Download Rates of infection for single-lumen versus multilumen

Review Article
Rates of infection for single-lumen versus multilumen central
venous catheters: A meta-analysis
Cameron Dezfulian, MD; James Lavelle, MD; Brahmajee K. Nallamothu, MD, MPH;
Samuel R. Kaufman, MA; Sanjay Saint, MD, MPH
Objective: Since the introduction of multilumen central venous
catheters two decades ago, there has been controversy whether
the additional lumens place patients with these catheters at
higher risk for infection. Our objective was to determine the risk
of catheter-related bloodstream infection (CRBSI) and catheter
colonization in multilumen catheters compared with single-lumen
catheters.
Data Source: Studies were identified by a computerized search
of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE
databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter
colonization among single-, double-, and triple-lumen central
venous catheters were included. We excluded studies if they
included central venous catheters that were long-term, cuffed,
tunneled, or coated with antibiotic or antiseptic agents.
Data Abstraction: Two independent reviewers abstracted data
on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter
colonization, and 4) study design and quality.
Data Synthesis: A total of 15 studies met inclusion criteria.
C
atheter-related bloodstream
infection (CRBSI) occurs
commonly (1) in the United
States, with a prevalence
ranging from 3% to 7% (2–5). The attributable mortality of CRBSI is approximately 15%, and each episode is estimated to cost approximately $9,000 (2).
Catheter colonization— or bacterial
growth from the catheter tip without bac-
From the Departments of Internal Medicine (CD,
JL, BKN, SS) and Pediatrics (CD), University of Michigan, Ann Arbor, MI; Ann Arbor VA Health Services
Research and Development Field Program, Ann Arbor,
MI (SS); and the Patient Safety Enhancement Program,
University of Michigan Health System, Ann Arbor, MI
(SRK, SS).
Dr. S. Saint is supported, in part, by a Career
Development Award from the Health Services Research and Development Program of the Department
of Veterans Affairs and a Patient Safety Developmental
Center Grant from the Agency for Healthcare Research
and Quality (P20-HS11540).
Copyright © 2003 by Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0000084843.31852.01
Crit Care Med 2003 Vol. 31, No. 9
Summary odds ratios were calculated using a random-effects
model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00 –
4.66), catheter colonization was not (summary odds ratios, 1.78;
95% confidence interval, 0.92–3.47). Tests for heterogeneity,
however, suggested substantial variation by study. When only
studies of higher quality were included, multilumen catheters
were found not to be associated with a significant increase in
CRBSI prevalence (summary odds ratios, 1.30; 95% confidence
interval, 0.50 –3.41).
Conclusions: Multilumen central venous catheters may be associated with a slightly higher risk of infection when compared
with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient
differences are considered. The slight increase in infectious risk
when using multilumen catheters is likely offset by their improved
convenience, thereby justifying the continued use of multilumen
vascular catheters. (Crit Care Med 2003; 31:2385–2390)
KEY WORDS: bactermia; central venous catheterization; indwelling catheters; cross infection; infection control; septicemia
teremia— occurs in 20% of central venous catheters (2, 6, 7), with an estimated cost of almost $400 per episode
(2). Despite these infectious complications, central venous catheters remain
essential in the treatment of many hospitalized patients, especially the critically
ill. Identifying modifiable risk factors for
catheter-related infection is therefore
crucial.
The use of multilumen central venous
catheters provides obvious advantages in
patients who may require numerous intravenous medications, laboratory tests,
blood product transfusions, and parenteral nutrition. Since their introduction
two decades ago, triple-lumen catheters
have become the preferred central venous
catheters for patients requiring central
venous access (6). Unfortunately, multilumen central venous catheters may lead
to a higher rate of catheter colonization
and CRBSI because of a higher frequency
of catheter manipulations, with subsequent bacterial introduction; however,
clinical trials directly comparing rates of
CRBSI and catheter colonization between
single- and multilumen catheters have
yielded mixed results (8 –28). Accordingly, we performed a systematic and
quantitative meta-analysis to compare
the rates of CRBSI and catheter colonization in single-lumen vs. multilumen
catheters.
MATERIALS AND METHODS
Study Design and Data Abstraction. We
conducted a computerized search of the MEDLINE, CINAHL, Currents Contents, EMBASE,
and PREMEDLINE databases. The exploded
and focused “Medical Subject Headings”
(MeSH) headings (or related text keywords)
“catheterization” or “catheter” were combined
with “infection” and, in MEDLINE, the floating subheading “adverse events.” The text
words “single,” “double,” or “triple,” when
found adjacent to the text word “lumen,” were
then combined with the above results. A research librarian was consulted to ensure a
thorough search. Titles and abstracts of all
articles were scanned independently by two
2385
authors (C. Dezfulian, B. K. Nallamothu) and
relevant articles identified. We also scanned
bibliographies of retrieved articles and related
review articles, and we contacted corresponding authors and experts to identify additional
published or unpublished reports. Finally, the
authors of all excluded articles containing potentially useful data were contacted in an effort to obtain these data.
Criteria for Inclusion and Exclusion. Articles were included in the meta-analysis if they
met the following criteria: 1) trials compared the
rates of infection of at least two of the three
different types of temporary central venous catheters (single-lumen catheters, double-lumen
catheters, and triple-lumen catheters); and 2)
the prevalence of catheter colonization or CRBSI
was reported per catheter with sufficient data to
calculate the odds ratio. We excluded studies
that focused on hemodialysis catheters, peripherally inserted central venous catheters, pulmonary artery catheters or their introducer
sheaths, and tunneled, cuffed, or antiseptic/
antibiotic– coated central venous catheters. Also
excluded were studies in which the definition of
CRBSI was unclear or overlapped with the definition of catheter colonization. In this event,
attempts were made to contact corresponding
authors to clarify these data and include them in
the analysis.
Definitions and Outcomes. Our primary
outcome of interest was the prevalence of CRBSI
by catheter type. To meet the definition of
CRBSI in our analysis, studies were required to
show isolation of the same organism from cultures of the catheter tip and blood. Catheter
colonization, on the other hand, was defined as
1) the presence of bacterial growth from culture
of the catheter tip in the absence of concomitant
positive blood cultures for the same organism or
2) the presence of local purulence or cellulitis at
the catheter insertion site, along with culture
results from this site. The method of culturing
catheter tips could be quantitative, semiquantitative, or qualitative. The qualitative culture
method accepted any growth as positive. The
semiquantitative method, based on the protocol
of Maki et al. (29), required the growth of ⬎15
colonies per plate to be considered positive. The
only use of purely quantitative cultures occurred
in one study whose definition of CRBSI differed
significantly from all others (16). In this study,
catheters were identified as the source of bacteremia if cultures drawn through the lumen grew
more than five times as many colonies as peripheral blood cultures in the absence of other anatomic sources for infection.
Data Extraction. Data abstraction was performed independently by two authors (C. Dezfulian, J. Lavelle) using standardized forms.
Data were abstracted on study design, study
setting and population, the types of catheters
used, the anatomic location and method of
catheter insertion, duration of catheterization,
type and frequency of site care performed, the
use of total parenteral nutrition or systemic
antimicrobial therapy, and the prevalence of
catheter colonization and CRBSI. Disagree-
2386
ments among abstracters were resolved by discussion and ultimately arbitrated by a third
author (S. Saint).
Assessment of Study Design and Quality.
Studies were assigned quality scores (A, B, or
C) based on their methodology for the purposes of a sensitivity analysis. The quality
score “A” was given to randomized, controlled
trials because confounding by co-morbid conditions or severity of illness were thought to
least likely affect this type of study design. The
quality score “B” was given to prospective
studies that demonstrated no statistically significant differences between the characteristics of their populations of patients. Although
not randomized, these studies analyzed a
number of known confounders and found no
significant differences between groups that
would bias the comparison of outcomes. All
remaining studies received the quality score
“C.” This group included prospective studies
in which comparison of the patient groups
revealed significant differences in one or more
known CRBSI risk factors (i.e., femoral location of catheterization, duration of catheterization, use of total parenteral nutrition, patient severity of illness, emergent placement
of catheters). Also included in group “C” were
retrospective studies in which reliance on
medical record review may have led to incomplete ascertainment of all catheterized patients during the study period.
Statistical Analysis. Data on CRBSI and
catheter colonization were analyzed separately. Separate pooled analyses were also performed for studies given different quality
scores. In each of the included studies, the
absolute risk of CRBSI and catheter colonization was calculated for all catheter types, along
with corresponding standard deviations and
95% confidence intervals (CI). Summary odds
ratios (OR) were calculated using the DerSimonian and Laird (30) method under a random-effects model. A random-effects model
was chosen, given significant heterogeneity
between the studies. All statistical analyses
were performed using STATA 7.0 (College Station, TX) (31).
RESULTS
Study Characteristics. Our initial
computerized search revealed 141 studies, 16 of which seemed to compare
CRBSI or catheter colonization between
two or more types of catheters. Four
studies were excluded because they contained data from patients with excluded
catheter types (pulmonary artery catheters, percutaneously inserted central
catheters [peripherally inserted central
venous catheters]) (23–25, 32). (The authors of these studies were contacted in
an effort to obtain additional information
on catheter types within the studies that
met inclusion criteria. Unfortunately,
this information was not available.) An
additional two studies and one abstract
were included after scanning bibliographies of the retrieved studies. Thus, a
total of 15 studies were available for analysis (8 –22) and are summarized in Table
1. Most studies compared single- and triple-lumen catheters (12 of 15), placed
catheters in the subclavian position (10 of
15), and gave total parenteral nutrition
through one of the lumens (total parenteral nutrition was given in all studies; 8
of 15 gave total parenteral nutrition to all
patients). Full barrier protection during
catheter insertion was generally used, except in two studies (10, 22) in which only
sterile gloves and drapes were used; data
on barrier protection were unavailable in
two other studies (8, 12).
Of the 15 studies included in our analysis, six were randomized, controlled trials (quality score A), three were prospective studies with similar groups (quality
score B), and the remaining six were either retrospective studies or prospective
studies in which there were significant
differences between groups (quality score
C). Within the group B studies, patients
were shown to be similar based on several
of the characteristics in Table 1 and on
either a review of patient diagnoses or
comparison of formal clinical scores to
assess the degree of illness of the patient
populations. Thus, this subset of observational studies was assigned a higher quality score than the other observational
studies (i.e., group C studies).
Prevalence of CRBSI and Colonization. Table 2 summarizes the prevalence
of CRBSI and catheter colonization, the
method of catheter tip culture, and the
definitions used for CRBSI. The intravascular catheter tip was usually cultured to
establish infection at the site of insertion;
in some studies (11, 13), however, local
wound culture was also accepted. Studies
usually required the presence of fever and
occasionally other signs and symptoms of
infection (such as elevated white blood
cell count, chills, or pus at the catheter
insertion site) as part of their definition.
Some studies also required resolution of
these signs and symptoms after removal
of the catheter or the absence of other
possible sites of infection.
Occasionally, studies were more flexible
in their definition of CRBSI, allowing for
culture of the blood to be different from
that of the catheter site or negative altogether. In these situations, the symptoms
of infection had to resolve after removal of
the catheter, and in some studies, no other
Crit Care Med 2003 Vol. 31, No. 9
Table 1. Summary of studies included in analysis
First Author’s Last Name
(Ref. No.)
Quality score
Types of catheters being
compared
Pomp
(8)
Farkas
(9)
Yeung
(10)
Miller
(11)
Powell
(12)
Goetz
(13)
Ma
(14)
Kemp
(15)
Clark
(16)
Johnson
(17)
Gil
(18)
Pemberton
(19)
McCarthy
(20)
Lee
(21)
Rose
(22)
C
SLC
TLC
A
SLC
TLC
C
SLC
TLC
B
SLC
TLC
A
SLC
DLC
C
SLC
TLC
A
DLC
TLC
C
SLC
DLC
TLC
A
SLC
TLC
A
SLC
DLC
B
SLC
TLC
C
SLC
TLC
A
SLC
TLC
B
SLC
TLC
C
SLC
TLC
Y
Y
Y
Y
NR
N
Y
Y
Y
N
N
NR
Y
NR
Y
Y
NR
Y
Y
N
Y
Y
NR
Y
Y
NR
Y
Y
NR
Y
Y
NR
Y
Y
Y
Y
N
N
Y
Y
NR
N
39
61
100
100
100
46
24
30
80
20
68
26
6
7.46
100
NR
39
54
7
NR
100
Mostly
Rarely
100
Catheters placed de novo
Initially
Y
Subsequently
N
Full barrier technique
NR
used
Anatomic location of
catheter placement, %
Subclavian
NR
Internal jugular
Femoral
Mean duration of
catheterization, days
SLC
DLC
TLC
3 to 4
TPN given (proportion), % Y (NR)
SLC
DLC
TLC
11.6
4.6
3.0
9.1
Y
98
14.7
Y
10
3.0
Y
100
98
35
100
NR
8.2
16.0
14.5
Y
10.0
Y
20
Y
100
100
Y
100
100
100
100
100
39
13.66–14.36
24.1
NR
NR
NR
9.5
11.4
20.5
Y
100
100
100
Y
100
100
100
Y (52)
Y
100
8.5
Y
100
11.2
Y
100
100
100
100
Y (42)
A, B, C, quality scores were assigned to each study as described in the METHODS section; SLC, DLC, TLC, single, double, triple lumen catheters,
respectively; NR, data not reported.
Key characteristics abstracted from the 15 studies included in the analysis are summarized above.
Table 2. Prevalence of catheter-related bloodstream infections (CRBSI) and catheter colonization
First Author’s Last Name
(Ref. No.)
Quality score
Method of culture
Definition of CRBSI
Signs of infection
Resolution of symptom
Positive catheter
culture
Positive blood culture
No other source of
infection
Prevalence of CRBSI (%)
SLC
Pomp Farkas Yeung Miller Powell
(8)
(9)
(10)
(11)
(12)
C
NR
A
L
⫹
⫹
⫹
⫹
Prevalence of
colonization (%)
SLC
Kemp
(15)
C
SQ
A
SQ
C
SQ
A
Q
A
SQ
B
SQ
C
NR
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⌬
⫹
⌬
⫹
⫹
2/78
(2.6)
B
L
A
L
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
8/617
(1.3)
5/68
(7.4)
3/1936 1/10
(0.15) (10.0)
2/22
(9.1)
0/22
(0)
4/165
(2.4)
7/595
(1.2)
5/61
(8.2)
18/495
(3.6)
2/27
(7.4)
18/68 5/1936 3/10
(26.5) (0.26) (30.0)
DLC
TLC
Ma
(14)
C
SQ
DLC
TLC
Goetz
(13)
14/61 16/495 14/27
(23.0) (3.2) (51.8)
4/130
(3.1)
1/22
(4.5)
0/22
(0)
21/165
(12.7)
15/130
(11.5)
0/6
(0)
1/49
0/18
(2.0)
(0)
1/52 37/373
(1.9) (9.9)
Clark-Cristoff Johnson
(16)
(17)
Lee
(21)
Rose
(22)
A
SQ
B
SQ
C
NR
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⌬
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
⫹
0/48
(0)
0/51
(0)
5/63
(7.9)
2/68
(3)
0/36
(0)
0/68
(0)
4/248
(1.6)
6/157
(3.8)
11/59
(18.6)
4/39
(10.3)
4/307
(1.3)
12/232
(4.9)
10/63
(15.8)
2/68
(2.9)
0/36
(0)
3/68
(4.4)
32/157
(20.3)
3/59
(5.1)
1/39
(2.6)
32/307
(10.4)
13/99
(13.1)
1/48
(2.1)
1/51
(2.0)
Gil
(18)
Pemberton McCarthy
(19)
(20)
⫹
A, B, C, quality scores were assigned to each study as described in the METHODS section of the text; NR, data were not reported; methods of culture
were qualitative (L), semiquantitative (SQ), or quantitative (Q); ⌬, studies that were more flexible in their definition of CRBSI; SLC, DLC, TLC, single,
double, triple lumen catheters, respectively.
For each study, the method of culture, the definition of CRBSI, and the number of infected catheters/total number of catheters (with percentage) are
given.
Crit Care Med 2003 Vol. 31, No. 9
2387
source of infection could be present (14, 15,
17). It was impossible in these cases to
discern which of the CRBSI diagnoses were
made with this alternative definition, and
therefore, the numbers provided by the authors had to be accepted.
Summary OR of CRBSI and Catheter
Colonization. For both end points, double-lumen catheters made up only 2% of
the total catheters analyzed and were
therefore grouped together with triplelumen catheters as multilumen catheters
when calculating summary ORs. Alternative groupings were also analyzed and
revealed no difference between several
possible permutations because of the
small number of double-lumen catheters.
Likewise, calculation of ORs comparing
only triple-lumen catheters with singlelumen catheters yielded no qualitative
differences in the results and required
exclusion of two A-quality studies that
were thought to be valuable in the overall
meta-analysis (analyses not shown).
Figures 1 and 2 summarize the OR for
CRBSI and catheter colonization when
comparing multilumen catheters with
single-lumen catheters. The OR for
CRBSI could not be calculated for one
study that did not have a single-lumen
catheter group (14) and for another study
in which the absolute rate of CRBSI was
zero for both single- and double-lumen
catheters (17). When the remaining studies were included in the analysis, the
summary OR for CRBSI was 2.15 (95%
CI, 1.00 – 4.66) and, for colonization, 1.78
(95% CI, 0.92–3.47), in both cases reflecting a higher risk of infection for multilumen catheters. When the analysis was
limited to higher-quality studies (quality
scores A and B), the OR for CRBSI was
1.30 (95% CI, 0.50 –3.41) and, for colonization, 1.30 (95% CI, 0.82–2.07). The test
for heterogeneity was significant (p ⫽
.001 for CRBSI, p ⫽ .004 for colonization) when all studies were included in
the analysis but not when only higherquality studies were analyzed (p ⫽ .11 for
CRBSI, p ⫽ .67 for colonization).
Sensitivity Analysis. Summary ORs
for both outcomes were calculated excluding each study individually. The exclusion of the study by Yeung et al. (10)
(quality score C) had the most significant
effect on the summary OR for both outcomes (summary OR for CRBSI, 1.64
[95% CI, 0.89 –3.00]; for colonization,
1.21 [95% CI, 0.82–1.76]). Review of this
study revealed the reported absolute
prevalence of both CRBSI (0.15%) and
colonization (0.26%) were far lower than
2388
Figure 1. Analysis of catheter-related bloodstream infections in (A) all studies and (B) only
higher-quality studies. The diamond indicates
the summary odds ratio (OR) and 95% confidence interval (CI). Studies are listed sequentially
by study reference number. The size of the
squares is proportional to the weight of the studies (inverse variance).
similar outcomes reported in the other
studies (Table 2) or in the literature (1, 5,
6, 33). Exclusion of this study alone made
the test for heterogeneity for both outcomes insignificant (p ⫽ .41 and p ⫽ .63
for CRBSI and colonization, respectively).
The next most influential study when excluded was that by Pemberton et al. (19)
(quality score C), which had a similar,
albeit lesser, effect on the tests for heterogeneity and the summary OR for both
outcomes. The study by Miller et al. (11)
involved a relatively small number of patients (n ⫽ 37), and we therefore questioned whether this study had sufficient
statistical power to detect meaningful
baseline clinical differences between patients in the single-lumen and multilumen catheter groups. Although this study
was assigned a quality score of B in the
base case analysis, we repeated our analyses using a quality score of C for this
study. The quality score assignment had
little effect on the summary ORs or the
CIs (data not shown).
DISCUSSION
We performed a systematic, evidencebased review that used meta-analysis to
quantify the risk of CRBSI and catheter
colonization in temporary multilumen
Figure 2. Analysis of catheter colonization in (A)
all studies and (B) only higher-quality studies.
The diamond indicates the summary odds ratio
(OR) and 95% confidence interval (CI). Studies
are listed sequentially by study reference number. The size of the squares is proportional to the
weight of the studies (inverse variance).
central venous catheters when compared
with single-lumen central venous catheters. We summarized data from 15 studies using a random-effects model. Our
results suggested an apparent increase in
CRBSI and a trend toward more catheter
colonization in multilumen catheters.
Tests for heterogeneity, however, demonstrated significant variation across the results of these studies. Importantly, exclusion of lower-quality studies diminished
the relationship between infection rate
and multilumen catheters.
An earlier review by Farkas et al. (9)
suggested similar results, noting a bias
toward “sicker” patients receiving triplelumen catheters. Gil et al. (18) also considered this potential bias in observational studies and attempted to
compensate for it by using the Acute
Physiology Scoring System to show similarity between their patient groups. Neither study, however, provided quantitative results to verify this bias nor did they
systematically review the literature to
find all relevant studies. Our comprehensive analysis expands on the work of these
authors and others and clarifies much of
the variability found in previous individual studies.
It has been suggested that increased
manipulations of central venous catheters contributes to higher rates of CRBSI
Crit Care Med 2003 Vol. 31, No. 9
(34). Clark-Cristoff et al. (16), in a randomized trial, found a higher risk of
CRBSI in triple-lumen compared with
single-lumen catheters. In their study,
the investigators reported “additional lumens of the triple-lumen catheters were
accessed from 15 to 20 times a day for
administration of drugs and for blood
sampling.” They concluded this was likely
to be responsible for the increased risk of
infection. Although their study was randomized and prospective, the catheters
used remained in place on average twice
as long as in other studies, and their
method of catheter tip culture was
unique. Furthermore, their measured
prevalence of CRBSI in multilumen catheters (13.1%) was significantly higher
than that reported in other randomized,
controlled trials (35).
Another possible reason for the observed increase in CRBSI and colonization prevalence found in observational
studies of multilumen catheters would be
their use for a longer period of time compared with single-lumen catheters. The
relationship between infection and duration of catheterization is clear (3). Our
present study is unable to evaluate this
hypothesis because most of the studies
reported the prevalence of infections as
episodes per catheter rather than episodes per catheter-day. In the studies in
which the duration of catheterization was
reported (Table 1), the duration between
the two groups is roughly comparable.
A recent meta-analysis of randomized
trials comparing antibiotic-coated and
uncoated triple-lumen catheters revealed
rates of CRBSI in the uncoated triple
lumen group to range from 2.1% to
11.7% (35), which is very similar to the
rate of CRBSI in triple-lumen catheters
found in our study. This range also includes the range of single lumen CRBSI
found in this study, and it is not surprising that the difference between the two
types of catheters is not statistically significant. The studies in which the OR for
CRBSI in multilumen catheters tended to
be the greatest have either excessively
high (⬎10%) rates of CRBSI in multilumen catheters (16, 19, 20) or a low rate of
CRBSI in the single-lumen catheters (10)
when compared with published values of
CRBSI in the literature (35).
Two high-quality studies cited in this
analysis compared double- and singlelumen catheters. In both, the prevalence
of CRBSI and colonization in doublelumen catheters was either less than (12)
or the same as (17) in single-lumen cathCrit Care Med 2003 Vol. 31, No. 9
eters. The latter study could not be included in our summary OR because of the
absence of infection in both groups.
Within these studies, increased manipulation of a double-lumen catheter’s extra
lumen—in contrast to triple-lumen catheters— did not significantly increase the
risk for CRBSI. This is inconsistent with
the hypothesis that additional lumens
yield increased infection because of increased manipulations. In addition, one
high-quality study comparing doubleand triple-lumen catheters, which also
could not be included in our metaanalysis for lack of a control (singlelumen catheter) group, demonstrated no
significant difference in CRBSI between
these two groups (14).
Most studies recruited any medical or
surgical inpatients needing a central venous catheter or total parenteral nutrition. Thus, a significant proportion of
non–intensive care unit patients were included. Only the studies of Farkas et al.
(9) and Gil et al. (18) explicitly stated they
recruited only intensive care unit patients, and the prevalence of catheter infections were similar in both groups compared in both studies (Table 2). Only the
studies of Ma et al. (14), Pemberton et al.
(19), and McCarthy et al. (20) reported
the proportion of patients in the intensive
care unit. The studies of Ma et al. (14) and
McCarthy et al. (20) were both randomized, controlled trials (quality A), and
similar proportions of patients were in
the intensive care unit in both catheter
groups (Ma et al., 23 [62%] patients with
double-lumen catheters and 28 [67%]
with triple-lumen catheters; McCarthy et
al., 21 [58%] patients with single-lumen
catheters and 22 [56%] with triple-lumen
catheters). Ma et al. (14) found no difference in infection rates between double
and triple-lumen catheters, whereas McCarthy et al. (20) found a higher rate of
CRBSI and colonization in triple vs. single-lumen catheters. The study by Pemberton et al. (19) was prospective but not
randomized (quality C), and significantly
more patients in the triple-lumen–
catheter group were in the intensive care
unit (32 patients, 78%) vs. those with
single-lumen catheters (22 patients,
39%). In addition, these triple-lumen–
catheter patients had higher rates of mortality, malnutrition, and major surgery.
This study found a higher rate of CRBSI
in triple-lumen catheters vs. singlelumen catheters.
We found that the risk of CRBSI and
catheter colonization for multilumen
T
he slight increase
in infectious risk
when using multi-
lumen catheters is likely offset by their improved convenience, thereby justifying
the continued use of multilumen vascular catheters.
catheters was greater than for singlelumen catheters, but this difference was
not statistically significant after accounting for differences in the quality of the
individual studies. Even if the upper limit
of the 95% CI was taken as the actual
effect size (a conservative estimate), then
the 3.4-fold increased risk of CRBSI and
2-fold increased risk of catheter colonization in multilumen catheters must be
weighed against the risks of increased
mechanical complications associated
with the placement of multiple singlelumen catheters.
When Powell et al. (12) randomized patients to receive one double-lumen catheter
vs. two single-lumen catheters, they found
a 3-fold increase in the rate of mechanical
complications (13.6% vs. 4.5%) in the single-lumen group. Misny et al. (28), in a
retrospective study published only in abstract form, likewise found a higher rate of
pneumothorax (3.0% vs. 0.5%) and thrombosis (1.1% vs. 0.5%) and a higher rate of
“primary sepsis” (1.5% vs. 0.5%) in singlelumen catheters when compared with triple-lumen catheters. Unfortunately, the authors of this study could not be located to
clarify their definitions of catheter-related
sepsis, and therefore, the study could not be
included in our analysis. The effects of the
higher rate of mechanical complications
involved in the placement of one or more
single-lumen catheter instead of a single
multilumen catheter would likely counterbalance any savings in CRBSI.
CONCLUSIONS
Meta-analyses have a number of limitations compared with large controlled
trials (36, 37); however, the cost of a
randomized, controlled trial adequately
powered to definitely answer the question
2389
of whether multilumen catheters cause
more infectious complications than single-lumen catheters would be high. Our
data demonstrate it is unlikely that there
is a substantial increase in the risk of
CRBSI or catheter colonization when
multilumen catheters are used instead of
single-lumen catheters. The controversy
regarding this issue likely stems from
poorly controlled prospective or retrospective observational studies that have
implicated multilumen catheters as a risk
factor for infection. Our analysis reveals
that the bulk of standardized, wellcontrolled studies comparing similar patient groups indicate multilumen catheters are not a significant risk factor for
increased bloodstream infections or local
catheter colonization when compared
with single-lumen catheters.
ACKNOWLEDGMENTS
We thank Gurpreet K. Rana, MLIS,
research librarian at the University of
Michigan Taubman Medical Library, for
her assistance with devising the search
strategy; Kathleen Welch, MA, MPH, and
Myra Kim, ScD, of the University of Michigan Center for Statistical Consultation
and Research for statistical support; Carlos H. Ramirez-Ronda, MD, MACP,
Horace F. Henriques III, MD, FACS,
Louis Flancbaum, and Debra S. Kovacevich, RN, MPH, for providing additional
information about their publications;
Carol E. Chenoweth, MD, Benjamin A.
Lipsky, MD, FACP, FIDSA, and Michele L
Pearson, MD, for acting as experts in evaluating the completeness of the literature
search strategy; and Catherine Gage
Michalak, MS, RN, for providing us information on catheter purchases within the
University of Michigan Health System.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
REFERENCES
16.
1. Mermel LA: Prevention of intravascular catheter-related infections. Ann Intern Med 2000;
132:391– 402
2. Saint S, Veenstra DL, Lipsky BA: The clinical
and economic consequences of nosocomial
central venous catheter-related infection:
Are antimicrobial catheters useful? Infect
Control Hosp Epidemiol 2000; 21:375–380
3. Maki DG: Infections caused by intravascular
devices used for infusion therapy. In: Infections Associated with Indwelling Medical Devices. Bisno AL, Waldvogel FA (Eds). Washington, DC, ASM Press, 1994, pp 155–205
4. Veenstra DL, Saint S, Sullivan SD: Costeffectiveness of antiseptic-impregnated cen-
2390
17.
18.
19.
20.
tral venous catheters for the prevention of
catheter-related bloodstream infection.
JAMA 1999; 282:554 –560
Kaufman JL, Rodriguez JL, McFadden JA, et
al: Clinical experience with the multiple lumen central venous catheter. JPEN J Parenter Enteral Nutr 1986; 10:487– 489
Apelgren KN: Triple lumen catheters: Technological advance or setback? Am Surg 1987;
53:113–116
Richet H, Hubert B, Nitemberg G, et al: Prospective multicenter study of vascularcatheter–related complications and risk factors for positive central-catheter cultures in
intensive care unit patients. J Clin Microbiol
1990; 28:2520 –2525
Pomp A, Varella L, Caldwell MD, et al: Catheterrelated sepsis: Single lumen catheters (SLC) vs.
triple lumen catheters (TLC). JPEN J Parenter
Enteral Nutr 1988; 12:23S, Abstract 122
Farkas JC, Liu N, Bleriot JP, et al: Single- versus
triple-lumen central catheter–related sepsis: A
prospective randomized study in a critically ill
population. Am J Med 1992; 93:277–282
Yeung C, May J, Hughes R: Infection rate for
single lumen v triple lumen subclavian catheters. Infect Control Hosp Epidemiol 1988;
9:154 –158
Miller JJ, Venus B, Mathru M: Comparison of
the sterility of long-term central venous
catheterization using single lumen, triple lumen, and pulmonary artery catheters. Crit
Care Med 1984; 12(8):634 – 637
Powell C, Fabri PJ, Kudsk KA: Risk of infection accompanying the use of single-lumen
vs. double-lumen subclavian catheters: A
prospective randomized study. JPEN J Parenter Enteral Nutr 1988; 12:127–129
Goetz AM, Wagener MM, Miller JM, et al: Risk of
infection due to central venous catheters: Effect
of site of placement and catheter type. Infect Control Hosp Epidemiol 1998; 19:842–845
Ma TY, Yoshinaka R, Banaag A, et al: Total
parenteral nutrition via multilumen catheters does not increase the risk of catheterrelated sepsis: A randomized, prospective
study. Clin Infect Dis 1998; 27:500 –503
Kemp L, Burge J, Choban P, et al: The effect
of catheter type and site on infection rates in
total parenteral nutrition patients. JPEN J
Parenter Enteral Nutr 1994; 18:71–74
Clark-Cristoff N, Watters VA, Sparks W, et al: Use
of triple-lumen subclavian catheters for administration of total parenteral nutrition. JPEN J Parenter Enteral Nutr 1992; 16:403–407
Johnson BH, Rypins EB: Single-lumen vs
double-lumen catheters for total parenteral
nutrition. Arch Surg 1990; 125:990 –992
Gil RT, Kruse JA, Thill-Baharozian MC, et al:
Triple- vs single-lumen central venous catheters. Arch Intern Med 1989; 149:1139 –1143
Pemberton LB, Lyman B, Lander V, et al:
Sepsis from triple- vs. single-lumen catheters during total parenteral nutrition in surgical or critically ill patients. Arch Surg
1986; 121:591–594
McCarthy MC, Shives JK, Robison RJ, et al: Pro-
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
spective evaluation of single and triple lumen
catheters in total parenteral nutrition. JPEN J
Parenter Enteral Nutr 1987; 11:259–262
Lee RB, Buckner M, Sharp KW: Do multilumen catheters increase central venous
catheter sepsis compared to single-lumen
catheters? J Trauma 1988; 28:1472–1475
Rose SG, Pitsch RJ, Karrer FW, et al: Subclavian catheter infections. JPEN J Parenter
Enteral Nutr 1988; 12:511–512
Henriques HF III, Karmy-Jones R, Knoll SM,
et al: Avoiding complications of long-term
venous access. Am Surg 1993; 59:555–558
Lugo LJ, Zapata NJ, Ramirez-Ronda CH:
Catheter related infections in Damas hospital. Bol Asoc Med P R 86(4 – 6):37– 41, 1994
Hilton E, Haslett TM, Borenstein MT, et al: Central catheter infections: Single- versus triplelumen catheters. Am J Med 1988; 84:667–672
Eyer S, Brummitt C, Crossley K, et al: Catheterrelated sepsis: Prospective, randomized study of
three methods of long-term catheter maintenance. Crit Care Med 1990; 18:1073–1079
Kovacevich DS, Faubion WC, Braunschweig
CL, et al: Prevalence of catheter sepsis in parenteral nutrition patients with triple lumen vs.
single lumen catheters. Abstr. JPEN J Parenter
Enteral Nutr 1988; 12:23S, Abstract 123
Misny P, Srp F, Marein C, et al: Complications of single lumen (SLC) versus multilumen (MLC) temporary central venous
catheters (TCVC) for total parenteral nutrition (TPN). JPEN J Parenter Enteral Nutr
1986; 17S, Abstract 86
Maki DG, Weise CE, Sarafin HW: A semiquantitative culture method for identifying
intravenous catheter-related infection.
N Engl Med 1977; 296:1305–1309
DerSimonian R, Laird N: Meta-analysis in clinical
trials. Control Clin Trials 1986; 7:177–188
Bradburn MJ, Deeks JJ, Altman DG: metan:
An alternative meta-analysis command.
Stata Tech Bull 1998; 44(sbe24):4 –15
Savage AP, Picard M, Hopkins CC, et al: Complications and survival of multilumen central
venous catheters used for total parenteral nutrition. Br J Surg 1993; 80:1287–1290
Mantese VA, German DS, Kaminski DL, et al:
Colonization and sepsis from triple-lumen
catheters in critically ill patients. Am J Surg
1987; 154:597– 601
Viale P, Politi E, Sisti M, et al: Impact of
central venous catheters (CVC) management
on infectious risk. Abstr. J Hosp Infect 1998;
40(Suppl A):8.1.8
Veenstra DL, Saint S, Saha S, et al: Efficacy of
antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream
infection. JAMA 1999; 281:261–267
Lelorier J, Gregoire G, Benhaddad A, et al:
Discrepancies between meta-analyses and
subsequent large randomized, controlled trials. N Engl J Med 1997; 8:536 –542
Ioannidis JPA, Cappelleri JC, Lau J: Issues in
comparisons between meta-analyses and
large trials. JAMA 1998; 279:1089 –1093
Crit Care Med 2003 Vol. 31, No. 9