ATLANTA—Although intravascular catheters are vital to medical practice, their use carries a risk of catheter-related bloodstream infection (CRBSI). “Each year there may be as many as 250,000 of these infections, 80,000 of which occur in the intensive care unit [ICU],” Michele L. Pearson, MD, told PULMONARY REVIEWS.

“Depending on the study, catheter-related bloodstream infection has an attributable mortality of 12% to 35%,” added Dr. Pearson, Medical Epidemiologist in the Division of Healthcare Quality Promotion, National Center for Infectious Diseases, at the Centers for Disease Control and Prevention. In the ICU, the central venous catheter (CVC) is the type of intravascular device most often associated with CRBSI, she noted.

Recently, as part of a multidisciplinary team, Dr. Pearson helped to develop guidelines for the prevention of CRBSI.[1] The guidelines are intended for physicians who insert intravascular catheters and for those involved with infection surveillance and control in hospital, outpatient, and home health care settings.

TOP RECOMMENDATIONS

Of the many strategies recommended in the guidelines, six or so are especially important because they deal with pressing issues or reflect recent changes in practice. Most of these are strongly supported by data from well-designed experimental, clinical, or epidemiologic studies.

“Next to the patient’s own skin, health care workers’ hands are the most common source of organisms that can contaminate catheters,” Dr. Pearson pointed out. Therefore, observing proper hand hygiene is a primary strategy for preventing CRBSI.

Specifically, practitioners should wash their hands with antibacterial soap and water or an alcohol-based gel or foam. This should be done before and after palpating a catheter insertion site, as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Wearing gloves does not obviate the need for proper hand hygiene, the guidelines stress.

A 2% chlorhexidine preparation is the preferred disinfectant for catheter insertion sites. Because this preparation has been available for only about two years, tincture of iodine, an iodophor, or 70% alcohol is also acceptable.

BARRIER PRECAUTIONS, ROUTINE REPLACEMENT

It was traditionally believed that intravascular catheters had to be inserted in the operating room or some other “supersterile” environment to minimize the risk of CRBSI. Performing the procedure in more “contaminated” areas, such as the ICU or at the bedside, increases the risk, practitioners have long assumed.

However, studies now show that the barrier precautions taken during catheter insertion are more important to CRBSI prevention than where the insertion is performed. “With full barrier precautions, the infection risk is the same, whether the procedure is done in an ICU, ward, or supersterile area,” Dr. Pearson stated. Full barrier precautions include a sterile cap, mask, gown, and gloves, and a sterile sheet to cover the patient.

Intravascular catheters do not need routine changing once they are in place. “Part of practice lore is to change the catheter at a scheduled frequency, [for instance] every week, to prevent infection,” Dr. Pearson explained. “But that does not appear to be beneficial and might even be associated with a higher risk of pneumothorax and other mechanical complications.”

Practitioners should be more concerned with removing an intravascular catheter as soon as it is no longer clinically indicated; they should also resist the temptation to leave it in place in the event that it might be needed later. “This may seem obvious, but patients will not have catheter-related infections if they do not have a catheter,” remarked Dr. Pearson.

EDUCATION AND TRAINING

Regular education and training—in the indications for intravascular catheters, their proper placement and maintenance, and appropriate infection control measures—clearly help to prevent CRBSI.[2,3] “That, too, may seem obvious, but it is also frequently overlooked,” Dr. Pearson said.

She emphasized that education and training may be especially important in the ICU and in academic teaching institutions, where caregiver turnover can be high and newcomers may lack knowledge about CRBSI prevention. Practitioners who insert and manage intravascular catheters should be periodically assessed for that knowledge, she added.

ANTIMICROBIAL PROPHYLAXIS

Intravascular catheters impregnated with antimicrobial or antiseptic agents have been shown to reduce CRBSI rates. However, studies of these catheters have been limited to adult patients whose catheters were cuffless, triple-lumen, and in place for less than 30 days.

The guidelines advise the use of antimicrobial or antiseptic-impregnated CVCs in adults expected to require a CVC for more than five days. This recommendation applies only if a rigorous prevention strategy (education, skin antisepsis with 2% chlorhexidine, and full barrier precautions) has not reduced the CRBSI rate below the goal set by an individual institution.

Unless a dialysis catheter is being used, antibiotic ointments or creams should not be applied to a catheter insertion site because they may promote antimicrobial resistance and increase the risk of fungal infections.[4] Antibiotic lock prophylaxis—locking an antibiotic solution in the catheter lumen—is recommended only for patients with a long-term cuffed or tunneled catheter and a history of multiple CRBSIs despite optimal aseptic technique by caregivers.

There is no proof that oral or parenteral antibacterial or antifungal prophylaxis reduces CRBSI incidence in adults. Thus, intranasal or systemic antimicrobial agents are not routinely recommended before or during intravascular catheterization.

—Timothy Begany

References
1. O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Morb Mortal Wkly Rep. 2002;51:1-29.
2. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med. 2000;132:641-648.
3. Davis D, O’Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867-874.
4. Zakrzewska-Bode A, Muytjens HL, Liem KD, Hoogkamp-Korstanje JA. Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters. J Hosp Infect. 1995;31:189-193.

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