Closed catheter access system implementation in reducing the bloodstream infection rate in low birth weight preterm infants

Effectiveness and safety of methods to prevent bloodstream and other infections and noninfectious complications associated with peripherally inserted central catheters: A systematic review and meta-analysis

BACKGROUND

Peripherally inserted central catheters (PICCs) have a 29% complication rate. This systematic review assessed 25 interventions to prevent PICC-associated infectious and noninfectious complications in participants of all ages.

METHODS

We searched electronic databases (MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL) and reference lists for randomized (RCTs) and nonrandomized studies published from January 1, 1980-May 8, 2024. We dually selected studies, assessed risk of bias, extracted data, and rated certainty of evidence (COE). We included both single interventions of interest and combinations of at least two (bundle/multimodal). If three or more RCTs existed, we conducted Bayesian random-effects meta-analyses.

RESULTS

Seventy-four studies met our eligibility criteria (60 on individual interventions, 14 on bundle/multimodal), addressing 13 of 25 research questions. The majority were conducted in high-income countries; 36 focused on neonates. Evidence was very uncertain for 11 of the 13 research questions. Evidence with a stronger COE showed that ultrasound-guided catheter insertion reduced phlebitis/thrombophlebitis in adults compared to non-ultrasound-guided insertion (five RCTs; risk ratio [RR] 0.19, 95% credible interval 0.08-0.50); silicone catheters increased phlebitis/thrombophlebitis compared to nonsilicone (one RCT, RR 2.00, 95% confidence interval [95%CI] 1.26-3.17). Bundle interventions decreased local infections (one RCT, RR 0.47, 95%CI 0.31-0.72) and phlebitis/thrombophlebitis in adults (one RCT, RR 0.35, 95%CI 0.22-0.56) compared to routine care.

CONCLUSIONS

Ultrasound-guided catheter insertion and nonsilicone catheters effectively prevented PICC complications. The evidence for other comparisons was too uncertain to draw conclusions, highlighting the urgent need for additional studies on prevention and control interventions.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

Historical Perspectives: Low Birthweight and Preterm Infants in Indonesia

The incidence of infants with low birthweight (LBW), prematurity, and small for gestational age (SGA) in Indonesia remains high, and the morbidity and mortality in these infants are significant. To study these groups of infants in Indonesia, the author searched PubMed/Medline, the Cochrane Library, Google, Indonesian reports, local publications, and doctoral and master theses in English and Indonesian from 1987 to February 2019. In this review, the development of local reference growth charts of infants born in Indonesia is described, as well as the importance of these curves in defining the prevalence of SGA infants. Some of the risk factors associated with LBW, preterm, and SGA Indonesian infants are described. The author also discusses the effectiveness of specific interventions, such as kangaroo mother care, early initiation of enteral feedings, increased breastfeeding rates, and identifying the optimal timing of hospital discharge. Some of the morbidities associated with LBW infants born in Indonesia are described. Advances in hospital care and postdischarge follow-up of LBW, preterm, and SGA infants born in Indonesia are critical to decrease the morbidity and mortality rates associated with these populations.

Central line associated blood stream infections in gastroschisis patients: A nationwide database analysis of risks, outcomes, and disparities

PURPOSE

The aim of this study was to determine the risk of central line associated blood-stream infections (CLABSI) in neonatal gastroschisis patients, risk factors, outcomes, and financial implications.

METHODS

The 2016 Healthcare Cost and Utilization Project (HCUP)'s kid's inpatient database (KID), a national database of pediatric inpatient admissions across the United States, was used to obtain a large sample of gastroschisis admissions. Incidence of CLABSI in the gastroschisis patient population was compared to the incidence of CLABSI in the database. To further study the factors influencing CLABSI in gastroschisis, demographic and clinical features of patients were analyzed. Categorical variables were analyzed using Fisher's exact test or Pearson's chi-squared test. Odds ratios (OR) with 95% confidence intervals (CI) for variables found to have significance (p < 0.05) were calculated.

FINDINGS

Incidence of CLABSI in this database for pediatric inpatients was 4449 out of 298,862 central line insertions [1.48%] and was 81 out of 2032 [3.9%] (OR 2.83, 95% CI 2.26-3.54, p < 0.001) in the gastroschisis cohort. African American neonates had a significantly higher risk of CLABSI with gastroschisis. Prematurity and low birth-weight in gastroschisis were protective from CLABSI, along with patients from suburban areas or admitted in the Southern USA. Average costs were greater in gastroschisis patients with CLABSI, increasing from $281,779 to $421,970 (p = 0.008). The average length of stay increased from 31 days to 38 days with a CLABSI (p < 0.001).

CONCLUSIONS

In gastroschisis patients, CLABSI incidence is high and adds great morbidity and expense. For uncertain reasons, premature and low birth weight babies appear to be protected.

LEVEL OF EVIDENCE

Level III.