access until placement or maturation of a permanent arteriovenous

fistula or permanent access for patients without alternative vascular

access.\272\ In 1990, an estimated 73% of centers participating in the

National Surveillance System for Hemodialysis Associated Diseases had

1 patients in whom CVCs were used for permanent vascular

access.\273\ However, only a limited number of controlled trials

examining the infectious risk associated with the use of CVCs for

hemodialysis have been published; most data are derived from small

studies at individual institutions.

Subclavian hemodialysis catheters have been associated with a rate

of BSI that exceeds that reported for virtually all other subclavian

catheters274-283 or for alternative forms of hemodialysis vascular

access275 284 and their use may be complicated by bacterial

endocarditis, septic pulmonary emboli,274 275 282 284 and/or

thrombosis (e.g., venous thrombosis, catheter occlusion). The factors

contributing to the increased rate of infection experienced with CVCs

used for hemodialysis have not been fully elucidated,277 278 but

manipulations and dressing changes of dialysis catheters by

inadequately trained personnel,\285\ duration of catheterization and

mean number of hemodialysis runs,\277\ and cutdown insertion of the

catheter\286\ may increase the risk of CRI among hemodialysis patients.

More recently, jugular vein catheters have been used for

hemodialysis access because descriptive studies indicate that they are

associated with fewer mechanical complications than subclavian

catheters, including subclavian thrombosis, stenosis, and

perforation.287-294 These double-lumen, Dacron-cuffed, silicone

CVCs have been used for exclusive, or prolonged, vascular access in

chronic hemodialysis patients286 295 and appear to have a longer

median use-life and fewer insertion complications than do either of

their single-lumened Teflon or polyurethane counterparts.280 295

296 Moss et al. recently reviewed the 4-year experience with double-

lumen, cuffed, silicone catheters at their institution. All catheters

(n=168) had been placed for long-term use (1 month) and were

the sole vascular access for hemodialysis.\286\ The median life span

for these catheters was 18.5 months, with 12- and 24-month catheter

survival being 65% and 30%, respectively. As with subclavian

hemodialysis catheters, thrombosis (catheter and vein) and infection

were the most frequent catheter complications. BSI occurred in 16/131

(12%) patients and exit-site infections in 28/131 (21%); diabetics

(33%) were significantly more likely to develop exit-site infections

than were nondiabetics (11%). Based on the duration of catheterization,

the authors determined the following rates of CRIs associated with the

use of double-lumen CVCs: 0.25 BSIs per patient-year, 0.36 exit-site

infections per patient-year (nondiabetics), and 0.87 exit-site

infections per patient-year (diabetics). The BSI rates reported in this

review were comparable to those reported for more conventional forms of

hemodialysis vascular access (0.09-0.20 BSIs per patient-year).284

297-299

Two studies have examined the potential impact of tunneled

hemodialysis catheters on the risk of subsequent CRI. In a

nonrandomized study, Hickman catheters used for prolonged hemodialysis

access was associated with a significantly lower rate of BSI (0.08 BSIs

per 100 catheter-days) than were nontunneled hemodialysis

catheter.\300\ Schwab et al. prospectively examined the use of cuffed,

tunneled, double-lumen jugular venous catheters for prolonged

hemodialysis access. Compared with percutaneously inserted, noncuffed

subclavian dialysis catheters, double-lumen jugular venous catheters

had a longer live span, a lower (1.3% vs 3.6%) incidence of associated

BSIs, but a significantly higher incidence of exit-site infection (29%

vs 9%).\295\

Hemodialysis catheters may become contaminated by a variety of

proposed mechanisms: (1) penetration of organisms from the skin due to

the pulsatile action of the dialysis pump; (2) manipulation of catheter

connections by medical personnel with contaminated hands; (3) leakage

of contaminated hemodialysis fluid into the blood compartment; or (4)

administration of contaminated blood or other solutions through the

catheter during the dialysis session.

Microbiology

CR-BSIs in hemodialysis patients, as in other patient populations,

are most frequently caused by S. epidermidis.274-276 281-283 285

However, because of their high rates of

[[Page 49989]]

colonization with S. aureus,\301\ hemodialysis patients have a greater

proportion of CR-BSIs due to S. aureus \284\ than among other patient

populations.

Strategies for Prevention of Hemodialysis Catheter-Related Infections

Strategies for the prevention of infections associated with the use

of hemodialysis catheters have not been as rigorously examined as those

proposed for the prevention of infections associated with CVCs used for

other purposes. Although there are limited data on infectious

complications in hemodialysis settings associated with various types of

catheters, frequency of catheter change, cutaneous antisepsis, and

prophylactic administration of antimicrobials, no studies examining

catheter-site dressing regimens, or the utility of newer devices, such

as antimicrobial-impregnated hemodialysis catheters have been

published.

Cutaneous antisepsis. In some series, as many as 50 to 62% of

hemodialysis patients have been found to be carriers of S.

aureus.301-304 Therefore, skin antisepsis is a crucial component

for the prevention of hemodialysis catheter-associated infections. In

one randomized, controlled study of 129 subclavian dialysis catheters,

the routine application of povidone-iodine ointment to catheter-

insertion sites was more effective than plain gauze in reducing the

incidence of exit-site infections (5% vs 18%), catheter-tip

colonization (17% vs 36%), and BSIs (2% vs 17%);304 duration of

catheterization was comparable for treated (mean, 38.6 days) and

nontreated (mean, 36.2 days) catheters, each ranging from 2-210 days.

The beneficial effect of povidone-iodine ointment was most evident

among patients with S. aureus nasal carriage where its use reduced the

incidences of BSI and exit-site infection by 100% and catheter-tip

colonization by 71%. No adverse effects were detected with the routine

application of povidone-iodine ointment to subclavian dialysis

catheter- insertion sites.

Catheter changes. Since attainment and preservation of vascular

access in patients with chronic renal failure are often difficult, the

frequency of catheter change and the role of guidewire catheter

exchange are of utmost importance. However, to date, there are limited

data on which to base recommendations for either of these issues in

hemodialysis patients. One prospective, randomized trial of subclavian

dialysis catheters using guidewire exchange suggested that the rate of

BSIs was comparable when catheters were changed weekly or when

clinically indicated.305 One recent study examined the role of

guidewire exchange in the treatment of infected jugular vein

hemodialysis catheters. In this study, a 92% one-year catheter survival

was observed with the combined use of guidewire exchange and

administration of antimicrobials 48 hours before and 2 weeks after

guidewire exchange, when frank pus was not present at the exit

site.306 These findings, however, are contrary to a large body of

data suggesting that guidewire exchange should not be done in the

setting of documented CRI.59 131 153 307 308

Prophylactic antimicrobials. Hemodialysis patients receiving

antistaphylococcal antimicrobials at the time of catheter placement

have been shown to have a lower incidence of CRI.274 276 277 309

However, the role of prophylactic antimicrobials has not been directly

studied.

Whether hemodialysis catheters can be treated in the same way as

CVCs used for other purposes is unclear. Prospective, controlled trials

of hemodialysis catheters are needed to determine the epidemiology of

CRIs associated with their use and to evaluate the role of preventive

role of different types of catheter materials, appropriate insertion

sites, intervals for catheter change, guidewire exchange, catheter-site

dressing regimens, and the use of newer modalities (e.g., such as

antimicrobial-impregnated hemodialysis catheters).

IX. Intravascular Device-Related Infections in Pediatric Patients

This section addresses some of the specific issues relevant to

intravascular access and intravascular device-related infections among

the pediatric population. However, the epidemiology of intravascular-

device related infections in pediatric patients is less well-described

than that in adults, and there are limitations to the existing data.

First, few controlled trials of intravascular devices in children have

been reported; most published data are derived from uncontrolled

retrospective or prospective studies. Second, pediatric data that are

available were derived, largely, from studies in neonatal (NICU) or

pediatric intensive care units (PICU) where rates of infection are

usually higher than on general pediatric wards. Finally,

semiquantitative culture methods have, in large part, not been used in

the studies of CRIs in children because such cultures require catheter

removal.

Microbiology

As in adults, most CR-BSIs in children are caused by staphylococcal

spp., with S. epidermidis being the predominant species.310 311

Other species of gram-positive cocci and fungi are the next most

frequently isolated pathogens, with Malassezia furfur being an

especially common pathogen in neonates receiving intravenous

intralipids.311-319

Bertone et al. performed quantitative skin cultures on 50 neonates

to determine the microbial flora present at commonly used catheter-

insertion sites.320 Only 33 neonates had an intravascular device

in place at the time of culturing; 25 had peripheral venous catheters

and eight had CVCs. The highest mean colony counts were found at

jugular sites (2.7 x 104 cfus/10cm2) and the lowest at

subclavian sites (5.2 x 103 cfus/10-cm2). However, femoral

and jugular sites had similar mean colony counts as did subclavian and

umbilical sites. Although CoNS was the pathogen most frequently

cultured from all body sites, other microbial species (e.g., aerobic

gram-negative bacilli, yeast, and Enterococcus spp.) were more commonly

cultured from umbilical and femoral sites.320

Epidemiology

The majority of nosocomial BSIs in children are also related to the

use of an intravascular device. During 1985-1990, children's hospitals

participating in NNIS and conducting ICU surveillance reported

significantly higher rates of BSI among PICU patients with CVCs (11.4

BSIs per 1,000 central-catheter days) compared with those without CVCs

(0.4 BSIs per 1,000 noncentral-catheter days).8 Participating

Level III NICUs reported a median of 5.1 BSIs per 1,000 umbilical or

central-catheter days for the 1,500 gram birthweight group

and 14.6 BSIs per 1,000 umbilical or central-catheter days for the

321 Birthweight

and device utilization were important determinants of a NICU infant's

risk for acquiring BSI.321 Others have shown receipt of

intravenous lipids to also be an important risk factor for the

acquisition of CR-BSI, particularly CoNS BSIs, among neonates.86

Cronin studied 376 catheters, of varying types, to determine the

incidence of catheter colonization and CR-BSI among NICU

patients.322 The incidence of catheter colonization varied by type

of catheter, site of insertion, and duration of catheterization.

Consistent with the findings of other investigators, the rate

[[Page 49990]]

of catheter colonization was significantly lower among patients

receiving systemic antimicrobials, having birthweight 1500

gm, and not receiving parenteral nutrition. In general, the

colonization rates detected in this study were higher than those

previously reported for catheters in adults and children.17 148

311 312 However, the authors could not conclusively determine the

relationship of catheter colonization to BSI.

Peripheral venous catheters. As in adults, the use of peripheral

venous catheters in pediatric patients may be complicated by phlebitis,

extravasation, and catheter colonization. Garland et al. prospectively

studied 654 peripheral Teflon catheters in PICU patients to determine

the incidence of and risk factors for each of these

complications.311 Of the 654 catheters studied, 83 (13%) were

associated with phlebitis. Catheter location, infusion of

hyperalimentation fluids with continuous intravenous lipid emulsions,

and length of ICU stay before catheter insertion were all factors that

increased a patient's risk for phlebitis. However, contrary to the

studies among adults, the risk of phlebitis did not increase with the

duration of cannulation. The overall incidence of phlebitis in this ICU

population (13%) was comparable to that reported in general pediatric

patients (10%); for children >10 years of age the incidence of

phlebitis (21%) was comparable to that reported for adults 169 and

older children.323

Of 459 peripheral venous catheters cultured by Garland, 54 (11.8%)

were colonized. However, only one (1.9%) of these colonized catheters

was associated with CR-BSI. In an earlier study, comparable rates of

catheter colonization (10.4%) were found for Teflon peripheral

catheters (n=115) used in patients on general pediatric wards.312

Time in place was the single most important predictor of subsequent

catheter colonization, with the incidence of colonization increasing

threefold after catheters remained in place >144 hours.311 Between

48 and 144 hours, the catheter colonization rate was stable at 11%.

Other factors significantly but less strongly associated with catheter

colonization were patient age and receipt of lipid emulsions. Catheters

inserted emergently were no more prone to colonization than were those

inserted electively.311

Extravasation, the most frequent complication, occurred with 28% of

catheters. Several risk factors for extravasation were identified,

including patient age (1 year), receipt of anticonvulsant,

and duration of catheterization (72 hours); the risk of

extravasation decreased significantly after the catheter was in place

for 72 hours.311

There are limited data examining the relationship of catheter

material to the risk of infection among pediatric patients. In one

study of premature infants, Teflon catheters and steel needles used in

scalp veins had a comparable risk of infection. However, Teflon

catheters had a significantly longer survival than did steel

needles.313

Peripheral arterial catheters. In a prospective study using

semiquantitative culture of 340 peripheral arterial catheters, Furfaro

identified two risk factors for CRI: (1) use of an arterial system of a

certain design, and (2) duration of catheterization.314 The

implicated arterial system (system A) contained a stopcock and a 120-cm

pressure tubing through which blood was drawn back to clear the line of

heparin before taking a sample. The alternate system (system B), with a

significantly lower risk of infection, contained a one-way valve that

did not permit blood backflow into the tubing. The authors noted that

the implicated arterial system (A) was the design most widely used in

U.S. hospitals.314

Although there was a correlation between duration of

catheterization and risk of catheter colonization, the risk remained

constant for 2-20 days at 6.2%. Catheters in place 48 hours

had a zero risk of colonization.314

Umbilical catheters (UCs). Although the umbilical stump becomes

heavily colonized soon after birth, umbilical vessel catheterization is

often used for vascular access in newborn infants because umbilical

vessels are easily cannulated, allow for delivery of intravenous

fluids/medications, permit easy collection of blood samples, and permit

measurement of hemodynamic status. Studies of the infectious

complications associated with UCs indicate that the incidences of

catheter colonization and BSI appear to be similar for umbilical vein

catheters (UVC) and umbilical artery catheters (UAC). The incidences of

colonization reported among UACs have ranged from 40 to 55%;324

325 those among UVCs have varied between 22% and 59%.324-326 The

incidences of BSI detected for the two types of catheters are also

similar, 5% for UACs and 3%-8% for UVCs.324 326 However, the risk

factors for infection appear to differ for the two types of catheters.

Landers et al. found that neonates with very low birthweight and

prolonged receipt of antimicrobials were at increased risk for UAC-

related BSIs. In contrast, those with higher birthweight and receipt of

parenteral nutrition fluids were at increased risk for UVC-related BSI;

duration of catheterization was not an independent risk factor for

infection either type of umbilical catheter.324

In addition to the risk of endemic infection, umbilical vessel

catheterization has been associated with epidemics among critically ill

NICU infants. Solomon et al. reported an outbreak of C. parapsilosis

fungemia among NICU infants 41 in which duration of umbilical

artery catheterization, prolonged receipt of parenteral nutrition, and

low gestational age were risk factors for fungemia.41

Several investigators have reported lower rates of UC colonization

among infants or neonates receiving systemic antimicrobials during

umbilical catheterization.315 325 326 However, the one prospective

study of prophylactic antimicrobials in patients with chronic UACs

found no clear benefit to this therapy.327

Central venous catheters. The use of indwelling catheters (e.g.,

Hickmans and Broviacs, TIDs) in children has become increasingly

important over the past decade for the treatment of children with

chronic medical conditions, especially malignancies. The Broviac,

rather than the Hickman, catheter is preferentially used in children

because of its smaller diameter; TIDs may be particularly advantageous

in younger pediatric patients (73 328 329

Although data from the Children's Cancer Study Group suggest that

as many as 18% of all chronic venous access devices in children are

removed due to infection,330 the use of these devices in children

have generally been associated with low rates of infections.64 66

71 73 77 331 332 Several factors have been associated with an increased

risk of infection among children with indwelling CVCs, including

younger age (333 Although Indwelling CVCs are largely used in

immunocompromised patients for the administration of chemotherapy,

neutropenia has not, in children, been shown to increase the risk of

infection associated with these devices.334

As with adults, the relative merits and risk associated with the

use of long-term vascular access devices in children have been the

source of considerable investigation. In most studies, TIDs had longer

survival and fewer infectious complications than other tunneled

catheters. In one study in which the

[[Page 49991]]

potentially confounding variables of patient age, underlying diagnosis,

and therapy were controlled for in a matched analysis, Hickmans and

TIDs were associated with comparable rates of infection. Broviacs still

had a higher rate of infection than TIDs, but this difference was only

significant after 400 days of catheterization.335

Because of the limited vascular sites, the required frequency of

catheter change in children is particularly important. Stenzel examined

the frequency of catheter change in PICU patients by using survival

analysis techniques. In that study of 395 CVCs, catheters remained free

of infection for a median of 23.7 days. More importantly, there was no

relationship between duration of catheterization and the daily

probability of infection (r=0.21, p>0.1), suggesting that routine

catheter replacement would not be expected to reduce the incidence of

CRI.336

Results of prospective randomized trials examining the effect

dressing regimens, frequency of catheter and administration sets

changes, or use of newer antimicrobial-coated catheters in reducing the

incidence of CRI among pediatric patients have not been published.

Table 1

Definitions for Catheter-Related Infection

Colonized catheter: growth of >15 colony forming units from a

proximal or distal catheter segment in the absence of accompanying

clinical symptoms.

Exit-site infection: erythema, tenderness induration, and/or

purulence within 2cm of the skin at the exit site of the catheter.

Pocket infection: erythema and necrosis of the skin over the

reservoir of a totally implantable device and/or purulent exudate in

the subcutaneous pocket containing the reservoir.

Tunnel infection: erythema, tenderness, and induration in the

tissues overlying the catheter and >2cm from the exit site.

Catheter-related bloodstream infection (CR-BSI): isolation of the

same organism (i.e., identical species, antibiogram) from a

semiquantitative or quantitative culture of a catheter segment and

from the blood (preferably drawn from a peripheral vein) of a

patient with accompanying clinical symptoms of BSI and no other

apparent source of infection. In the absence of laboratory

confirmation, defervescence after removal of an implicated catheter

from a patient with BSI may be considered indirect evidence of CR-

BSI.

Infusate-related bloodstream infection: isolation of the same

organism from infusate and from separate percutaneous blood

cultures, with no other identifiable source of infection.

Table 2

Factors Associated With Infusion-Related Phlebitis Among Patients

With Peripheral Venous Catheters

Catheter material

Catheter size

Site of catheter insertion

Experience of personnel inserting catheter

Duration of catheterization

Composition of infusate

Frequency of dressing change

Catheter-related infection

Skin prep

Host factors

Emergency room insertion

BILLING CODE 4163-18-P

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[GRAPHIC][TIFF OMITTED]TN27SE95.001

BILLING CODE 4163-18-C

[[Page 49993]]

Part 2. Recommendations for the Prevention of Nosocomial Intravascular

Device-Related Infections

Contents

I. Introduction

II. General Recommendations for Intravascular-Device Use

A. Health Care Worker Education and Training

B. Surveillance

C. Handwashing

D. Barrier Precautions during Catheter Insertion and Care

E. Catheter-site Care

1. Cutaneous antisepsis and antimicrobial ointments

2. Catheter-site dressing regimens

F. Changing Intravenous Catheters and Administration Sets

G. Preparation and Quality Control of Intravenous Admixtures

H. ``Hang time'' for Parenteral Fluids

I. In-line Filters

J. Intravenous Therapy Personnel

K. Needleless Intravascular Devices

L. Prophylactic Antimicrobials

III. Peripheral Venous Catheters

A. Selection of Catheter

B. Selection of Catheter-insertion Site

C. Catheter Changes

D. Catheter and Catheter-site Care

1. Flush solutions, anticoagulants and other intravenous

additives

2. Cutaneous antiseptics and antimicrobial ointments

IV. Central Venous and Arterial Catheters

A. Selection of Catheter

B. Selection of Catheter-insertion Site

C. Barrier Precautions during Catheter Insertion

D. Catheter Changes

E. Catheter and Catheter-site Care

1. General measures

2. Flush solutions, anticoagulants, and other intravenous

additives

3. Cutaneous antiseptics and antimicrobial ointments

4. Catheter-site dressing regimens

V. Additional Recommendations for Central Venous Hemodialysis

Catheters

A. Selection of Catheter

B. Selection of Catheter-insertion Site

C. Catheter Changes

D. Catheter and Catheter-site Care

1. General measures

2. Cutaneous antiseptics and antimicrobial ointments

VI. Peripheral Arterial Catheters and Pressure-Monitoring Devices

A. Selection of Pressure-monitoring System

B. Catheter and Pressure-monitoring System Changes

C. Care of Pressure-monitoring Systems

1. General measures

2. Sterilization or disinfection of pressure-monitoring systems

VII. Additional Recommendations for Umbilical Catheters

A. Catheter Changes

B. Catheter-site Care

Appendix. Summary of Recommended Procedures for Maintenance of

Intravascular Catheters, Administration Sets and Parenteral Fluids

References

I. Introduction

This guideline presents general recommendations for intravascular-

device use in all patients, device-specific recommendations, and

recommendations for special circumstances, i.e., intravascular-device

use in pediatric patients, and central venous catheter use for

parenteral nutrition administration and hemodialysis access.

As in previous CDC guidelines, each recommendation is categorized

on the basis of existing scientific data, theoretical rationale,

applicability, and economic impact. However, the previous CDC system

for categorizing recommendations has been modified as follows:

Category IA. Strongly recommended for all hospitals and strongly

supported by well-designed experimental or epidemiologic studies.

Category IB. Strongly recommended for all hospitals and viewed as

effective by experts in the field and a consensus of HICPAC based on

strong rationale and suggestive evidence, even though definitive

scientific studies may not have been done.

Category II. Suggested for implementation in many hospitals.

Recommendations may be supported by suggestive clinical or

epidemiologic studies, a strong theoretical rationale, or definitive

studies applicable to some, but not all, hospitals.

No Recommendation; Unresolved Issue. Practices for which

insufficient evidence or consensus regarding efficacy exists.

II. General Recommendations for Intravascular-Device Use

A. Health Care Worker Education and Training

Conduct ongoing education and training of health care workers

regarding indications for the use of and procedures for the insertion

and maintenance of intravascular devices, and appropriate infection

control measures to prevent intravascular device-related infections.

285 337 338

Category IA

B. Surveillance

1. Conduct surveillance for intravascular device-related infections

to determine device-specific infection rates, monitor trends in those

rates, and assist in identifying lapses in infection control practices

within one's own institution. Express data as the number of catheter-

related infections or catheter-related bloodstream infections per 1000

catheter-days to facilitate comparisons with national trends. 7

339-341

Category II

2. Palpate the catheter insertion site for tenderness daily through

the intact dressing.

Category IB

3. Visually inspect the catheter site if the patient develops

tenderness at the insertion site, fever without obvious source, or

symptoms of local or bloodstream infection.

Category IB

4. In patients who have large, bulky dressings that prevent

palpation or direct visualization of the catheter-insertion site,

remove the dressing and visually inspect the catheter site at least

daily and apply a new dressing.

Category II

5. Record the date and time of catheter insertion in a obvious

location near the catheter-insertion site (e.g., on the dressing or on

the bed).

Category IB

6. Do not routinely perform surveillance cultures of patients or of

devices used for intravascular access.

Category IB

C. Handwashing

Wash hands using an antiseptic-containing product before palpating,

inserting, changing, or dressing any intravascular device.

Category II

D. Barrier Precautions During Catheter Insertion and Care

1. Wear vinyl or latex gloves when inserting an intravascular

catheter as required by the Occupational Safety and Health

Administration (OSHA) Bloodborne Pathogens Standard.342

Category IB

2. Wear vinyl or latex gloves when changing the dressings on

intravascular catheters.342

Category IB

3. NO RECOMMENDATION for the use of sterile versus nonsterile

gloves during dressing changes.

Unresolved Issue

E. Catheter-Site Care

1. Cutaneous Antisepsis and Antimicrobial Ointments

Cleanse the skin site with an appropriate antiseptic including 70%

alcohol, 10% povidone-iodine, or 2% tincture of iodine before catheter

insertion.269 (EXCEPTION: see umbilical catheter section)

[[Page 49994]]

Category IA

2. Catheter-Site Dressing Regimens

a. Use either a sterile gauze or transparent dressing to cover the

catheter site. 10 165 211 268

Category IA

b. Leave dressings in place until the catheter is removed, or

changed, or the dressing becomes damp, loosened, or soiled. Change

dressings more frequently in diaphoretic patients.165

Category IB

F. Changing Intravenous Catheters and Administration Sets

1. Remove an intravascular device as soon as its use is no longer

clinically indicated.

Category IA

2. Change intravenous tubing, including ``piggyback'' tubing no

more frequently than at 72-hour intervals, unless clinically

indicated.173-175 (Exception: See F3 Below)

Category IA

3. No Recommendation for intravenous tubing changes beyond 72- hour

intervals.

Unresolved Issue

4. Change tubing used to administer blood, blood products, or lipid

emulsions within 24 hours of completing the infusion.178 179

Category IB

G. Preparation and Quality Control of Intravenous Admixtures

1. Admix all parenteral fluids in the pharmacy in a laminar-flow

hood using aseptic technique.

Category II

2. Check all containers of parenteral fluid for visible turbidity,

leaks, cracks, particulate matter, and the manufacturer's expiration

date before use.

Category IA

3. Use single-dose vials for parenteral additives or medications

whenever possible.256 257 259

Category II

4. If Multidose Vials are Used:

a. Refrigerate multidose vials after they are opened unless

otherwise specified by the manufacturer.258

Category II

b. Cleanse the rubber diaphragm of multidose vials with alcohol

before inserting needle into the vial.343

Category IA

c. Use a sterile needle and syringe each time a multidose vial is

accessed and avoid touch contamination of the needle prior to

penetrating the rubber diaphragm.259 344-346

Category IA

d. Discard multidose-vials when empty, when suspected or visible

contamination occurs, or when the manufacturer's stated expiration date

is reached.256-259

Category IA

H. ``Hang Time'' for Parenteral Fluids

1. Do not leave parenteral nutrition fluids hanging for longer than

24 hours.347 348

Category IA

2. No Recommendation for the ``hang time'' of intravenous fluids

other than parenteral nutrition fluids.

Unresolved Issue

I. In-Line Filters

Do not routinely use filters for infection control

purposes.220 222-224

Category IA

J. Intravenous Therapy Personnel

Designate trained personnel for the insertion and maintenance of

intravascular devices.229-231

Category IB

K. Needleless Intravascular Devices

No Recommendation for use, maintenance, or frequency of change of

needleless intravenous devices.

Unresolved Issue

L. Prophylactic Antimicrobials

Do not routinely administer antimicrobials for prophylaxis of

catheter colonization or bloodstream infection before insertion or

during use of an intravascular device.69 234 235

Category IB

III. Peripheral Venous Catheters

A. Selection of Catheter

1. Select catheters based on the intended purpose and duration of

use, known complications (e.g., phlebitis and infiltration), and

experience at the institution. Use a Teflon catheter, a polyurethane

catheter, or a steel needle.12 17 165 168 169

Category IB

2. Avoid the use of steel needles for the administration of fluids/

medications that may cause tissue necrosis if extravasation

occurs.\169\

Category IA

3. No Recommendation for the use of antimicrobial-impregnated

peripheral venous catheters.

Unresolved Issue

B. Selection of Catheter-Insertion Site

1. In adults, use an upper extremity site in preference to one on a

lower extremity for catheter insertion. Transfer a catheter inserted in

a lower extremity site to an upper extremity site as soon as the latter

is available.160-164

Category IA

2. In pediatric patients, insert catheters into a scalp, hand, or

foot site in preference to a leg, arm, or antecubital fossa site.\311\

Category II

C. Catheter Changes

1. In adults, change peripheral venous catheters and rotate

peripheral venous sites every 48-72 hours to minimize the risk of

phlebitis.12 165 168

Category IB

2. In adults, remove catheters inserted under emergency conditions,

where breaks in aseptic technique are likely to have occurred. Insert a

new catheter at a different site within 24 hours.

Category IB

3. In pediatric patients, No Recommendation for the frequency of

change of peripheral venous catheters.

Unresolved Issue

4. In pediatric patients, No Recommendation for removal of

catheters inserted under emergency conditions, where breaks in aseptic

technique are likely to have occurred.

Unresolved Issue

5. No Recommendation for the frequency of change of midline

catheters.

Unresolved Issue

6. Remove peripheral venous catheters when the patient develops

signs of phlebitis (i.e., warmth, tenderness, erythema, palpable venous

cord) at the insertion site.11 12 148

Category IA

D. Catheter and Catheter-Site Care

1. Flush Solutions, Anticoagulants and Other Intravenous Additives

a. Routinely flush peripheral venous heparin locks with normal

saline unless they are used for obtaining blood specimens in which case

a dilute heparin (10 units per ml) flush solution should be

used.241 349

[[Page 49995]]

Category IB

b. No Recommendation for the routine application of topical

nitrates near the insertion site of peripheral venous

catheters.249 250 252

Unresolved Issue

2. Cutaneous Antiseptics and Antimicrobial Ointments

No Recommendation for the routine application of topical

antimicrobial ointment to the insertion site of peripheral venous

catheters.197 198 200

Unresolved Issue

IV. Central Venous and Arterial Catheters

A. Selection of Catheter

1. Use a single-lumen central venous catheter unless multiple ports

are essential for the management of the patient.26-29

Category IB

2. Use tunneled catheters (e.g., Hickman or Broviac) or implantable

vascular access devices (i.e., ports) for patients 4 years

of age in whom long-term vascular access (>30 days) is

anticipated.61-63, 68, 72, 73, 350 Use totally implantable access

devices for younger pediatric patients (age 71, 73, 332, 351, 352

Category IA

3. In adults, consider use of a silver-impregnated, collagen-cuffed

or antimicrobial-impregnated central venous catheter if, after full

adherence to other catheter infection control measures (e.g., maximal

barrier precautions), there is still an unacceptably high rate of

infection.201, 225, 228 Designate trained personnel to insert

cuffed catheters to ensure maximal efficacy and prevent possible

extrusion.201, 225

Category II

4. In pediatric patients, No Recommendation for the use of

antimicrobial/antiseptic-impregnated central venous catheters.

Unresolved Issue

B. Selection of Catheter-Insertion Site

1. Use subclavian, rather than jugular or femoral, sites for

central venous catheter placement unless medically contraindicated

(e.g., coagulopathy).31-35

Category IB

2. No Recommendation on preferred site for insertion of pulmonary

artery (Swan-Ganz) catheters.36-40

Unresolved Issue

C. Barrier Precautions During Catheter Insertion

Use sterile technique including a sterile gown and gloves, a mask,

and a large sterile drape for the insertion of central venous

catheters. Use these precautions even if the catheter is inserted in

the operating room.36, 203

Category IB

D. Catheter Changes

1. No Recommendation for the frequency of routine changes of

dressings used on central venous catheter sites.268

Unresolved Issue

2. No Recommendation for frequency of change of totally implantable

devices (i.e., ports) or the needles used to access them.

Unresolved Issue

3. Change peripherally inserted central venous catheters at least

every 6 weeks.\59\

Category IB

4. No Recommendation for the frequency of change of peripherally

inserted central venous catheters when the duration of therapy is

expected to exceed 6 weeks.

Unresolved Issue

5. Change pulmonary artery catheters at least every 5 days.21

36 37

Category IB

6. No Recommendation for the removal of central catheters inserted

under emergency conditions, where breaks in aseptic technique are

likely to have occurred.

Unresolved Issue

7. Do not routinely change percutaneously inserted central venous

catheters by any means as a method to prevent catheter-related

infections.186 187 357

Category IA

8. Use guidewire-assisted catheter exchange to replace a

malfunctioning catheter or to convert an existing catheter if there is

no evidence of infection at the catheter site.131 153 186-190

Category IB

9. If catheter-related infection is suspected, but there is no

evidence of local catheter-related infection (e.g., purulent drainage,

erythema, tenderness), change the catheter over a guidewire. Send the

removed catheter for semiquantitative or quantitative culture. Leave

the newly inserted catheter in place if the catheter culture is

negative. If the catheter culture indicates colonization/infection,

remove the newly inserted catheter and insert a new catheter at a

different site.131 153 187 188

Category IB

10. Do not use guidewire-assisted catheter exchange whenever

catheter-related infection is documented. If the patient requires

continued vascular access, remove the implicated catheter and replace

it with another catheter at a different insertion site.131, 153,

187, 188

Category IA

E. Catheter and Catheter-Site Care

1. General Measures

a. Do not use parenteral nutrition catheters for purposes other

than hyperalimentation (e.g., administration of fluids, blood/blood

products).167 224 264 265

Category IA

b. No Recommendation for obtaining blood samples for culture

through central venous or central arterial catheters.353-356

Unresolved Issue

2. Flush Solutions, Anticoagulants, and other Intravenous Additives

Flush indwelling central venous catheters (e.g., Hickman and

Broviac) routinely with an anticoagulant. Groshongs do not require

routine flushing with an anticoagulant.62 64-66 69

Category IB

3. Cutaneous Antiseptics and Antimicrobial Ointments

a. Do not routinely apply antimicrobial ointment to central venous

catheter-insertion sites.30 200

Category IB

b. Do not apply organic solvents (e.g., acetone or ether) to the

skin before insertion of parenteral nutrition catheters.\270\

Category IA

4. Catheter-Site Dressing Regimens

Change catheter-site dressings when they become damp, soiled, or

loose or if inspection of the site or catheter change is necessary.

Category IA

V. Additional Recommendations for Central Venous Hemodialysis

Catheters

A. Selection of Catheter

Use cuffed central venous catheters for hemodialysis if the period

of

[[Page 49996]]

temporary access is anticipated to be 1 month.286 295

Category IB

B. Selection of Catheter-Insertion Site

No Recommendation for the site of insertion of central venous

hemodialysis catheters.

Unresolved Issue

C. Catheter Changes

1. No Recommendation for the frequency of routine changes of

dressings used on hemodialysis catheter sites.

Unresolved Issue

2. No Recommendation for the removal of hemodialysis catheters when

a patient develops fever without an obvious source.

Unresolved Issue

D. Catheter and Catheter-Site Care

1. General Measures

a. Do not use hemodialysis catheters for purposes other than

hemodialysis (e.g., administration of fluids, blood/blood products, or

parenteral nutrition).

Category II

b. Restrict manipulations of the hemodialysis catheter, including

dressing changes, to trained dialysis personnel.285

Category IB

2. Cutaneous Antiseptics and Antimicrobial Ointments

Apply povidone-iodine ointment to the catheter insertion site

before and after hemodialysis.304

Category IB

VI. Peripheral Arterial Catheters and Pressure-Monitoring Devices

A. Selection of Pressure-Monitoring System

Use disposable, rather than reusable, transducer assemblies when

possible.45 47 58

Category IA

B. Catheter and Pressure-Monitoring System Changes

1. In adults, change peripheral arterial catheters and rotate

catheter-insertion sites every 4 days.20 21

Category IB

2. In pediatric patients, No Recommendation for the frequency of

change of peripheral arterial catheters.

Unresolved Issue

3. Replace disposable or reusable transducers at 96-hour intervals.

Replace other components of the system, including the tubing,

continuous-flush device, and flush solution at the time the transducer

is changed.47 58

Category IB

4. Replace the arterial catheter and the entire monitoring system

if the patient develops a bacteremia while the catheter is in place,

irrespective of the source of bacteremia. The catheter and monitoring

system should be replaced 24 to 48 hours after antimicrobial therapy

has been started.42 47

Category IB

C. Care of Pressure-Monitoring Systems

1. General Measures

a. Keep sterile all devices and fluids that come into contact with

the fluid of the pressure-monitoring circuit (e.g., calibration

devices, heparinized saline).43 49 55 56

Category IA

b. Minimize the number of manipulations and entries into the

pressure-monitoring system. Use a closed-flush system (i.e., continuous

flush), rather than an open system (i.e., one that requires a syringe

and stopcock), to maintain the patency of the pressure-monitoring

catheters. If stopcocks are used, treat them as a sterile field and

cover them with a cap or syringe when not in use.47 57

Category IA

c. When the pressure monitoring system is accessed through a rubber

diaphragm rather than a stopcock, wipe the diaphragm with an

appropriate antiseptic before and after accessing the system.183

Category IA

d. Do not administer dextrose-containing solutions or parenteral

nutrition fluids through the pressure-monitoring circuit. Use only

heparinized normal saline.47

Category IA

e. Do not routinely use pressure-monitoring devices to obtain blood

cultures.47

Category IB

2. Sterilization or Disinfection of Pressure-Monitoring Systems

a. Clean reusable transducers first with soap and water and then

sterilize with ethylene oxide or subject to high-level disinfection

when: (1) The transducer is used between patients, (2) the transducer

is reused on a single patient who requires prolonged pressure

monitoring, or (3) the monitoring circuit (including chamber-dome and

continuous flow device) is replaced.47 54 Because transducers

differ in design, consult the manufacturers' instructions for detailed

reprocessing recommendations.

Category IA

b. Sterilize and disinfect transducers in a central processing

area. Reprocess and disinfect reusable transducers in patient care

areas only in emergency situations.47

Category IB

VII. Additional Recommendations for Umbilical Catheters

A. Catheter Changes

1. No Recommendation for the frequency of change of umbilical

catheters.

Unresolved Issue

2. No Recommendation for the removal or exchange of umbilical vein

catheters when the patient develops a fever without an obvious source.

Unresolved Issue

B. Catheter-Site Care

1. Cleanse the umbilical insertion site with an appropriate

antiseptic, including alcohol or 10% povidone-iodine before catheter

insertion.322 324 325 Do not use tincture of iodine because of the

potential effect on the neonatal thyroid.

Category IB

2. No Recommendation for the routine application of polymicrobial

ointment to umbilical catheter insertion sites.

Unresolved Issue

[[Page 49997]]

Appendix.--Summary of Recommended Procedures for Maintenance of Intravascular Catheters, Administration Sets and

Parenteral Fluids

----------------------------------------------------------------------------------------------------------------

Frequency of

Frequency of catheter/ Frequency of dressing administration set ``Hang time'' for Use of antimicrobial

device change change change parenteral fluids ointments

----------------------------------------------------------------------------------------------------------------

Peripheral Venous

Catheters:

In adults, change Leave dressings in Change intravenous Do not leave NO RECOMMENDATION

catheter and place until the tubing, including parenteral nutrition for the routine

rotate site catheter is removed, ``piggyback'' tubing fluids hanging >24 application of

every 48-72 or changed, or the no more frequently hours. antimicrobial

hours. Replace dressing becomes than at 72-hour ointments to

catheters damp, loosened, or intervals. catheter site.

inserted under soiled.

emergency

conditions

within 24 hours.

In pediatric ..................... NO RECOMMENDATION for NO RECOMMENDATION for ....................

patients, NO intravenous tubing the ``hang time'' of

RECOMMENDATION changes beyond 72- intravenous fluids

for the hour intervals. other than

frequency of Change tubing used to parenteral nutrition

catheter change administer blood, fluids.

or for the blood products, or

removal of lipid emulsions

catheters within 24 hours of

inserted under completing the

emergency infusion.

conditions.

Peripheral Arterial

Catheters and

Pressure-monitoring

Devices:

In adults, change Leave dressing in Change intravenous Do not administer NO RECOMMENDATION

catheter and place until the tubing, including dextrose-containing for the routine

rotate insertion catheter is removed, ``piggyback'' tubing solutions or application of

sites every 4 or changed, or the no more frequently parenteral nutrition antimicrobial

days. dressing becomes than at 72-hour fluids through the ointments to

In pediatric damp, loosened, or intervals. pressure monitoring catheter site.

patients, NO soiled. circuit. Use only

RECOMMENDATION heparinized normal

for the saline.

frequency of

catheter change.

Replace ..................... NO RECOMMENDATION for NO RECOMMENDATION for ....................

disposable or intravenous tubing the ``hang time'' of

reusable changes beyond 72- heparinized normal

transducers at hour intervals. saline.

96-hour

intervals.

Replace other

components of

the system,

including the

tubing,

continuous-flush

device and flush

solution at the

time the

transducer is

changed.

Midline Catheters:

NO RECOMMENDATION Leave dressing in Change intravenous Do not leave NO RECOMMENDATION

for the place until the tubing, including parenteral nutrition for the routine

frequency of catheter is removed, ``piggyback'' tubing fluids hanging >24 application of

catheter change. or changed, or the no more frequently hours. antimicrobial

dressing becomes than at 72-hour NO RECOMMENDATION for ointments to

damp, loosened, or intervals. the ``hang time'' of catheter site.

soiled. NO RECOMMENDATION for intravenous fluids

intravenous tubing other than

changes beyond 72- parenteral nutrition

hour intervals. fluids.

Change tubing used to

administer blood,

blood products, or

lipid emulsions

within 24 hours of

completing the

infusion.

[[Page 49998]]

Central Venous

Catheters

(nontunneled

catheters and

tunneled catheters

[Hickmans,

Groshongs, Ports]:

Do not routinely Leave dressing in Change intravaneous Do not leave Do not routinely

change place until he tubing, including parenteral nutrition apply antimicrobial

percutaneously catheter is removed, ``piggyback tubing'' fluids hanging >24 ointment to

inserted or change, or the no more frequently hours. catheter insertion

(nontunneled) dressing becomes than at 72-hour site.

central venous damp, loosened, or intervals.

catheters by soiled.

either rotating

insertion sites

or by guidewire-

assisted

catheter

exchange.

NO RECOMMENDATION NO RECOMMENDATION for NO RECOMMENDATION for NO RECOMMENDATION for ....................

for frequency of the frequency of intravenous tubing the ``hang time'' of

change of routine changes of changes beyond 72- intravenous fluids

tunneled dressing used on hour intervals. other than

catheters, catheter site. Change tubing used to parenteral nutrition

totally administer blood, fluids.

implantable blood products, or

devices (i.e., lipid emulsions

ports), or the within 24 hours of

needles used to completing the

access them. infusion.

Peripherally Inserted

Central Venous

Catheters:

Change at least Leave dressing in Change intravenous Do not leave Do not routinely

every 6 weeks. place until the tubing, including parenteral nutrition apply antimicrobial

NO RECOMMENDATION catheter is removed, ``piggyback'' tubing fluids hanging >24 ointment to

for frequency of or changed, or the no more frequently hours. catheter insertion

change when the dressing becomes than at 72 hour NO RECOMMENDATION for site.

duration of damp, loosened, or intervals. the ``hang time'' of

therapy is soiled. NO RECOMMENDATION for intravenous fluids

expected to NO RECOMMENDATION for intravenous tubing other than

exceed 6 weeks. the frequency of changes beyond 72- parenteral nutrition

routine changes of hour intervals. fluids.

dressing used on Change tubing used to

catheter site. administer blood,

blood products, or

lipid emulsions

within 24 hours of

completing the

infusion.

Central Arterial

Catheters (pulmonary

artery catheters):

Change catheter Leave dressing in Change intravenous NO RECOMMENDATION for Do not routinely

at least every 5 place until the tubing, including the ``hang time'' of apply antimicrobial

days. catheter is removed, ``piggyback'' tubing intravenous fluids ointment to

or changed, or the no more frequently other than catheter insertion

dressing becomes than at 72 hour parenteral nutrition site.

damp, loosened, or intervals. fluids.

soiled. NO RECOMMENDATION for

NO RECOMMENDATION for intravenous tubing

the frequency of changes beyond 72-

routine changes of hour intervals.

dressing used on

catheter site.

Central Hemodialysis

Catheters:

NO RECOMMENDATION Leave dressing in NOT APPLICABLE (Do NOT APPLICABLE (Do Apply povidone-

for the place until the not use hemodialysis not use hemodialysis iodine ointment to

frequency of catheter is removed, catheters for catheters for the catheter

catheter change. or changed, or the purposes other than purposes other than insertion site

dressing becomes hemodialysis [e.g., hemodialysis [e.g., before and after

damp, loosened, or administration of administration of hemodialysis.

soiled. fluids, blood/blood fluids, blood/blood

NO RECOMMENDATION for products, or products, or

the frequency of parenteral parenteral

dressing change. nutrition). nutrition).

[[Page 49999]]

Umbillical Catheters:

NO RECOMMENDATION NOT APPLICABLE....... Change intravenous Do not leave NO RECOMMENDATION

for frequency of tubing, including parenteral nutrition for the routine

catheter change. ``piggyback tubing'' fluids hanging >24 application of

no more frequently hours. antimicrobial

than at 72-hour NO RECOMMENDATION for ointments to the

intervals. the ``hang time'' of catheter site.

NO RECOMMENDATION for intravenous fluids

intravenous tubing other than

changes beyond 72- parenteral nutrition

hour intervals. fluids.

Change tubing used to

administer blood,

blood products or

lipid emulsions

within 24 hours of

completing the

infusion.

----------------------------------------------------------------------------------------------------------------

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