Central venous catheters revisited--infection rates and an assessment of the new Fibrin Analysing System brush

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.

Clinical and Regulatory Considerations for Central Venous Catheters for Hemodialysis

Central venous catheters remain a vital option for access for patients receiving maintenance hemodialysis. There are many important and evolving clinical and regulatory considerations for all stakeholders for these devices. Innovation and transparent and comprehensive regulatory review of these devices is essential to stimulate innovation to help promote better outcomes for patients receiving maintenance hemodialysis. A workgroup that included representatives from academia, industry, and the US Food and Drug Administration was convened to identify the major design considerations and clinical and regulatory challenges of central venous catheters for hemodialysis. Our intent is to foster improved understanding of these devices and provide the foundation for strategies to foster innovation of these devices.

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Controlled Trials, Embase, CINAHL) and internet sources for randomized controlled trials, ongoing clinical trials, and unpublished studies up to August 2016.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.

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.

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.

Impact of catheter antimicrobial coating on species-specific risk of catheter colonization: a meta-analysis

Background

Antimicrobial catheters have been utilized to reduce risk of catheter colonization and infection. We aimed to determine if there is a greater than expected risk of microorganism-specific colonization associated with the use of antimicrobial central venous catheters (CVCs).

Methods

We performed a meta-analysis of 21 randomized, controlled trials comparing the incidence of specific bacterial and fungal species colonizing antimicrobial CVCs and standard CVCs in hospitalized patients.

Results

The proportion of all colonized minocycline-rifampin CVCs found to harbor Candida species was greater than the proportion of all colonized standard CVCs found to have Candida. In comparison, the proportion of colonized chlorhexidine-silver sulfadiazine CVCs specifically colonized with Acinetobacter species or diphtheroids was less than the proportion of similarly colonized standard CVCs. No such differences were found with CVCs colonized with staphylococci.

Conclusion

Commercially-available antimicrobial CVCs in clinical use may become colonized with distinct microbial flora probably related to their antimicrobial spectrum of activity. Some of these antimicrobial CVCs may therefore have limited additional benefit or more obvious advantages compared to standard CVCs for specific microbial pathogens. The choice of an antimicrobial CVC may be influenced by a number of clinical factors, including a previous history of colonization or infection with Acinetobacter, diphtheroids, or Candida species.

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.

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.

Effect of Chlorhexidine/Silver Sulfadiazine-Impregnated Central Venous Catheters in an Intensive Care Unit with a Low Blood Stream Infection Rate after Implementation of an Educational Program: A Before–After Trial

BACKGROUND

Current guidelines recommend using antiseptic- or antibiotic-impregnated central venous catheters (CVCs) if, following a comprehensive strategy to prevent catheter-related blood stream infection (CR-BSI), infection rates remain above institutional goals based on benchmark values. The purpose of this study was to determine if chlorhexidine/silver sulfadiazine-impregnated CVCs could decrease the CR-BSI rate in an intensive care unit (ICU) with a low baseline infection rate.

METHODS

Pre-intervention and post-intervention observational study in a 24-bed surgical/trauma/burn ICU from October, 2002 to August, 2005. All patients requiring CVC placement after March, 2004 had a chlorhexidine/silver sulfadiazine-impregnated catheter inserted (post-intervention period).

RESULTS

Twenty-three CR-BSIs occurred in 6,960 catheter days (3.3 per 1,000 catheter days)during the 17-month control period. After introduction of chlorhexidine/silver sulfadiazine-impregnated catheters, 16 CR-BSIs occurred in 7,732 catheter days (2.1 per 1,000 catheter days; p = 0.16). The average length of time required for an infection to become established after catheterization was similar in the two groups (8.4 vs. 8.6 days; p = 0.85). Chlorhexidine/silver sulfadiazine-impregnated catheters did not result in a statistically significant change in the microbiological profile of CR-BSIs, nor did they increase the incidence of resistant organisms.

CONCLUSIONS

Although chlorhexidine/silver sulfadiazine-impregnated catheters are useful in specific patient populations, they did not result in a statistically significant decrease in the CR-BSI rate in this study, beyond what was achieved with education alone.

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.

Old and new tools in the diagnosis of central venous catheter-related bloodstream infections: is there a role for brushing?

Bloodstream infections (BSIs) are the third most common nosocomial infections. Catheters and other medical devices are the first exogenous causes of preventable infections in hospital. The estimated attributable mortality for catheter-associated BSI ranges from 1-35%, mainly depending on etiological agents and underlying disease. In considering this, it is necessary to reduce central venous catheter- (CVC)-related BSI prevalence and to obtain a rapid and accurate method for an early diagnosis. This review indicates the advantages and the disadvantages of old and new tools for the early diagnosis of CVC-related BSIs.

Central venous catheter colonization in critically ill patients: a prospective, randomized, controlled study comparing standard with two antiseptic-impregnated catheters

In this prospective, randomized, controlled, unblinded study, we compared colonization rates of a standard, unimpregnated central venous catheter (CVC) with rates for silver-coated and chlorhexidine-silversulfadiazine (CH-SS)-impregnated CVC. Patient characteristics, CVC insertion site, indwelling time, and colonization detected by semiquantitative and quantitative microbiologic techniques were documented. Two-hundred-seventy-five critically ill patients were included into the study protocol. One-hundred-sixty standard, 160 silver (S)-coated, and 165 externally impregnated CH-SS CVC were inserted. There was a significant difference in CVC colonization rates among study groups (P = 0.029). There was no difference in the colonization rate and the colonization per 1000 catheter days between standard and S-coated (P = 0.564; P = 0.24) or CH-SS-coated CVC (P= 0.795; P = 0.639). When comparing antiseptic CVC with each other, colonization rates were significantly less with CH-SS-impregnated than with S-coated CVC (16.9% versus 7.3%; P = 0.01; 18.2 versus 7.5 of 1000 catheter days; P = 0.003; relative risk, 0.43; 95% confidence interval, 0.21-0.85). Whereas standard and S-coated CVC were first colonized 2 and 3 days after insertion, respectively, CH-SS CVC were first colonized only after 7 days. In conclusion, antiseptic-impregnated CVC could not prevent catheter colonization when compared with standard polyurethane catheters in a critical care setting with infrequent catheter colonization rates and CVC left in place for >10 days.

Drug/device combinations for local drug therapies and infection prophylaxis

Combination devices-those comprising drug releasing components together with functional prosthetic implants-represent a versatile, emerging clinical technology promising to provide functional improvements to implant devices in several classes. Landmark antimicrobial catheters and the drug-eluting stent have heralded the entrance, and significantly, routes to FDA approval, for these devices into clinical practice. This review describes recent strategies creating implantable combination devices. Most prominent are new combination devices representing current orthopedic and cardiovascular implants with new added capabilities from on-board or directly associated drug delivery systems are now under development. Wound coverings and implantable sensors will also benefit from this combination enhancement. Infection mitigation, a common problem with implantable devices, is a current primary focus. On-going progress in cell-based therapeutics, progenitor cell exploitation, growth factor delivery and advanced formulation strategies will provide a more general and versatile basis for advanced combination device strategies. These seek to improve tissue-device integration and functional tissue regeneration. Future combination devices might best be completely re-designed de novo to deliver multiple bioactive agents over several spatial and temporal scales to enhance prosthetic device function, instead of the current 'add-on' approach to existing implant device designs never originally intending to function in tandem with drug delivery systems.

Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients--a double-blind, randomised, prospective, controlled trial

BACKGROUND

Central venous catheters (CVCs) are essential for the intensive care of patients with haematological illness. Catheter-related infections (CRI) are an important problem in modern medicine, which may lead to life-threatening situations, to prolonged hospitalisation and increased cost. In immunocompromised patients suffering from haemato-oncological diseases, CRI is a significant factor for adverse outcome. Several clinical studies have shown that CVCs coated with antiseptics such as chlorhexidine and silver-sulfadiazine (CHSS) reduce the risk of catheter-related bacteraemia. Most studies, however, were performed on intensive care patients not suffering from chemotherapy-induced immunosuppression.

PATIENTS AND METHODS

A prospective double-blind, randomised, controlled trial was performed to investigate the effectiveness of CHSS-coated catheters in haemato-oncological patients. A total number of 184 catheters (median duration of placement, 11 days) were inserted into 184 patients (male 115, female 69), of which 90 were antiseptically coated. After removal, all catheters were investigated for bacterial growth.

MAIN RESULTS

Catheters coated with CHSS were effective in reducing the rate of significant bacterial growth on either the tip or subcutaneous segment (26%) compared to control catheters (49%). The incidence of catheter colonisation was also significantly reduced (12% coated vs 33% uncoated). Data obtained show a significant reduction of catheter colonisation in CHSS catheters. There was no significant difference in the incidence of catheter-related bacteraemia (3% coated vs 7% uncoated). However, due to the overall low rate of CRI, we could not observe a significant reduction in the incidence of catheter-related bacteraemia.

CONCLUSION

Our data show that the use of CHSS catheters in patients with haematological malignancy reduces the overall risk of catheter colonisation and CRI, although the incidence of catheter-related bacteremia was similar in both groups.

Infection control issues in central venous catheter care

Central venous catheters (CVCs) are now a routine part of patient management in the intensive care unit (ICU). Over time, a vast amount of literature associated with the use and care of CVCs has accumulated. The purpose of this article is to discuss the literature associated with the care of these devices in a narrative format. Although particular attention is paid to infection control issues, other fundamental areas such as catheter design, dressings, line changing and post insertion management are also discussed. The article goes on to look at the future of CVC design and concludes with an analysis of future developments related to CVCs.

Are Antimicrobial-Impregnated Catheters Effective? Don't Throw Out the Baby with the Bathwater

The antimicrobial-impregnated central venous catheter (CVC) has been the most intensively studied technology for the prevention of CVC-related bloodstream infections (BSIs) over the past 30 years. Although more than a dozen randomized trials have shown significant benefit, authors of an analysis published in a recent issue of Clinical Infectious Diseases have raised questions about the efficacy of antimicrobial-impregnated CVCs because of perceived defects in the experimental design of the studies and statistical analyses of the data. They have further argued that even if this technology might be effective in preventing CVC-related BSI, its cost-effectiveness is questionable. Although most of the studies scrutinized by the authors of this analysis indeed had shortcomings, we believe that their analysis unjustifiably downplays a large body of research that has demonstrated a consistent reduction in CVC-related BSI and a clear-cut cost-effectiveness associated with the use of antimicrobial-impregnated CVCs.

The relationship between methodological trial quality and the effects of impregnated central venous catheters

OBJECTIVE

We assessed the methodological trial quality of individual randomized controlled studies on chlorhexidine silver sulfadiazine impregnated catheters and the effect on catheter-related infection (CRI).

DESIGN

Only the studies identified in the Medline database from 1966 to December 2001 were considered, abstracts being excluded. The outcome of this investigation centered on bloodstream CRI. The trial quality of the 11 studies identified and published (total 3,131 catheters) was assessed using a scoring system based on allocation, patient selection, patient characteristics, blinding of the intervention and the diagnosis of CRI (range 0-2 points, 10 points maximum).

RESULTS

The mean methodological quality score was 7.1 (range 5-9). The relative risk reduction for bloodstream CRI ranged from -0.14 to 1.0. No association between trial quality and the impact of chlorhexidine silver sulfadiazine impregnated catheters on CRI was found. The summary odds ratio for CRI was 0.69 (95% CI 0.46-1.03). Taking only those studies with 2 points for diagnosis of CRI a summary odds ratio of 0.87 (95% CI 0.44-1.72) resulted, whereas studies with a diagnosis score of only 1 point led to a summary odds ratio of 0.60 (95% CI 0.35-1.02).

CONCLUSIONS

The quality of the studies seems to have had no influence on the outcome, according to the results of this investigation, but the use of only a single quality score may not be sufficient to investigate the prevention effect of impregnated catheters.

Prevention of bloodstream infections with central venous catheters treated with anti-infective agents depends on catheter type and insertion time: evidence from a meta-analysis

OBJECTIVE

To test the evidence that the risk of infection related to central venous catheters (CVCs) is decreased by anti-infective coating or cuffing.

DESIGN

Systematic review of randomized, controlled trials comparing anti-infective with inactive (control) CVCs.

INTERVENTIONS

Average insertion times were taken as a measurement of the length of insertion. Dichotomous data were combined using a fixed effect model and expressed as odds ratio (OR) with 95% confidence interval (CI95).

RESULTS

Two trials on antibiotic coating (343 CVCs) had an average insertion time of 6 days; the risk of BSI decreased from 5.1% with control to 0% with anti-infective catheters. There were no trials with longer average insertion times. In three trials on silver collagen cuffs (422 CVCs), the average insertion time ranged from 5 to 8.2 days (median, 7 days); the risk of BSI was 5.6% with control and 3.2% with anti-infective catheters. In another trial on silver collagen cuffs (101 CVCs), the average insertion time was 38 days; the risk of BSI was 3.7% with control and 4.3% with anti-infective catheters. In five trials on chlorhexidine-silver sulfadiazine coating (1,269 CVCs), the average insertion time ranged from 5.2 to 7.5 days (median, 6 days); the risk of BSI decreased from 4.1% with control to 1.9% with anti-infective catheters. In five additional trials on chlorhexidine-silver sulfadiazine coating (1,544 CVCs), the average insertion time ranged from 7.8 to 20 days (median, 12 days); the risk of BSI was 4.5% with control and 4.2% with anti-infective catheters.

CONCLUSIONS

Antibiotic and chlorhexidine-silver sulfadiazine coatings are anti-infective for short (approximately 1 week) insertion times. For longer insertion times, there are no data on antibiotic coating, and there is evidence of lack of effect for chlorhexidine-silver sulfadiazine coating. For silver-impregnated collagen cuffs, there is evidence of lack of effect for both short- and long-term insertion.

A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies

Strategies for preventing central venous catheter (CVC)-related bloodstream infection are most likely to be effective if guided by an understanding of the risk factors associated with these infections. In this critical review of published studies of risk factors for CVC-related bloodstream infection that were prospective and used multivariable techniques of data analysis or that were randomized trials of a preventive measure, a significantly increased risk of catheter-related bloodstream infection was associated with inexperience of the operator and nurse-to-patient ratio in the intensive care unit, catheter insertion with less than maximal sterile barriers, placement of a CVC in the internal jugular or femoral vein rather than subclavian vein, placement in an old site by guidewire exchange, heavy colonization of the insertion site or contamination of a catheter hub, and duration of CVC placement > 7 days. Prospective studies or randomized trials of control measures focusing on these risk factors have been shown to reduce risk significantly: formal training in CVC insertion and care, use of maximal sterile barriers at insertion, use of chlorhexidine rather than povidone-iodine for cutaneous antisepsis, applying a topical anti-infective cream or ointment or a chlorhexidine-impregnated dressing to the insertion site, and the use of novel catheters with an anti-infective surface or a contamination resistant hub. Better prospective studies of sufficient size to address all potential risk factors, including insertion site and hub colonization, insertion technique, and details of follow-up care, would enhance our understanding of the pathogenesis of CVC-related bloodstream infection and guide efforts to develop more effective strategies for prevention.

The Role of Intravascular Devices in Sepsis

Intravascular devices (IVDs) are widely used in modern day health care. Unfortunately, their use is associated with substantial risk of bloodstream infection (BSI) and sepsis, with increased hospitalization and hospital mortality. IVDs are the most common cause of nosocomial BSI. The wider use of new methodologies for diagnosis of IVD-related infection should allow earlier and more focused therapy and, especially, improve the accuracy of surveillance. Of all nosocomial infections, IVD-related BSIs are most amendable to prevention.

Antimicrobial-coated/bonded and -impregnated intravascular catheters

OBJECTIVE

To review the literature regarding the prevention of catheter colonization and catheter-related bloodstream infections (CRBIs) with the use of antimicrobial-coated/bonded and -impregnated intravascular catheters.

DATA SOURCES

Primary and review English-language literature were identified using MEDLINE (1966-September 2000) pertaining to the key terms antibiotic, antimicrobial, antiseptic, silver, and bonded, coated, Impregnated catheters. In addition, textbooks and relevant reference lists were reviewed.

DATA EXTRACTION

All articles identified through the data sources were evaluated. Information deemed relevant to the objectives of the review was included.

DATA SYNTHESIS

Significant morbidity and mortality are associated with the development of CRBIs. Preventative measures such as modification of these catheters with antimicrobial coating/bonding have produced varying results. Trials evaluating cefazolin, teicoplanin, vancomycin, silver, and chlorhexidine-silver sulfadiazine (C-SS) used for coated/bonded intravascular catheters have not demonstrated a consistent decrease in the incidence of CRBIs. However, a meta-analysis of trials evaluating C-SS intravascular catheters demonstrated a statistically significant reduction in CRBIs. A larger reduction in CRBIs has been reported with minocycline-rifampin (M-R) versus C-SS intravascular catheters. Use of the M-R and C-SS catheters may result in a cost savings of $100 million and reduce as many as 12,000 CRBI-related deaths annually when used short term (<7 d).

CONCLUSIONS

When used for short-term catheterization, M-R catheters appear to be superior to the currently available C-SS catheters at preventing CRBIs. Significant cost savings and reduction in mortality can be anticipated with the use of M-R catheters.

New technologies to prevent intravascular catheter-related bloodstream infections

Most intravascular catheter-related infections are associated with central venous catheters. Technologic advances shown to reduce the risk for these infections include a catheter hub containing an iodinated alcohol solution, short-term chlorhexidine-silver sulfadiazine- impregnated catheters, minocycline-rifampin-impregnated catheters, and chlorhexidine- impregnated sponge dressings. Nontechnologic strategies for reducing risk include maximal barrier precautions during catheter insertion, specialized nursing teams, continuing quality improvement programs, and tunneling of short-term internal jugular catheters.

The clinical and economic consequences of nosocomial central venous catheter-related infection: are antimicrobial catheters useful?

Central venous catheters (CVCs) are essential for many hospitalized patients, but they are associated with important infectious complications. Recent studies have indicated that CVCs coated with antimicrobial agents reduce the incidence of catheter-related bloodstream infection (CR BSI). To estimate the clinical and economic consequences of short-term central venous catheter-related infection and the potential usefulness of antimicrobial-coated catheters, we reviewed and synthesized the available relevant literature. Statistical pooling was used to estimate the incidence of both catheter colonization and CR BSI. The attributable mortality of CR BSI was also evaluated. In addition, the economic consequences of both local and systemic catheter-related infection was estimated from literature reports that used micro-costing and other techniques. Among patients in whom standard, noncoated CVCs are in place for an average of 8 days, 24.7% are expected to develop catheter colonization (95% confidence interval [CI(95)], 22.0%-27.5%). Approximately 5.2% (CI(95), 3.9%-6.5%) will develop CR BSI. The attributable mortality of CR BSI remains unclear, but recent studies are consistent with a range from 4% to 20%. An episode of local catheter-related infection leads to an additional cost of approximately $400, whereas the additional cost of CR BSI ranges from approximately $6,005 to $9,738. Formal economic analyses indicate that CVCs coated with antibacterial agents (such as chlorhexidine-silver sulfadiazine or minocycline-rifampin) likely reduce infectious complications, yielding economic advantages. In light of the substantial clinical and economic burden of catheter-related infection, hospital personnel should adopt proven cost-effective methods to reduce this common and important nosocomial complication.

Brushing has made a sweeping change: use of the endoluminal FAS brush in haemodialysis central venous catheter management

Common usage of central venous catheter (CVC) access for haemodialysis has presented the haemodialysis nurse with the challenge of maintaining CVCs as a viable form of access. The major complications seen with CVC use are obstruction and infection. A project was undertaken to identify the usefulness of the endoluminal fibrin analysis system (FAS) brush as an intervention in haemodialysis CVC management. The aims of the study were to identify: the reasons for brushing CVCs and the number of occasions brushing is indicated; how successful brushing is in unblocking and improving flow from CVCs, and the length of time the catheter remains patent following successful declotting. Seventeen patients were found suitable for CVC brushing and divided into two groups depending on the indication for brushing. In the group in which the catheter was brushed to restore flow, 73 per cent of brushings were successful, and in 50 per cent of those cases the CVC remained patent for 6 weeks. Sixty per cent of catheter brushings to improve flow were successful, and in 50 per cent of the CVCs flow was sustained over a 6-week period. Overall, the findings support the use of the endoluminal FAS brush for the applications trialled.

Antiseptic-bonded central venous catheters and bacterial colonisation

This study was undertaken to evaluate the impact of chlorhexidine/silver sulphadiazine-bonded catheters on the incidence of colonisation and catheter-related sepsis in critically ill patients. Threehundred and fifty-one catheters were inserted into 228 patients during the study period, 174chlorhexidine/silver sulphadiazine-bonded catheters and 177 standard catheters. Indications for catheter removal were: death, clinical redundancy and clinical evidence of local or systemic infection. All catheter tips were sent to the microbiology laboratory for semiquantitative analysis of bacterial colony count. Seventy-one (40.2%) of the standard catheters and 47 (27.2%) of the antiseptic-bonded catheters were found to be colonised on removal (p < 0.01). Eight cases (4.7%) of catheter-related sepsis were associated with standard catheters and three cases (1.7%) with antiseptic-bonded catheters, however, this reduction was not statistically significant. Our results indicate that the use of antiseptic-bonded catheters in critically ill patients significantly reduces the incidence of bacterial colonisation.

Risk reduction in the intensive care unit

Many potentially preventable complications occur in patients who receive intensive care. We have reviewed the epidemiology of three important complications (venous thromboembolism, stress-related upper gastrointestinal bleeding, and vascular catheter-related infection) and evaluated common preventive treatments to provide evidence-based recommendations for prevention. We used English language articles located by MEDLINE or cross-citation, giving preference to articles published in the last 10 years, meta-analyses, and clinical trials that were randomized, double-blinded, and used intention-to-treat analysis. We recommend prophylaxis against venous thromboembolism in most patients, whereas those without respiratory failure or coagulopathy may not require prophylaxis against stress-related upper gastrointestinal hemorrhage. Chlorhexidine gluconate is the preferred antiseptic for disinfecting the skin prior to and during intravascular catheterization. Central venous catheters impregnated with antibacterial or antiseptic agents should be considered in patients at high risk for vascular catheter-related infection. Finally, central venous, pulmonary arterial, and systemic arterial catheters should be changed only when clinically indicated.

Biopatch--a new concept in antimicrobial dressings for invasive devices

A randomised controlled trial (RCT) was conducted to assess the reduction in the rate of catheter-related infections associated with the Biopatch dressing (Johnson & Johnson Medical Inc., Arlington, Texas, USA) used for insertion-site management of central venous catheters (CVCs) placed in the intensive care unit. Patients having a CVC placed were randomly assigned to receive either a Biopatch keyhole dressing to the occlusive Opsite IV 3000 (Smith and Nephew Medical Ltd., Hull, UK) (experimental group) or the Opsite IV 3000 alone (control group). There was a very low colonisation rate of CVC tip and skin exit-site swabs in both the experimental group (6 of 17) and the control group (5 of 16). No statistical difference was found between the two groups with regard to CVC or exit-site colonisation. A calculated sample size of 11,000 would be required to statistically demonstrate a 10 per cent reduction in CVC infection rate using the new Biopatch dressing. A much larger RCT would be required to demonstrate the efficacy of this new device.

Infection in central lines: antiseptic-impregnated vs standard non-impregnated catheters

We report a survey of 196 consecutive central venous catheters (CVCs) placed in 151 patients in the Intensive Care Unit (ICU) over a ten-month period. Over this time the use of a new antiseptic-impregnated triple lumen CVC (Arrowgard Blue, Arrow International Inc., Pennsylvania, U.S.A.) was alternated on a bimonthly basis with the standard triple-lumen CVC (Arrow International Inc., Pennsylvania, U.S.A.). The overall rate of CVC tip infection was lower in the impregnated CVC group (15.6% vs 30.9%, P < 0.05). The impregnated CVC group had a much lower cumulative infection rate when the dwell time in patients was five days or less (3.3% vs 26.9%, P < 0.05). However, the difference between the cumulative infection rate was not statistically significant (P > 0.05) for dwell times of 6, 7 or 8 days respectively. There was no difference in the CVC related bacteraemia rates between the two groups (3.9% vs 3.7%, P > 0.05).

Endoluminal brushing for detection of central venous catheter colonization--a comparison of daily vs. single brushing on removal

The fibrin assay system (FAS) has been designed to address the problem of in-situ diagnosis of central venous catheter (CVC) colonization. The FAS was evaluated in 12 critically ill patients with daily brushings, comparing results with culture of the catheter tip and blood. Data analysis of the FAS showed a sensitivity of 0 with a specificity of 1.0. The study was repeated in a further 12 high-risk patients with a single terminal brushing on catheter removal. This gave a sensitivity of 0.14 and a specificity of 0.8. Differences in sensitivity may be due to daily disruption of the endoluminal fibrin clot. Our results do not support the routine use of the FAS to detect CVC colonization in the intensive care unit.