Intravenous tubing containing burettes can be safely changed at 72 hour intervals

Routine Changing of Intravenous Administration Sets Does Not Reduce Colonization or Infection in Central Venous Catheters

Objective:

To determine the effect of routine intravenous (IV) administration set changes on central venous catheter (CVC) colonization and catheter-related bacteremia.

Design:

Prospective, randomized, controlled trial.

Setting:

Eighteen-bed intensive care unit (ICU) in a large metropolitan hospital.

Participants:

Two hundred fifty-one patients with 404 chlorhexidine gluconate and silver sulfadiazine–coated multilumen CVCs.

Interventions:

CVCs inserted in the ICU and in situ on day 4 were randomized to have their IV administration sets changed on day 4 (n = 203) or not at all (n = 201). Use of fluid containers and blood product administration sets was limited to 24 hours. CVCs were removed when not required, infection was suspected, or in place on day 7. Catheter cultures were performed on removal by blinded laboratory staff. Catheter-related bacteremia was diagnosed by a blinded intensivist using strict definitions. Data were collected regarding catheter duration, site, Acute Physiology and Chronic Health Evaluation (APACHE) II score, patient age, diagnosis, hyperglycemia, hypoalbuminemia, immune status, number of fluid containers and IV injections, and administration of propofol, blood, total parenteral nutrition, or lipid infusion.

Results:

There were 10 colonized CVCs in the group receiving a set change and 19 in the group not receiving one. This difference was not statistically significant on Kaplan–Meier survival analysis. There were 3 cases of catheter-related bacteremia per group. Logistic regression found that burns diagnosis and increased ICU stay significantly predicted colonization.

Conclusion:

IV administration sets can be used for 7 days in patients with short-term, antiseptic-coated CVCs.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

Background:

Although many catheter-related blood-stream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented.

Objective:

To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs.

Data Sources:

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.

Studies Included:

Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations.

Outcome Measures:

Reduction in CRBSI, catheter colonization, or catheter-related infection.

Synthesis:

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis).

Conclusion:

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine

Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.

Optimal timing for intravascular administration set replacement

BACKGROUND

The tubing (administration set) attached to both venous and arterial catheters may contribute to bacteraemia and other infections. The rate of infection may be increased or decreased by routine replacement of administration sets. This review was originally published in 2005 and was updated in 2012.

OBJECTIVES

The objective of this review was to identify any relationship between the frequency with which administration sets are replaced and rates of microbial colonization, infection and death.

SEARCH METHODS

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), MEDLINE (1950 to June 2012), CINAHL (1982 to June 2012), EMBASE (1980 to June 2012), reference lists of identified trials and bibliographies of published reviews. The original search was performed in February 2004. We also contacted researchers in the field. We applied no language restriction.

SELECTION CRITERIA

We included all randomized or controlled clinical trials on the frequency of venous or arterial catheter administration set replacement in hospitalized participants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed all potentially relevant studies. We resolved disagreements between the two review authors by discussion with a third review author. We collected data for seven outcomes: catheter-related infection; infusate-related infection; infusate microbial colonization; catheter microbial colonization; all-cause bloodstream infection; mortality; and cost. We pooled results from studies that compared different frequencies of administration set replacement, for instance, we pooled studies that compared replacement ≥ every 96 hours versus every 72 hours with studies that compared replacement ≥ every 48 hours versus every 24 hours.

MAIN RESULTS

We identified 26 studies for this updated review, 10 of which we excluded; six did not fulfil the inclusion criteria and four did not report usable data. We extracted data from the remaining 18 references (16 studies) with 5001 participants: study designs included neonate and adult populations, arterial and venous administration sets, parenteral nutrition, lipid emulsions and crystalloid infusions. Most studies were at moderate to high risk of bias or did not adequately describe the methods that they used to minimize bias. All included trials were unable to blind personnel because of the nature of the intervention.No evidence was found for differences in catheter-related or infusate-related bacteraemia or fungaemia with more frequent administration set replacement overall or at any time interval comparison (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.67 to 1.69; RR 0.67, 95% CI 0.27 to 1.70). Infrequent administration set replacement reduced the rate of bloodstream infection (RR 0.73, 95% CI 0.54 to 0.98). No evidence revealed differences in catheter colonization or infusate colonization with more frequent administration set replacement (RR 1.08, 95% CI 0.94 to 1.24; RR 1.15, 95% CI 0.70 to 1.86, respectively). Borderline evidence suggested that infrequent administration set replacement increased the mortality rate only within the neonatal population (RR 1.84, 95% CI 1.00 to 3.36). No evidence revealed interactions between the (lack of) effects of frequency of administration set replacement and the subgroups analysed: parenteral nutrition and/or fat emulsions versus infusates not involving parenteral nutrition or fat emulsions; adult versus neonatal participants; and arterial versus venous catheters.

AUTHORS' CONCLUSIONS

Some evidence indicates that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the risk of infection. Other evidence suggests that mortality increased within the neonatal population with infrequent administration set replacement. However, much the evidence obtained was derived from studies of low to moderate quality.

Reduction in coagulase-negative staphylococcus infection rates in the NICU using evidence-based research

Coagulase-negative Staphylococcus (CoNS) bloodstream infection is the most common cause of sepsis in the NICU and can lead to significant morbidity and mortality. There is evidence that hand hygiene using an alcohol-based gel and wearing gloves during patient care, management of central and peripheral intravenous lines using the Centers for Disease Control and Prevention (CDC) guidelines, and a closed medication administration system can reduce the incidence to CoNS sepsis in the (NICU). To successfully apply the evidence and decrease the CoNS infection rate, a systematic process is necessary. One approach to process change that significantly reduced the CoNS infection rate in a health care system with two Level III NICUs included using system thinking; working within a multidisciplinary team; using evidence to revise, develop, and implement policies and procedures; developing staff education programs; and monitoring and providing feedback to all staff members.

Contamination of intravenous fluids: a continuing cause of hospital bacteremia

BACKGROUND

Nosocomial bacteremia caused by the contamination of intravenous (IV) infusates is considered rare. Unfortunately, this problem has been underestimated because its identification requires culturing infusates, a procedure not performed routinely.

METHODS

This study was conducted in a referral hospital where IV infusates are admixed in nursing areas. The aim was to determine the prevalence of infusate contamination in adult patients with gram-negative rod (GNR) bacteremia. Over a period of 32 months, a specimen of infusate was drawn for culture from each patient recruited after the laboratory reported a GNR in the blood.

RESULTS

A total of 384 infusates were cultured from 384 patients who had been diagnosed with GNR bacteremia. Seven infusates grew a GNR in culture, for a contamination rate of 2% (7/384; 95% confidence interval [CI] = 1% to 3%). In all cases, the infectious organism was the same as the organism isolated from the blood. Infusate contamination was responsible for 7% (7/108; 95% CI = 2% to 11%) of all primary bloodstream infections and 11% (7/62; 95% CI = 2% to 22%) of all primary bloodstream infections not associated with central venous catheter infection.

CONCLUSIONS

For patients in hospitals where IV drugs are admixed in nursing units, we recommend instituting infusate culture as routine practice following the diagnosis of a GNR in the blood.

Decreasing central line associated bloodstream infection in neonatal intensive care

Central Line Associated Bloodstream Infections (CLABSIs) have come to be recognized as preventable adverse events that result from lapses in technique at multiple levels of care. CLABSIs are associated with increased mortality and adverse outcomes that may have lifelong consequences. This review provides a summary of evidence-based strategies to reduce CLABSI in the newborn intensive care unit that have been described in the literature over the past decades. Implementation of these strategies in "bundles" is also discussed, citing examples of successful quality improvement collaboratives. The methods of implementation require an understanding of the scientific data and technical developments, as well as knowledge of how to influence change within the unique and complicated milieu of the newborn intensive care unit.

Endemic infusate contamination and related bacteremia

BACKGROUND

Recent reports suggest that in-use contamination of intravenous infusates is uncommon in hospitals with good standards of care.

METHODS

We conducted a survey in a referral hospital in Mexico with good standards of care but no pharmacists to prepare intravenous infusates; we tested the a priori hypothesis that the contamination rate is zero. Using a sterile syringe, we took an initial infusate specimen at the time of recruitment, specimen 1, for culture. We took a second specimen, specimen 2, from administration sets that were maintained for 72 hours. Blood cultures were obtained at the discretion of the physicians caring for the patients.

RESULTS

We cultured 1093 infusate specimens from 621 administration sets comprising 421 patients. We obtained a specimen 1 from each of the enrolled sets and a specimen 2 from 472 sets (76%). We analyzed 10 significant cultures and obtained a global infusate contamination rate of 0.9% (10/1093; 95% CI: 0.5%-1.7%). Two cases of infusate-related bacteremia occurred, establishing a global rate of 0.003/72 infusion hours.

CONCLUSIONS

Even in institutions with good nursing standards, endemic in-use infusate contamination may be a present danger. We must avoid the use of intravenous therapy whenever possible.

Optimal timing for intravenous administration set replacement

BACKGROUND

Administration of intravenous therapy is a common occurrence within the hospital setting. Routine replacement of administration sets has been advocated to reduce intravenous infusion contamination. If decreasing the frequency of changing intravenous administration sets does not increase infection rates, a change in practice could result in considerable cost savings.

OBJECTIVES

The objective of this review was to identify the optimal interval for the routine replacement of intravenous administration sets when infusate or parenteral nutrition (lipid and non-lipid) solutions are administered to people in hospital via central or peripheral venous catheters.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE: all from inception to February 2004; reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. We did not have a language restriction.

SELECTION CRITERIA

We included all randomized or quasi-randomized controlled trials addressing the frequency of replacing intravenous administration sets when parenteral nutrition (lipid and non-lipid containing solutions) or infusions (excluding blood) were administered to people in hospital via a central or peripheral catheter.

DATA COLLECTION AND ANALYSIS

Two authors assessed all potentially relevant studies. We resolved disagreements between the two authors by discussion with a third author. We collected data for the outcomes; infusate contamination; infusate-related bloodstream infection; catheter contamination; catheter-related bloodstream infection; all-cause bloodstream infection and all-cause mortality.

MAIN RESULTS

We identified 23 references for review. We excluded eight of these studies; five because they did not fit the inclusion criteria and three because of inadequate data. We extracted data from the remaining 15 references (13 studies) with 4783 participants. We conclude that there is no evidence that changing intravenous administration sets more often than every 96 hours reduces the incidence of bloodstream infection. We do not know whether changing administration sets less often than every 96 hours affects the incidence of infection. In addition, we found that there were no differences between participants with central versus peripheral catheters; nor between participants who did and did not receive parenteral nutrition, or between children and adults.

AUTHORS' CONCLUSIONS

It appears that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the incidence of infection. There was no evidence to suggest that administration sets which contain lipids should not be changed every 24 hours as currently recommended.

Pediatric catheter-related bloodstream infections: latest strategies to decrease risk

Central venous catheters are often mandatory devices when caring for critically ill children. They are required to deliver medications, nutrition, and blood products, as well as for monitoring hemodynamic status and drawing laboratory samples. Any foreign object that is introduced to the body is at risk for infection. Central venous catheters carry a particularly high risk of infection and these infections can be life threatening. Advanced practice nurses possess the power to influence catheter-related line infections in their critical care units. Understanding current recommendations for catheter material selection, site selection, site preparation, and site care can affect rates of catheter-related bloodstream infections. This article discusses risk factors for developing catheter-related bloodstream infections in critically ill children, as well as measures to decrease incidence of catheter-related bloodstream infections, including a review of recommendations from the Centers for Disease Control and Prevention.

Central venous catheter use in the pediatric patient: mechanical and infectious complications

OBJECTIVE

Following the introduction and widespread use of central venous catheters (CVCs) in adults, these devices are being used with increasing frequency in the pediatric population. This review will focus on differences between adults and children regarding CVC use and its potential complications. Both mechanical and infectious complications will be discussed.

DATA SOURCES

Systematic review of the literature.

CONCLUSIONS

CVC-related complications in pediatric patients are closely linked to age, body size, and age-related immune status. In older children, many complications are similar to those encountered in adult patients. Because of ongoing growth and body changes, a cutoff point beyond which children can be regarded as "young adults" is difficult to define; many of our recommendations are therefore age-related. More frequently than in adults, an implanted port may be the first choice in pediatric patients when long indwelling times are expected. The optimal site of insertion also depends on factors such as the patients' age as well as the need for sedation and analgesia during the insertion procedure. In contrast to guidelines in adult patients, we recommend that a radiograph always be made following CVC insertion to check the position of the catheter. Regarding prevention of infectious complications, we recommend full sterile barrier precautions during CVC insertion and strict protocols for catheter care. CVCs should be removed as soon as possible when they are no longer needed, but there is no place for elective CVC replacement on a routine basis. New developments such as the use of impregnated catheters might help reduce infection rates; however, additional research will be required to provide more evidence of benefit in the pediatric population.

Timing of intravenous administration set changes: a systematic review

OBJECTIVE

To determine the optimal time interval for the routine replacement of intravenous administration sets when crystalloids or parenteral nutrition are administered via a central or peripheral catheter in an acute care setting.

DESIGN

Systematic review of all randomized or systematically allocated controlled trials addressing the frequency of replacing intravenous administration sets.

METHODS

The Cochrane Controlled Trials Register (June 2001) and the Ovid databases (Medline, CINAHL, and CancerLit-July 2001) were searched. Bibliographies, relevant conference proceedings, and any product information were also checked for references.

RESULTS

Eighteen studies were selected for review. The 12 included studies were separated into 3 intravenous administration set change comparisons: 24 hours versus 48 hours or more; 48 hours versus 72 hours or more; and 72 hours versus 96 hours or more. There was good evidence that changing intravenous administration sets every 72 hours or more does not increase the risk of infusate-related bloodstream infection (BSI) in patients with central or peripheral catheters and a fair level of evidence that it does not increase the risk of catheter-related BSI. There were insufficient data regarding the incidence of BSI among patients receiving parenteral nutrition, particularly lipid-containing parenteral nutrition.

CONCLUSIONS

It appears that intravenous administration sets containing crystalloids can be changed in patients with central or peripheral catheters every 72 hours or more without increasing the risk of BSI. However, it is not possible to conclude that intravenous administration sets containing parenteral nutrition, particularly lipid-containing parenteral nutrition, can be changed at this interval.

Guidelines for the prevention of intravascular catheter-related infections

BACKGROUND

Although many catheter-related bloodstream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented.

OBJECTIVE

To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs.

DATA SOURCES

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.

STUDIES INCLUDED

Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations.

OUTCOME MEASURES

Reduction in CRBSI, catheter colonization, or catheter-related infection.

SYNTHESIS

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis).

CONCLUSION

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device–Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e., education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

Guidelines for the prevention of intravascular catheter-related infections

BACKGROUND

Although many catheter-related bloodstream infections (CR-BSIs) are preventable, measures to reduce these infections are not uniformly implemented.

OBJECTIVE

To update an existing evidenced-based guideline that promotes strategies to prevent CR-BSIs.

DATA SOURCES

The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.Studies Included: Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiological investigations.

OUTCOME MEASURES

Reduction in CR-BSI, catheter colonization, or catheter-related infection.

SYNTHESIS

The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e. education and training, maximal sterile barrier precautions and 2% chlorhexidine for skin antisepsis).

CONCLUSION

Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Guidelines for the prevention of intravascular catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for Disease Control and Prevention, U.S

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device-Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

Intravascular administration sets are accurate and in appropriate condition after 7 days of continuous use: an in vitro study

BACKGROUND

The ideal duration of intravascular administration set use is unknown. Studies have compared the infective implications of 1--7 days of use. The Centers for Disease Control recommend at least 3 days usage. No previous study has evaluated the accuracy of volume delivery or integrity of administration sets after prolonged use.

AIM

To evaluate the accuracy and condition of intravascular administration sets used continuously for 7 days.

DESIGN

Prospective, randomized, experimental study in the laboratory setting.

METHODS

Four administration sets were randomly assigned to deliver 2 mL/hour (IMEDreg syringe set 2280--0000), 20, 50 or 100 mL/hour (IMEDreg infusion sets 2210--0500) of crystalloid solution continuously for 7 days through an IMEDreg Geminireg four channel infusion pump (PC4). At study commencement and daily for 7 days, a 4-hour volume measurement and an inspection for leaks/erosion of administration sets occurred for each administration set (total measurements = 32).

RESULTS

Mean volume outputs over 4 hours were 7.84 mL (2 mL/hour), 80.66 mL (20 mL/hour), 205.35 (50 mL/hour) and 406.37 (100 mL/hour). These differed significantly from the programmed volumes (P=0.00--0.01). Usage duration did not influence performance (F=0.866, P=0.55). Accuracy of volume delivery differed significantly with pump speed (F=106.933, P < 0.001) exhibiting increased volume to 50 mL/hour then a reduction at 100 mL/hour. Differences were within manufacturer specifications (+/-5%) and were clinically acceptable. All administration sets remained in appropriate condition displaying no leakage or erosion.

CONCLUSION

There were small inaccuracies found between programmed and delivered volumes, however, there was no deterioration in performance over time. This suggests that inaccuracies were because of normal pump performance rather than the administration sets. Administration sets retain acceptable accuracy and condition after 7 days continuous use. Further research should assess the infective and other impacts of prolonged usage.

Optimal frequency of changing intravenous administration sets: is it safe to prolong use beyond 72 hours?

OBJECTIVE

To determine the safety and cost-effectiveness of replacing the intravenous (IV) tubing sets in hospitalized patients at 4- to 7-day intervals instead of every 72 hours.

DESIGN

Prospective, randomized study of infusion-related contamination associated with changing IV tubing sets within 3 days versus within 4 to 7 days of placement.

SETTING

A tertiary university cancer center.

PATIENTS AND METHODS

Cancer patients requiring IV infusion therapy were randomized to have the IV tubing sets replaced within 3 days (280 patients) or within 4 to 7 days of placement (232 patients). Demographic, microbiological, and infusion-related data were collected for all participants. The main outcome measures were infusion- or catheter-related contamination or colonization of IV tubing, determined by quantitative cultures of the infusate, and infusion- or catheter-related bloodstream infection (BSI), determined by quantitative culture of the infusate in association with blood cultures in febrile patients.

RESULTS

The two groups were comparable in terms of patient and catheter characteristics and the agents given through the IV tubing. Intent-to-treat analysis demonstrated a higher level of tubing colonization in the 4- to 7-day group versus the 3-day group (median, 145 vs 50 colony-forming units; P=.02). In addition, there were three episodes of possible infusion-related BSIs, all of which occurred in the 4- to 7-day group (P=.09). However, when the 84 patients who received total parenteral nutrition, blood transfusions, or interleukin-2 through the IV tubing were excluded, the two groups had a comparable rate of colonization (0.4% vs 0.5%), with no catheter- or infusion-related BSIs in either group.

CONCLUSION

In patients at low risk for infection from infusion- or catheter-related infection who are not receiving total parenteral nutrition, blood transfusions, or interleukin-2, delaying the replacement of IV tubing up to 7 days may be safe, as well as cost-effective

The health professional's role in preventing nosocomial infections

Despite their best intentions, health professionals sometimes act as vectors of disease, disseminating new infections among their unsuspecting clients. Attention to simple preventive strategies may significantly reduce disease transmission rates. Frequent hand washing remains the single most important intervention in infection control. However, identifying mechanisms to ensure compliance by health professionals remains a perplexing problem. Gloves, gowns, and masks have a role in preventing infections, but are often used inappropriately, increasing service costs unnecessarily. While virulent microorganisms can be cultured from stethoscopes and white coats, their role in disease transmission remains undefined. There is greater consensus about sterile insertion techniques for intravascular catheters-a common source of infections-and their care. By following a few simple rules identified in this review, health professionals may prevent much unnecessary medical and financial distress to their patients.

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

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

I.v. devices and related infections: causes and complications

The use of intravenous devices has long been established as a life-saving and important part of total patient management. However, such devices are not without risk and their use is frequently complicated by local or systemic infections and complications. Twenty-five million patients are estimated to enter the NHS annually and receive some form of intravenous therapy by the peripheral route (Campbell, 1998). It behoves all staff who are involved in the management of intravenous devices to base their practice on what is agreed by consensus in the literature as being effective in reducing the risk of hospital-acquired infections. This article draws together such literature and presents recommendations for good practice for the management of intravenous-related devices.

Intravenous therapy in critically ill adults: developing a clinically and cost-effective approach

Intravenous therapies are the most common intervention for critically ill adults. Using a systematic approach as described by Droogan and Song (1996), a review of the literature was undertaken to determine whether the frequency of changing intravenous administration sets in critically ill adults with central venous catheters (CVCs) affected the incidence of CVC-related sepsis/systemic inflammatory response syndrome (SIRS)/bacteraemia. Two major randomized controlled trials were included in the review (Maki et al. 1987; Snydman et al. 1987), which conclude that increasing the change frequency of administration sets from 24 to 72 hours does not significantly increase the incidence of sepsis. This can therefore lead to considerable cost savings as well as ensuring clinically effective care. The review criteria excluded a plethora of related studies. However, these studies do corroborate the findings of Maki et al. and Snydman et al. They are summarized in the tables and are taken into account when making recommendations for clinical practice and future research. Clinical practice guidelines which are being implemented and evaluated locally are offered for the reader's consideration.

Parenteral infusions bacterial contamination in a multi-institutional survey in Mexico: considerations for nosocomial mortality

BACKGROUND

Parenteral infusions can be contaminated during administration (extrinsic contamination). A previous survey found that extrinsic contamination was not uncommon in a hospital in Mexico with lapses in aseptic techniques. To determine whether this problem exists in other similar institutions, we undertook a multi-institutional study.

METHODS

We surveyed 6 hospitals (A to F) lacking an infection control committee to determine the level of extrinsic contamination. We visited each hospital and obtained samples of all the parenteral infusions in use, drawing 0.5-1 mL from the tubing injection port. Quantitative and qualitative bacterial cultures were performed. Chlorine levels of the tap water were measured. Visits were repeated until the survey was completed.

RESULTS

A total of 751 infusions were cultured, of which 16 (2.13%) were contaminated. Hospital contamination rates varied from zero to 5.56%. Klebsiella pneumoniae was the most common isolate (10 cases). During the first sampling day in hospital C, the 7 infusions from the pediatric ward were found to be contaminated with a similar K pneumoniae strain. In-service education was started in this hospital. Infusion contamination was eliminated followed by a reduction in mortality rate. Overall, a higher risk for infusion contamination was noted for pediatric patients (P =.01, odds ratio = 3.28, 95% CI, 1.10-9.91) and in wards with inadequate water chlorine levels (P =. 02, odds ratio = 3.64, 95% CI, 1.08-13.51).

CONCLUSIONS

If the hospitals surveyed are representative of others in developing countries, an endemic level of parenteral infusion contamination could exist in many hospitals throughout the world.

Prevention of central venous catheter-related infection

Infections associated with central venous catheters continue to be a major source of sepsis, particularly in hospitalized patients. In developing a strategy for the prevention of these infections, the source and route of invasion of the causative micro-organisms need to be considered. The main source of micro-organisms is the patient's skin. They can gain access to a catheter at the time of insertion, as well as via the external or internal catheter surfaces. Attempts to reduce the incidence of infections range from the type of skin preparation selected, to care of the insertion site post-catheterization. Improvements in catheter design have also reduced the likelihood of infection and include the development of non-leachable smooth catheters with anti-adhesive coatings. More recently, catheters containing antimicrobial agents have become available and preliminary studies have demonstrated a reduction in microbial colonization and associated sepsis. Future preventative strategies may include the application of low voltage electric current in combination with antimicrobials.

Total nutrient admixtures appear safer than lipid emulsion alone as regards microbial contamination: growth properties of microbial pathogens at room temperature

BACKGROUND

The extraordinary growth properties of most microorganisms in 10% and 20% lipid emulsions has led to the Centers for Disease Control and Prevention recommendation that if lipids are given through an i.v. line, the administration set should be replaced every 24 hours rather than the usual 72-hour interval used for crystalloid solutions, including those used for conventional total parenteral nutrition. For nearly 15 years, parenteral alimentation has been given as a total nutrient admixture (TNA), with the glucose, amino acids, and lipid mixed within the same bag and infused continuously over 24 hours.

METHODS

We prospectively studied in a representative TNA (17.6% glucose, 5% amino acids, 4% lipid; pH 5.6, osmolality 1778) and in a control solution, 5% dextrose-in-water (D5%/W), the growth properties at 4, 25, and 35 degrees C of three isolates each of Staphylococcus epidermidis, Staphylococcus aureus, Enterobacter cloacae, Klebsiella oxytoca, Serratia marcescens, Acinetobacter calcoaceticus, Stenotrophomonas maltophilia, Pseudomonas aeruginosa, Burkholderia cepacia, Flavobacterium spp, and Candida albicans, and two isolates of Staphylococcus saprophyticus, the species that are most likely to contaminate TNA during preparation or administration and that have been implicated in >95% of all outbreaks and sporadic cases of nosocomial bloodstream infections traced to contaminated parenteral admixtures reported in the world literature.

RESULTS

Growth in TNA at 25 and 35 degrees C occurred with only two species, C. albicans and S. saprophyticus, and only after 24 to 48 hours; D5%/W allowed growth at 25 degrees C of two gram-negative species, S. marcescens and B. cepacia.

CONCLUSIONS

We conclude that TNA is a poor growth medium for most nosocomial pathogens and is no better than D5%/W. The need to replace administration sets every 24 hours with TNA should be reconsidered and ideally be studied in a prospective randomized trial.

Bacterial colonization and endotoxin contamination of intravenous infusion fluids

Bacterial colonization and endotoxin contamination of intravenous infusion fluids and catheter systems were examined in a surgical intensive care unit. Nineteen consecutive patients were randomly assigned to 48 h (N = 8) or 96 h (N = 11) change of infusion systems. Fluid from infusion bottles (51), infusion bottles plus burettes (102) and catheter systems (104) was cultured quantitatively for aerobic and anaerobic bacteria. Swabs (362) were taken from three-way stopcocks before and after the in-line infusion filters. Total and free endotoxin levels in infusion fluids were measured by quantitative chromogenic Limulus assay. The overall rate of bacterial colonization of bottles/burettes was 7.8% at 48 h and 15.7% at 96 h, while colonization rates of catheter fluid were 34.0% and 24.1%, respectively (n.s.). These high rates of colonization, despite regularly reinforced hand disinfection practices, may be explained by the high frequency of manipulations of the catheter systems, during acute interventions in emergency situations. Cell-bound endotoxin was found in 8.8% of the samples, but only 2.5% of the samples contained free endotoxin. The data support the use of in-line infusion filters, with bacterial-retaining property; however, these filters need not have endotoxin-retaining properties.

Prevalence of use of infection control rituals and outdated practices: Education Committee survey results

BACKGROUND

To better serve APIC membership, the National APIC Education Committee periodically conducts educational needs assessments.

METHODS

In the July/August 1995 issue of APIC News, the committee published a survey on the prevalence of infection control "sacred cows," practices considered to be outdated and ritualistic. A response was requested only from ICPs working in inpatient facilities. We asked ICPs which of the listed practices were part of their facility's infection control program, and whether they were interested in changing those that were. We also asked about the certification status of the program's manager (CIC vs non-CIC).

RESULTS

A total of 506 survey forms were completed and returned, with 74% from acute care only, 7% from long-term care only, 10% from acute and long-term care, and 8% from other types of facilities. Mean number of beds was 226. Infection control programs had existed for a mean of 15 years. Most respondents' facilities still engaged in infection control rituals. Fifty-eight percent of respondents were still doing total surveillance, 43% were still using reverse or protective isolation, and 11% were still subjecting employees with positive reactions to purified protein derivative of tuberculin testing to annual chest radiographs, to name a few. Certified respondents were significantly less likely to include outdated practices than were non-CICs for 11 of 15 practices (73%). CICs were no more likely than non-CICs, however, to be interested in changing any current rituals.

CONCLUSION

The Education Committee will use this information to plan future educational offerings.

Polymicrobial gram-negative bacteremia associated with saline solution flush used with a needleless intravenous system

BACKGROUND

During a 2-week period, seven cases of nosocomial polymicrobial gram-negative rod bacteremia occurred on a 39-bed medical and cardiac step-down unit. Combinations of Enterobacter cloacae (seven isolates), Klebsiella pneumoniae (five isolates), and Citrobacter freundii (two isolates) were isolated from blood cultures.

METHODS

Concurrent and retrospective chart reviews were used to look for further cases and common exposures. Epidemiologic methods were used to refine determination of common exposure. Restriction enzyme DNA analysis was performed on the isolates.

RESULTS

Concurrent and retrospective chart reviews revealed four additional possible cases during the same period. All case patients were exposed, through peripheral saline solution locks or central venous catheters, to saline solution "flush" from a central 0.9% saline solution bag and a needleless dispensing pin. Epidemiologic methods implicated probable extrinsic contamination of a single bag and pin used during a 24-48-hour period (Fisher's Exact Test, p < 0.002). There were no other common exposures. Restriction enzyme DNA analysis of the isolates further supported a common source for the outbreak.

CONCLUSIONS

The introduction of needleless intravascular systems has been embraced for employee protection. Our report is the first to raise the question of patient safety with such systems. This outbreak highlights the inherent risks in rapid introduction of new technologies and points out the delicate balance among patient health, employee safety, and cost containment.

Central venous catheter infections: concepts and controversies

Central venous catheters (CVCs) are widely used in critically ill patients in intensive care units. However, infectious complications are common and may limit their utility. We critically review the literature to determine the impact of CVC design and composition, insertion site selection, insertion procedures, care and removal of temporary CVCs on infectious complications. Relevant articles were identified and selected for review using a database search (Medline and manual of the English language literature) based upon study design and sample size with an emphasis on prospective randomized trials. To minimize infectious complications and maintain a reasonable cost-benefit ratio, we recommend: i) use a single lumen catheter unless clear indications for a multi-lumen catheter exist; ii) insert the catheter via the subclavian vein if no relative contraindication exists (bleeding diathesis, positive pressure ventilation); iii) disinfect the insertion site employing sterile technique; iv) apply a dry, sterile dressing and change the dressing every other day; v) inspect the insertion site for signs of infection and remove the catheter if pus is present; vi) if a catheter-related infection is suspected, change the catheter over a guidewire and culture the distal segment. The replacement catheter should be removed if an original catheter segment culture is positive.

Pathogenesis of infections related to intravascular catheterization

Over the past few decades, there have been major technological improvements in the manufacture of intravenous solutions and the manufacture and design of catheter materials. However, the risk of infection in patients receiving infusion therapy remains substantial, in part because of host factors (for example, increased use of immunosuppressive therapy, more aggressive surgery and life support, and improved survival at the extremes of life) and in part because of the availability of catheters that can be left in place for very long periods. Microbial components of normal skin flora, particularly coagulase-negative staphylococci, have emerged as the predominant pathogens in catheter-associated infections. Therefore, efforts to prevent skin microorganisms from entering the catheter wound (such as tunnelling of catheters and use of catheter cuffs and local antimicrobial agents) are logical and relatively effective. The specific properties of microorganisms that transform normally harmless commensals such as coagulase-negative staphylococci into formidable pathogens in the presence of a plastic foreign body are being explored. For example, Staphylococcus epidermidis elaborates a polysaccharide adhesin that also functions as a capsule and is a target for opsonic killing. However, the interactions between microorganism and catheter that lead to adherence, persistence, infection, and dissemination appear to be multifactorial.

Intravenous therapy management: who will develop insertion site symptoms?

In this multisite study, symptoms at the intravenous (IV) insertion site and the relationship of patient and clinical data to these symptoms are described. It was found that approximately 40% of the subjects experienced at least one site symptom. The most common was pain. Presence of symptoms was associated with IV site duration, potassium chloride concentration, number of antibiotics, and solution osmolarity. Infusions started by anesthesiologists and sites with no dressings were least likely to be symptomatic.

Vascular-access infections in hospitalized patients

Vascular catheters are a common source of nosocomial infections, although many of these infections are potentially preventable. A long duration of catheterization, multiple catheter manipulations, the inexperience of some inserters, use of transparent plastic dressings, violations of aseptic technique, the use of multilumen catheters, and inadequate sterilization of reusable pressure transducers all increase the risk of these infections. The only interventions that have been proved to reduce the risk are standardized insertion and maintenance technique by an intravenous-therapy team, preinsertion skin preparation with chlorhexidine gluconate, and the use of topical antibiotics at the insertion site. The goal of the physician should be to prevent catheter infection, because the treatment of established infection can be difficult and costly. Treatment must be individualized for each patient on the basis of the clinical presentation and the causative organism.