Reduction of catheter-related infections in neutropenic patients: a prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter-related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients.

Practice Guidelines for Central Venous Access 2020

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

Supplemental Digital Content is available in the text.

Febrile Neutropenia in Acute Leukemia. Epidemiology, Etiology, Pathophysiology and Treatment

Acute leukemias are a group of aggressive malignant diseases associated with a high degree of morbidity and mortality. An important cause of both the latter is infectious complications. Patients with acute leukemia are highly susceptible to infectious diseases due to factors related to the disease itself, factors attributed to treatment, and specific individual risk factors in each patient. Patients with chemotherapy-induced neutropenia are at particularly high risk, and microbiological agents include viral, bacterial, and fungal agents. The etiology is often unknown in infectious complications, although adequate patient evaluation and sampling have diagnostic, prognostic and treatment-related consequences. Bacterial infections include a wide range of potential microbes, both Gram-negative and Gram-positive species, while fungal infections include both mold and yeast. A recurring problem is increasing resistance to antimicrobial agents, and in particular, this applies to extended-spectrum beta-lactamase resistance (ESBL), Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and even carbapenemase-producing Enterobacteriaceae (CPE). International guidelines for the treatment of sepsis in leukemia patients include the use of broad-spectrum Pseudomonas-acting antibiotics. However, one should implant the knowledge of local microbiological epidemiology and resistance conditions in treatment decisions. In this review, we discuss infectious diseases in acute leukemia with a major focus on febrile neutropenia and sepsis, and we problematize the diagnostic, prognostic, and therapeutic aspects of infectious complications in this patient group. Meticulously and thorough clinical and radiological examination combined with adequate microbiology samples are cornerstones of the examination. Diagnostic and prognostic evaluation includes patient review according to the multinational association for supportive care in cancer (MASCC) and sequential organ failure assessment (SOFA) scoring system. Antimicrobial treatments for important etiological agents are presented. The main challenge for reducing the spread of resistant microbes is to avoid unnecessary antibiotic treatment, but without giving to narrow treatment to the febrile neutropenic patient that reduce the prognosis.

Validity of surrogate endpoints assessing central venous catheter-related infection: evidence from individual- and study-level analyses

OBJECTIVES

The prevention of catheter-related bloodstream infection (CRBSI) has been an area of intense research, but the heterogeneity of endpoints used to define catheter infection makes the interpretation of randomized controlled trials (RCTs) problematic. The aim of this study was to determine the validity of different endpoints for central venous catheter infections.

DATA SOURCES

(a) Individual-catheter data were collected from 9428 catheters from four large RCTs; (b) study-level data from 70 RCTs were identified with a systematic search. Eligible studies were RCTs published between January 1987 and October 2018 investigating various interventions to reduce infections from short-term central venous catheters or short-term dialysis catheters. For each RCT the prevalence rates of CRBSI, quantitative catheter tip colonization, catheter-associated infection (CAI) and central line-associated bloodstream infection (CLABSI) were extracted for each randomized study arm.

METHODS

CRBSI was used as the gold-standard endpoint, for which colonization, CAI and CLABSI were evaluated as surrogate endpoints. Surrogate validity was assessed as (1) the individual partial coefficient of determination (individual-pR²) using individual catheter data; (2) the coefficient of determination (study-R²) from mixed-effect models regressing the therapeutic effect size of the surrogates on the effect size of CRBSI, using study-level data.

RESULTS

Colonization showed poor agreement with CRBSI at the individual-patient level (pR² = 0.33 95% CI 0.28-0.38) and poor capture at the study level (R² = 0.42, 95% CI 0.21-0.58). CAI showed good agreement with CRBSI at the individual-patient level (pR² = 0.80, 95% CI 0.76-0.83) and moderate capture at the study level (R² = 0.71, 95% CI 0.51-0.85). CLABSI showed poor agreement with CRBSI at the individual patient level (pR² = 0.34, 95% CI 0.23-0.46) and poor capture at the study level (R² = 0.28, 95% CI 0.07-0.76).

CONCLUSIONS

CAI is a moderate to good surrogate endpoint for CRBSI. Colonization and CLABSI do not reliably reflect treatment effects on CRBSI and are consequently more suitable for surveillance than for clinical effectiveness research.

Increased Incidence of Central Venous Catheter-Related Infection in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intra-Peritoneal Chemotherapy

Background: Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) is a complex surgical intervention with associated risks. Central venous catheter (CVC) line sepsis is one of a number of potential morbidities. The aim of this study was to calculate the incidence of catheter-related infection (CRI) in a CRS and HIPEC patient population and to assess its influence on length of hospital stay. Methods: Data were collected on consecutive patients who underwent CRS HIPEC between August 2013 and October 2017. Data included patient demographics, timing of CVC insertion/removal, time spent in critical care, and CVC tip/blood culture results. Charts were reviewed for patients with both positive CVC culture and positive blood cultures to assess for evidence of catheter related infection and systemic inflammatory response syndrome (SIRS). Results: Data on 100 consecutive CRS HIPEC operations performed between August 2013 and October 2017 was analyzed. There were 11 CRIs in 100 CVCs, resulting in a CRI rate of 16.2 per 1,000 CVC days. Patients within the CRI group had a longer high-dependency unit (HDU) stay compared with the non-septic group (6 days vs. 4.07 days, p < 0.05). The CVC duration for the CRI and non-CRI group was 8.4 and 7.6 days, respectively (p = 0.12). The CRI group also had an increased total hospital length of stay (LOS; 20.8 days vs. 15.4 days, p < 0.05). On average, CRIs occurred eight days post-operative and four days post-HDU discharge. There was no association identified with longer CVC duration (p = 0.34). There has been an annual decline in CRI rates in CRS and HIPEC patients over the duration of the study period from 19.1 per 1,000 CVC days in 2016 to 8.2 per 1,000 CVC days in 2017. Conclusion: This is the first study to report on CRI rates in patients undergoing CRS and HIPEC. The CRI rate of 16.2 per 1,000 CVC days is higher than the overall national figure of 5.2 per 1,000 for CVC lines inserted in the operating room. Patients who developed line sepsis had longer HDU and longer overall hospital stay. Catheter-related infection was noted post-HDU discharge in all cases. Implementation of a CVC care bundle in the later years of the study period coincided with a reduction in CRI rates.

Effectiveness of antimicrobial-coated central venous catheters for preventing catheter-related blood-stream infections with the implementation of bundles: a systematic review and network meta-analysis

Background

Catheter-related blood-stream infections (CRBSIs) are the most common complication when using central venous catheters (CVCs). Whether coating CVCs under bundles could further reduce the incidence of CRBSIs is unclear. We aimed to assess the effectiveness of implementing the use of bundles with antimicrobial-coated CVCs for preventing catheter-related blood-stream infections.

Methods

In this systematic review and network meta-analyses, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library in addition to the EMBASE, MEDLINE, CINAHL, and Web of Science databases for studies published before July 2017. The primary outcome was the rate of CRBSIs per 1000 catheter-days, and the secondary outcome was the incidence of catheter colonization.

Results

Twenty-three studies revealed significant differences in the rate of CRBSIs per 1000 catheter-days between antimicrobial-impregnated and standard CVCs (RR 0.70, 95% CI 0.53–0.91, p = 0.008). Thirty-three trials were included containing 10,464 patients who received one of four types of CVCs. Compared with a standard catheter, chlorhexidine/silver sulfadiazine- and antibiotic-coated catheters were associated with lower numbers of CRBSIs per 1000 catheter-days (ORs and 95% CrIs: 0.64 (0.40–0.955) and 0.53 (0.25–0.95), respectively) and a lower incidence of catheter colonization (ORs and 95% CrIs: 0.44 (0.34–0.56) and 0.30 (0.20–0.46), respectively).

Conclusions

Outcomes are superior for catheters impregnated with chlorhexidine/silver sulfadiazine or other antibiotics than for standard catheters in preventing CRBSIs and catheter colonization under bundles. Compared with silver ion-impregnated CVCs, chlorhexidine/silver sulfadiazine antiseptic catheters resulted in fewer cases of microbial colonization of the catheter but did not reduce CRBSIs.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0416-4) contains supplementary material, which is available to authorized users.

Comparative Efficacy of Antimicrobial Central Venous Catheters in Reducing Catheter-Related Bloodstream Infections in Adults: Abridged Cochrane Systematic Review and Network Meta-Analysis

Background

The efficacy of antimicrobial central venous catheters (CVCs) remains questionable. In this network meta-analysis, we aimed to assess the comparative efficacy of antimicrobial CVC impregnations in reducing catheter-related infections in adults.

Methods

We searched 4 electronic databases (Medline, the Cochrane Central Register of Controlled Trials, Embase, CINAHL) and internet sources for randomized controlled trials, ongoing clinical trials, and unpublished studies up to August 2016. Studies that assessed CVCs with antimicrobial impregnation with nonimpregnated catheters or catheters with another impregnation were included. Primary outcomes were clinically diagnosed sepsis, catheter-related bloodstream infection (CRBSI), and all-cause mortality. We performed a network meta-analysis to estimate risk ratio (RR) with 95% confidence interval (CI).

Results

Sixty studies with 17255 catheters were included. The effects of 14 impregnations were investigated. Both CRBSI and catheter colonization were the most commonly evaluated outcomes. Silver-impregnated CVCs significantly reduced clinically diagnosed sepsis compared with silver-impregnated cuffs (RR, 0.54 [95% CI, .29-.99]). When compared to no impregnation, significant CRBSI reduction was associated with minocycline-rifampicin (RR, 0.29 [95% CI, .16-.52]) and silver (RR, 0.57 [95% CI, .38-.86]) impregnations. No impregnations significantly reduced all-cause mortality. For catheter colonization, significant decreases were shown by miconazole-rifampicin (RR, 0.14 [95% CI, .05-.36]), 5-fluorouracil (RR, 0.34 [95% CI, .14-.82]), and chlorhexidine-silver sulfadiazine (RR, 0.60 [95% CI, .50-.72]) impregnations compared with no impregnation. None of the studies evaluated antibiotic/antiseptic resistance as the outcome.

Conclusions

Current evidence suggests that the minocycline-rifampicin-impregnated CVC appears to be the most effective in preventing CRBSI. However, its overall benefits in reducing clinical sepsis and mortality remain uncertain. Surveillance for antibiotic resistance attributed to the routine use of antimicrobial-impregnated CVCs should be emphasized in future trials.

Minimising central line-associated bloodstream infection rate in inserting central venous catheters in the adult intensive care units

AIMS AND OBJECTIVES

To investigate the procedural aspects in inserting central venous catheters that minimise central line-associated bloodstream infection rates in adult intensive care units through a structured literature review.

BACKGROUND

In adult intensive care units, central line-associated bloodstream infections are a major cause of high mortality rates and increased in costs due to the consequences of complications.

METHODS

Eligible articles were identified by combining indexed keywords using Boolean operator of "AND" under databases of Ovid and CINAHL. Titles and abstract of retrieved papers were screened and duplicates removed. Inclusion and exclusion criteria were applied to derive the final papers, which contained seminal studies. The quality of papers was assessed using a special data extraction form.

RESULTS

The number of papers retrieved from all databases was 337, reduced to 302 after removing duplicates. Papers were scanned for titles and abstract to locate those relevant to the review question. After this, 250 papers were excluded for different reasons and a total of 52 papers were fully accessed to assess for eligibility. The final number of papers included was 10 articles.

CONCLUSION

Many interventions can be implemented in the adult intensive care unit during the insertion of a central venous catheter to minimise central line-associated bloodstream infections rates. These include choosing the subclavian site to insert the catheters as the least infectious and decolonising patients' skin with alcoholic chlorhexidine gluconate preparation due to its broad antimicrobial effect and durability.

RELEVANCE TO CLINICAL PRACTICE

Choosing optimal sites for central venous catheter insertion is a complex process that relies on many factors. Furthermore, the introduction of chlorhexidine gluconate preparations should be accompanied with multifaceted interventions including quality improvement initiatives to improve healthcare workers' compliance. As a quality marker in adult intensive care units, healthcare sectors should work on establishing benchmarks with other sectors around the world.

Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults

BACKGROUND

The central venous catheter (CVC) is essential in managing acutely ill patients in hospitals. Bloodstream infection is a major complication in patients with a CVC. Several infection control measures have been developed to reduce bloodstream infections, one of which is impregnation of CVCs with various forms of antimicrobials (either with an antiseptic or with antibiotics). This review was originally published in June 2013 and updated in 2016.

OBJECTIVES

Our main objective was to assess the effectiveness of antimicrobial impregnation, coating or bonding on CVCs in reducing clinically-diagnosed sepsis, catheter-related blood stream infection (CRBSI), all-cause mortality, catheter colonization and other catheter-related infections in adult participants who required central venous catheterization, along with their safety and cost effectiveness where data were available. We undertook the following comparisons: 1) catheters with antimicrobial modifications in the form of antimicrobial impregnation, coating or bonding, against catheters without antimicrobial modifications and 2) catheters with one type of antimicrobial impregnation against catheters with another type of antimicrobial impregnation. We planned to analyse the comparison of catheters with any type of antimicrobial impregnation against catheters with other antimicrobial modifications, e.g. antiseptic dressings, hubs, tunnelling, needleless connectors or antiseptic lock solutions, but did not find any relevant studies. Additionally, we planned to conduct subgroup analyses based on the length of catheter use, settings or levels of care (e.g. intensive care unit, standard ward and oncology unit), baseline risks, definition of sepsis, presence or absence of co-interventions and cost-effectiveness in different currencies.

SEARCH METHODS

We used the standard search strategy of the Cochrane Anaesthesia, Critical and Emergency Care Review Group (ACE). In the updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE (OVID SP; 1950 to March 2015), EMBASE (1980 to March 2015), CINAHL (1982 to March 2015), and other Internet resources using a combination of keywords and MeSH headings. The original search was run in March 2012.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that assessed any type of impregnated catheter against either non-impregnated catheters or catheters with another type of impregnation in adult patients cared for in the hospital setting who required CVCs. We planned to include quasi-RCT and cluster-RCTs, but we identified none. We excluded cross-over studies.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methodological procedures expected by Cochrane. Two authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our results using risk ratio (RR), absolute risk reduction (ARR) and number need to treat to benefit (NNTB) for categorical data and mean difference (MD) for continuous data, where appropriate, with their 95% confidence intervals (CIs).

MAIN RESULTS

We included one new study (338 participants/catheters) in this update, which brought the total included to 57 studies with 16,784 catheters and 11 types of impregnations. The total number of participants enrolled was unclear, as some studies did not provide this information. Most studies enrolled participants from the age of 18, including patients in intensive care units (ICU), oncology units and patients receiving long-term total parenteral nutrition. There were low or unclear risks of bias in the included studies, except for blinding, which was impossible in most studies due to the catheters that were being assessed having different appearances. Overall, catheter impregnation significantly reduced catheter-related blood stream infection (CRBSI), with an ARR of 2% (95% CI 3% to 1%), RR of 0.62 (95% CI 0.52 to 0.74) and NNTB of 50 (high-quality evidence). Catheter impregnation also reduced catheter colonization, with an ARR of 9% (95% CI 12% to 7%), RR of 0.67 (95% CI 0.59 to 0.76) and NNTB of 11 (moderate-quality evidence, downgraded due to substantial heterogeneity). However, catheter impregnation made no significant difference to the rates of clinically diagnosed sepsis (RR 1.0, 95% CI 0.88 to 1.13; moderate-quality evidence, downgraded due to a suspicion of publication bias), all-cause mortality (RR 0.92, 95% CI 0.80 to 1.07; high-quality evidence) and catheter-related local infections (RR 0.84, 95% CI 0.66 to 1.07; 2688 catheters, moderate quality evidence, downgraded due to wide 95% CI).In our subgroup analyses, we found that the magnitudes of benefits for impregnated CVCs varied between studies that enrolled different types of participants. For the outcome of catheter colonization, catheter impregnation conferred significant benefit in studies conducted in ICUs (RR 0.70;95% CI 0.61 to 0.80) but not in studies conducted in haematological and oncological units (RR 0.75; 95% CI 0.51 to 1.11) or studies that assessed predominantly patients who required CVCs for long-term total parenteral nutrition (RR 0.99; 95% CI 0.74 to 1.34). However, there was no such variation for the outcome of CRBSI. The magnitude of the effects was also not affected by the participants' baseline risks.There were no significant differences between the impregnated and non-impregnated groups in the rates of adverse effects, including thrombosis/thrombophlebitis, bleeding, erythema and/or tenderness at the insertion site.

AUTHORS' CONCLUSIONS

This review confirms the effectiveness of antimicrobial CVCs in reducing rates of CRBSI and catheter colonization. However, the magnitude of benefits regarding catheter colonization varied according to setting, with significant benefits only in studies conducted in ICUs. A comparatively smaller body of evidence suggests that antimicrobial CVCs do not appear to reduce clinically diagnosed sepsis or mortality significantly. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings. Further randomized controlled trials assessing antimicrobial CVCs should include important clinical outcomes like the overall rates of sepsis and mortality.

Use of Maximal Sterile Barrier Precautions and/or Antimicrobial-Coated Catheters to Reduce the Risk of Central Venous Catheter-Related Bloodstream Infection

Central venous catheter-related bloodstream infection is clinically important because of its high mortality rate. This prospective study shows by multivariate analysis that the use of maximal sterile barrier precautions (odds ratio, 5.205 [95% confidence interval, 0.015-1.136]; P= .023) and the use of antimicrobial-coated catheters (odds ratio, 5.269 [95% confidence interval, 0.073-0.814]; P = .022) are independent factors associated with a lowered risk of acquiring a central venous catheter-related bloodstream infection.

Chlorhexidine-silver sulfadiazine-impregnated venous catheters save costs

BACKGROUND

Previous cost-effectiveness analyses have found that the use of chlorhexidine-silver sulfadiazine (CHSS)-impregnated catheters is associated with decreased catheter-related bloodstream infections (CRBSI) and central venous catheter (CVC)-related costs. However, in these analyses, the CVC-related cost included the increase of hospital stay.

OBJECTIVE

Our aim was to determine the immediate CVC-related cost (including only the cost of CVC, diagnosis of CRBSI, and antimicrobials for the treatment of CRBSI) of using a CHSS or a standard catheter in internal jugular venous access.

METHODS

We performed a prospective, observational, cohort study of patients admitted to the intensive care unit (ICU), Hospital Universitario de Canarias (Tenerife, Spain), who received 1 or more internal jugular venous catheters.

RESULTS

The study included 245 CHSS-impregnated catheters and 391 standard catheters. Exact logistic regression analysis showed that CHSS-impregnated catheters were associated with a lower incidence of CRBSI, controlling for catheter duration, than standard catheters (0 vs 5.04 CRBSI per 1,000 catheter-days, respectively; odds ratio, 0.80; 95% confidence interval: 0.712-0.898; P < .001). Poisson regression showed that CHSS-impregnated catheters were associated with lower CVC-related cost per day than standard catheters (€3.78 ± €4.45 vs €7.28 ± €16.71, respectively; odds ratio, 0.52; 95% confidence interval: 0.504-0.535; P < .001). Survival analysis showed that CHSS-impregnated catheters were associated with increased CRBSI-free time compared with standard catheters (χ(2) = 14.9; P < .001).

CONCLUSION

The use of CHSS-impregnated catheters reduced the incidence of CRBSI and immediate CVC-related costs in the internal jugular venous access.

Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology

BACKGROUND

Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted.

PATIENTS AND METHODS

A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held.

RESULTS

Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Reducing the risk of infection associated with vascular access devices through nanotechnology: a perspective

Intravascular catheter-related infections are still a major problem in health care and are associated with significant morbidity, mortality, and additional cost. The formation of microbial biofilm on catheters makes these infections particularly complicated, as microbial cells that detach from the biofilm can lead to infection, and because these microorganisms are highly resistant to many antimicrobial agents; thus, catheter removal is often required to successfully treat infection. To reduce the risks of catheter-related infections, many strategies have been applied, such as improvements in aseptic insertion and post-insertion care practices, implantation techniques, and antibiotic coated or impregnated materials. However, despite significant advances in using these methods, it has not been possible to completely eradicate biofilm infections. Currently, nanotechnology approaches seem to be among the most promising for preventing biofilm formation and resultant catheter-related bloodstream infection (especially with multi-resistant bacterial strains). In this review, current knowledge about catheter technology and design, the mechanisms of catheter-related bloodstream infection, and the insertion and care practices performed by medical staff, are discussed, along with novel, achievable approaches to infection prevention, based on nanotechnology.

Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults

BACKGROUND

The central venous catheter (CVC) is a commonly used device in managing acutely ill patients in the hospital. Bloodstream infections are major complications in patients who require a CVC. Several infection control measures have been developed to reduce bloodstream infections, one of which is CVC impregnated with various forms of antimicrobials (either with an antiseptic or with antibiotics).

OBJECTIVES

We aimed to assess the effects of antimicrobial CVCs in reducing clinically diagnosed sepsis, established catheter-related bloodstream infection (CRBSI) and mortality.

SEARCH METHODS

We used the standard search strategy of the Cochrane Anaesthesia Review Group (CARG). We searched MEDLINE (OVID SP) (1950 to March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2012), EMBASE (1980 to March 2012), CINAHL (1982 to March 2012) and other Internet resources using a combination of keywords and MeSH headings.

SELECTION CRITERIA

We included randomized controlled trials that assessed any type of impregnated catheter against either non-impregnated catheters or catheters with another impregnation. We excluded cross-over studies.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the CARG. Two authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our results using risk ratio (RR), absolute risk reduction (ARR) and number need to treat to benefit (NNTB) for categorical data and mean difference (MD) for continuous data where appropriate with their 95% confidence intervals (CIs).

MAIN RESULTS

We included 56 studies with 16,512 catheters and 11 types of antimicrobial impregnations. The total number of participants enrolled was unclear as some studies did not provide this information. There were low or unclear risks of bias in the included studies, except for blinding, which was impossible in most studies due to different appearances between the catheters assessed. Overall, catheter impregnation significantly reduced CRBSI, with an ARR of 2% (95% CI 3% to 1%), RR of 0.61 (95% CI 0.51 to 0.73) and NNTB of 50. Catheter impregnation also reduced catheter colonization, with an ARR of 10% (95% CI 13% to 7%), RR of 0.66 (95% CI 0.58 to 0.75) and NNTB of 10. However, catheter impregnation made no significant difference to the rates of clinically diagnosed sepsis (RR 1.0 (95% CI 0.88 to 1.13)) and all-cause mortality (RR 0.88 (95% CI 0.75 to 1.05)).In our subgroup analyses, we found that the magnitudes of benefits for impregnated CVCs varied in studies that enrolled different types of participants. For the outcome of catheter colonization, catheter impregnation conferred significant benefit in studies conducted in intensive care units (ICUs) (RR 0.68 (95% CI 0.59 to 0.78)) but not in studies conducted in haematological and oncological units (RR 0.75 (95% CI 0.51 to 1.11)) or studies that assessed predominantly patients who required CVCs for long-term total parenteral nutrition (TPN)(RR 0.99 (95% CI 0.74 to 1.34)). However, there was no such variation for the outcome of CRBSI. The magnitude of the effects was also not affected by the participants' baseline risks.There were no significant differences between the impregnated and non-impregnated groups in the rates of adverse effects, including thrombosis/thrombophlebitis, bleeding, erythema and/or tenderness at the insertion site.

AUTHORS' CONCLUSIONS

This review confirms the effectiveness of antimicrobial CVCs in improving such outcomes as CRBSI and catheter colonization. However, the magnitude of benefits in catheter colonization varied according to the setting, with significant benefits only in studies conducted in ICUs. Limited evidence suggests that antimicrobial CVCs do not appear to significantly reduce clinically diagnosed sepsis or mortality. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings. Further randomized controlled trials assessing antimicrobial CVCs should include important clinical outcomes like the overall rates of sepsis and mortality.

Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline

PURPOSE

To develop an evidence-based guideline on central venous catheter (CVC) care for patients with cancer that addresses catheter type, insertion site, and placement as well as prophylaxis and management of both catheter-related infection and thrombosis.

METHODS

A systematic search of MEDLINE and the Cochrane Library (1980 to July 2012) identified relevant articles published in English.

RESULTS

The overall quality of the randomized controlled trial evidence was rated as good. There is consistency among meta-analyses and guidelines compiled by other groups as well.

RECOMMENDATIONS

There is insufficient evidence to recommend one CVC type or insertion site; femoral catheterization should be avoided. CVC should be placed by well-trained providers, and the use of a CVC clinical care bundle is recommended. The use of antimicrobial/antiseptic-impregnated and/or heparin-impregnated CVCs is recommended to decrease the risk of catheter-related infections for short-term CVCs, particularly in high-risk groups; more research is needed. The prophylactic use of systemic antibiotics is not recommended before insertion. Data are not sufficient to recommend for or against routine use of antibiotic flush/lock therapy; more research is needed. Before starting antibiotic therapy, cultures should be obtained. Some life-threatening infections require immediate catheter removal, but most can be treated with antimicrobial therapy while the CVC remains in place. Routine flushing with saline is recommended. Prophylactic use of warfarin or low-molecular weight heparin is not recommended, although a tissue plasminogen activator (t-PA) is recommended to restore patency to occluded catheters. CVC removal is recommended when the catheter is no longer needed or if there is a radiologically confirmed thrombosis that worsens despite anticoagulation therapy.

An organoselenium compound inhibits Staphylococcus aureus biofilms on hemodialysis catheters in vivo

Colonization of central venous catheters (CVCs) by pathogenic bacteria leads to catheter-related bloodstream infections (CRBSIs). These colonizing bacteria form highly antibiotic-resistant biofilms. Staphylococcus aureus is one of the most frequently isolated pathogens in CRBSIs. Impregnating CVC surfaces with antimicrobial agents has various degrees of effectiveness in reducing the incidence of CRBSIs. We recently showed that organoselenium covalently attached to disks as an antibiofilm agent inhibited the development of S. aureus biofilms. In this study, we investigated the ability of an organoselenium coating on hemodialysis catheters (HDCs) to inhibit S. aureus biofilms in vitro and in vivo. S. aureus failed to develop biofilms on HDCs coated with selenocyanatodiacetic acid (SCAA) in either static or flowthrough continuous-culture systems. The SCAA coating also inhibited the development of S. aureus biofilms on HDCs in vivo for 3 days. The SCAA coating was stable and nontoxic to cell culture or animals. This new method for coating the internal and external surfaces of HDCs with SCAA has the potential to prevent catheter-related infections due to S. aureus.

Managing intravascular catheter-related infections in heart transplant patients: how far can we apply IDSA guidelines for immunocompromised patients?

PURPOSE OF REVIEW

This study discusses the applicability to heart transplant patients of recently issued guidelines on the diagnosis, management and prevention of catheter-related bloodstream infections (CR-BSIs). It also updates newly available information of possible interest to the care of heart transplant patients.

RECENT FINDINGS

Catheters remain the leading cause of early bloodstream infections in heart transplant patients. The cause of CR-BSI is mainly attributable to Gram-positive microorganisms. Very frequently, the origin of a bloodstream infection in a heart transplant patient with multiple catheters is not clear, and a precise diagnosis is required. Management without catheter removal may be undertaken when indicated. Empiric therapy should cover Gram-positive, multidrug resistant and Gram-negative bacteria along with Candida. Prolonged antibiotic treatment exceeding 14 days is recommended and should be continued up to 4-6 weeks in the case of Staphylococcus aureus. Prevention measures include education and training, maximal sterile barrier precautions during catheter insertion, a 2% chlorhexidine preparation for skin antisepsis, avoiding routine replacement of catheters and using antimicrobial/antiseptic impregnated short-term central vein catheters (CVCs) and chlorhexidine sponge dressings.

SUMMARY

Until confirmatory data are obtained, present guidelines for diagnosing, managing and preventing CR-BSI can be applied to heart transplant patients. We would nevertheless highlight that the additional precautions should be taken of broader empiric antimicrobial therapy followed by longer duration treatment in these patients.

Controle de infecção relacionada a cateter venoso central impregnado com antissépticos: revisão integrativa

O uso de cateter venoso central é apontado como um dos principais fatores para infecção da corrente sanguínea. Objetiva-se, neste estudo, buscar evidências científicas sobre o controle de infecção relacionada ao cateter venoso central impregnado com antissépticos utilizado em pacientes adultos hospitalizados. Para seleção dos estudos, foram utilizadas as bases de dados LILACS, CINAHL e MEDLINE. Totalizaram-se nove artigos por meio da revisão integrativa da literatura. As publicações acerca da utilização de cateteres impregnados com antissépticos mostraram diferença estatisticamente significante quanto à redução da colonização microbiana. Entretanto, apenas um estudo demonstrou redução na ocorrência da infecção. Diante das análises dos estudos, há necessidade de pesquisas adicionais em diferentes populações de pacientes com a finalidade de efetuar generalizações.

Effectiveness of different central venous catheters for catheter-related infections: a network meta-analysis

We aimed to compare the effectiveness of various catheters for prevention of catheter-related infection and to evaluate whether specific catheters are superior to others for reducing catheter-related infections. We identified randomised, controlled trials that compared different types of central venous catheter (CVC), evaluating catheter-related infections in a systematic search of articles published from January 1996 to November 2009 via Medline, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. Network meta-analysis with a mixed treatment comparison method using Bayesian Markov Chain Monte Carlo simulation was used to combine direct within-trial, between-treatment comparisons with indirect trial evidence. Forty-eight clinical trials (12 828 CVCs) investigating 10 intervention catheters contributed to the analyses. For prevention of CVC colonisation, adjusted silver iontophoretic catheters (odds ratio: 0.58; 95% confidence interval: 0.33-0.95), chlorhexidine and silver sulfadiazine catheters (0.49; 0.36-0.64), chlorhexidine and silver sulfadiazine blue plus catheters (0.37; 0.17-0.69), minocycline-rifampicin catheters (0.28; 0.17-0.43) and miconazole-rifampicin catheters (0.11; 0.02-0.33) were associated with a significantly lower rate of catheter colonisation compared with standard catheters. For prevention of CRBSI, adjusted heparin-bonded catheters (0.20; 0.06-0.44) and minocycline-rifampicin catheters (0.18; 0.08-0.34) were associated with a significantly lower rate of CRBSI with standard catheters. Rifampicin-based impregnated catheters seem to be better for prevention of catheter-related infection compared with the other catheters.

Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9

Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7-10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7-10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.

The clinical effectiveness of central venous catheters treated with anti-infective agents in preventing catheter-related bloodstream infections: a systematic review

OBJECTIVES

To assess the clinical effectiveness of central venous catheters (CVCs) treated with anti-infective agents (AI-CVCs) in preventing catheter-related bloodstream infections (CRBSI).

DATA SOURCES

MEDLINE (OVID), EMBASE, SCI//Web of Science, SCI/ISI Proceedings, and the Cochrane Library.

STUDY SELECTION

A systematic review of the literature was conducted using internationally recognized methodology. All included articles were reports of randomized controlled trials comparing the clinical effectiveness of CVCs treated with AI-CVCs with either standard CVCs or another anti-infective treated catheter. Articles requiring in-house preparation of catheters or that only reported interim data were excluded.

DATA EXTRACTION

Data extraction was carried out independently and crosschecked by two reviewers using a pretested data extraction form.

DATA SYNTHESIS

Meta-analyses were conducted to assess the effectiveness of AI-CVCs in preventing CRBSI, compared with standard CVCs. Results are presented in forest plots with 95% confidence intervals.

RESULTS

Thirty-eight randomized controlled trials met the inclusion criteria. Methodologic quality was generally poor. Meta-analyses of data from 27 trials assessing CRBSI showed a strong treatment effect in favor of AI-CVCs (odds ratio 0.49 (95% confidence interval 0.37-0.64) fixed effects, test for heterogeneity, chi-square = 28.78, df = 26, p = 0.321, I = 9.7). Results subgrouped by the different types of anti-infective treatments generally demonstrated treatment effects favoring the treated catheters. Sensitivity analyses investigating the effects of methodologic differences showed no differences to the overall conclusions of the primary analysis.

CONCLUSION

AI-CVCs appear to be effective in reducing CRBSI compared with standard CVCs. However, it is important to establish whether this effect remains in settings where infection-prevention bundles of care are established as routine practice. This review does not address this question and further research is required.

Thrombotic and infectious complications of central venous catheters in patients with hematological malignancies

Central venous catheters (CVCs) have considerably improved the management of patients with hematological malignancies, by facilitating chemotherapy, supportive therapy and blood sampling. Complications of insertion of CVCs include mechanical (arterial puncture, pneumothorax), thrombotic and infectious complications. CVC-related thrombosis and infections are frequently occurring complications and may cause significant morbidity in patients with hematological malignancies. CVC-related thrombosis and infections are related and can therefore not be seen as separate entities. The incidence of symptomatic CVC-related thrombosis had been reported to vary between 1.2 and 13.0% of patients with hematological malignancy. The incidence of CVC-related bloodstream infections varies between 0.0 and 20.8%. There is need for a specific approach regarding diagnosis and treatment of CVC-related thrombosis and infection with specific attention to the preservation of the catheter. Since data on CVC-related infections and thrombosis in hematological patients have been obtained mainly from retrospective studies of small sample size, prospective, randomized studies of prophylactic measures concerning CVC-related thrombosis and infection are warranted.

Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients*

OBJECTIVES

To evaluate a new silver-impregnated multi-lumen central venous catheter for reducing catheter-related colonization in intensive care patients.

DESIGN

Multicenter, prospective, randomized, controlled clinical study.

SETTING

Ten adult intensive care units (multidisciplinary, medical and surgical, university and nonuniversity hospitals) in eight institutions.

PATIENTS

A total of 577 patients who required 617 multi-lumen central venous catheters between November 2002 and April 2004 were studied.

INTERVENTIONS

Intensive care adult patients requiring multi-lumen central venous catheters expected to remain in place for >or=3 days were randomly assigned to undergo insertion of silver-impregnated catheters (silver group) or standard catheters (standard group). Catheter colonization was defined as the growth of >or=1,000 colony-forming units in culture of the intravascular tip of the catheter by the vortexing method. Diagnosis of catheter-related infection was performed by an independent and blinded expert committee.

RESULTS

A total of 320 catheters were studied in the silver group and 297 in the standard group. Characteristics of the patients, insertion site, duration of catheterization (median, 11 vs. 10 days), and other risk factors for infection were similar in the two groups. Colonization of the catheter occurred in 47 (14.7%) vs. 36 (12.1%) catheters in the silver and the standard groups (p = .35), for an incidence of 11.2 and 9.4 per 1,000 catheter days, respectively. Catheter-related bloodstream infection was recorded in eight (2.5%) vs. eight (2.7%) catheters in the silver and the standard groups (p = .88), for an incidence of 1.9 and 2.1 per 1,000 catheter days, respectively.

CONCLUSION

The use of silver-impregnated multi-lumen catheters in adult intensive care patients is not associated with a lower rate of colonization than the use of standard multi-lumen catheters.

Antimicrobial impregnated catheters in the prevention of catheter-related bloodstream infection in hospitalized patients

Catheter-related bloodstream infections have a significant impact on increasing health care costs and morbidity and mortality in hospitalized patients. Many technologies have been created in an attempt to decrease the incidence of catheter-related bloodstream infection. One of these is the impregnation of central venous catheters with antiseptics (e.g., chlorhexidine and silver sulfadiazine) or antibiotics (e.g., minocycline and rifampin). While studies evaluating the efficacy of impregnated catheters have been conducted, the data are limited and their use remains variable across institutions. This paper will discuss catheter-related factors that predispose patients to catheter-related bloodstream infection, the types of antimicrobial-impregnated catheters in use today, studies evaluating their efficacy, and common concerns associated with the use of these catheters. Issues related to the cost-effectiveness of impregnated catheters and future directions for the prevention of catheter-related bloodstream infection will also be presented.

Protective effects of local administration of ciprofloxacin on the risk of pneumococcal meningitis after cochlear implantation

OBJECTIVES

To determine whether ciprofloxacin retains its antimicrobial activity after storage with Healon at ambient temperature and at 37 degrees C over 5 weeks and then to establish whether the application of ciprofloxacin/Healon onto scala tympani electrode arrays reduces the risk of meningitis in implanted rats inoculated with S. pneumoniae.

STUDY DESIGN

In vitro laboratory and in vivo animal studies

METHODS

The antibacterial activity of three concentrations of ciprofloxacin/Healon (7.5, 75, and 750 microg/mL) was examined over 5 weeks at both ambient temperature (23 degrees C) and body temperature (37 degrees C). Thirty-six rats (18 implanted with ciprofloxacin [750 mg/mL]/Healon-coated electrode array and 18 without the coating) were infected with S. pneumoniae 4 weeks after implantation by way of three different routes of infection (hematogenous, middle ear, and inner ear) and observed for the development of meningitis.

RESULTS

The antibacterial activity of ciprofloxacin/Healon was maintained over 5 weeks at both 23 degrees C and 37 degrees C. The implanted rats with the ciprofloxacin/Healon-coated electrode array were protected from meningitis when the bacteria were given by way of the hematogenous route (Fisher's exact test, P = .008) but not when the bacteria were inoculated directly into the middle or inner ear. However, the time to develop meningitis was significantly longer in rats implanted with a coated array, irrespective of the route of inoculation (P < .05, log rank test).

CONCLUSION

Our animal model demonstrated that a ciprofloxacin-coated electrode array can protect healthy implanted rats from meningitis when the route of infection is hematogenous and can delay the onset of meningitis when bacteria are inoculated directly into the middle or inner ear.

Prevention of catheter-related bloodstream infections: analysis of studies published between 2002 and 2005

As the most recent guidelines for the prevention of catheter-related bloodstream infections (CR-BSIs) were published four years ago, a systematic review was conducted to determine whether any recently published articles should further influence existing guidelines. Articles published between 2002 and 2005 dealing with infection control measures for prevention of CR-BSI were evaluated in order to identify evidence for the possible modification of routine practice. Special emphasis was placed on randomized controlled trials (RCTs), meta-analyses or systematic reviews, and studies applying multi-module interventions. Thirty-three RCTs and 10 meta-analyses or systematic reviews were retrieved. In addition, 10 cohort studies were identified where multi-module programmes were introduced for reducing CR-BSI rates. It was found that RCTs and meta-analyses only have a minor influence on the existing guidelines for the prevention of CR-BSIs and confirm the earlier recommendations on several points. Studies investigating multi-module programmes, however, found a substantial reduction in CR-BSIs ranging from 29% to 95%. The data show that many CR-BSIs are preventable and that there is room for improvement in many institutions. Simple interventions are often useful for reducing CR-BSI rates and the opportunities to decrease CR-BSI rates appear to be greatest when multi-module programmes are applied. An average reduction of more than 50% seems to be possible.

The significance of infection related to orthopedic devices and issues of antibiotic resistance

Over the last 15 years, with the advent of modern standards in the control of sterility within the operating room environment and adequate protocols of peri-operative antibiotic prophylaxis, the incidence of infections associated to orthopedic implants has become very low. Nevertheless, the event of infection still represents one of the most serious and devastating complications which may involve prosthetic devices. It leads to complex revision procedures and, often, to the failure of the implant and the need for its complete removal. In orthopedics, for the enormous number of surgical procedures involving invasive implant materials, even if nowadays rare, infections have a huge impact in terms of morbidity, mortality, and medical costs. The difficult battle to prevent and fight bacterial infections associated to prosthetic materials must be played on different grounds. A winning strategy requires a clear view of the pathogenesis and the epidemiology of implant-related infections, with a special attention on the alarming phenomenon of antibiotic resistance. In this regard staphylococci are the prevalent and most important causative pathogens involved in orthopedic implant-related infections, and, thus, the main enemy to defeat. In this paper, we offer an overview of the complexity of this battleground and of the current and new, in our opinion most promising, strategies in the field of biomaterials to reduce the risks and counteract the establishment of implant infections.