Download ROMA, 9 aprile 2008

ROMA, 10 aprile 2008
Linea Guida
La prevenzione delle infezioni associate a cateteri venoso centrali (CVC)
Luisa Leone, Settore Documentazione, SIDBAE, ISS
Referente: Prof. G. Donelli
Anni: 2000-2008
Lingua: Inglese - Italiano
Base dati: PUBMED
N. Record: 90
Quesito 5: Quali sono i dressing più idonei ad evitare la
contaminazione microbica dei siti di inserzione del CVC?
Strategia di ricerca
#28 Search ((#4) AND (#21)) AND (#27) Limits: Publication Date from
2000 to 2008, English, Italian
#27 Search "Bandages"[Mesh] OR Bandages OR Bandage OR
Dressing OR dressings OR Patch OR Patches Limits: Publication
Date from 2000 to 2008, English, Italian
#21 Search infection OR infections OR local infection OR local
infections OR contamination OR contaminations Limits:
Publication Date from 2000 to 2008, English, Italian Limits:
Publication Date from 2000 to 2008, English, Italian
#4 Search "Catheterization, Central Venous"[Mesh] OR Central
Venous catheter OR Central Venous catheters OR CVC OR
CVCS OR Central Venous catheterization Limits: Publication Date
from 2000 to 2008, English, Italian
07:29:29
90
06:24:06
39792
06:09:05 372882
04:37:58
5323
1: Arch Intern Med. 2007 Oct 22;167(19):2066-72.
Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for
central venous catheter care.
Mimoz O, Villeminey S, Ragot S, Dahyot-Fizelier C, Laksiri L, Petitpas F, Debaene
B.
Département d'Anesthésie Réanimation, Centre Hospitalier et Universitaire de
Poitiers, 86021 Poitiers, France. [email protected]
BACKGROUND: Although chlorhexidine-based solutions and alcohol-based
povidone-iodine have been shown to be more efficient than aqueous povidone-iodine
for skin disinfection at catheter insertion sites, their abilities to reduce
catheter-related infection have never been compared. METHODS: Consecutively
scheduled central venous catheters inserted into jugular or subclavian veins were
randomly assigned to be disinfected with 5% povidone-iodine in 70% ethanol or
with a combination of 0.25% chlorhexidine gluconate, 0.025% benzalkonium
chloride, and 4% benzylic alcohol. Solutions were used for skin disinfection
before catheter insertion (2 consecutive 30-second applications separated by a
period sufficiently long to allow for dryness) and then as single applications
during subsequent dressing changes (every 72 hours, or earlier if soiled or wet).
RESULTS: Of 538 catheters randomized, 481 (89.4%) produced evaluable culture
results. Compared with povidone-iodine, the chlorhexidine-based solution was
associated with a 50% decrease in the incidence of catheter colonization (11.6%
vs 22.2% [P = .002]; incidence density, 9.7 vs 18.3 per 1000 catheter-days) and
with a trend toward lower rates of catheter-related bloodstream infection (1.7%
vs 4.2% [P = .09]; incidence density, 1.4 vs 3.4 per 1000 catheter-days).
Independent risk factors for catheter colonization were catheter insertion into
the jugular vein (adjusted relative risk, 2.01; 95% confidence interval,
1.24-3.24) and use of povidone-iodine (adjusted relative risk, 1.87; 95%
confidence interval, 1.18-2.96). CONCLUSION: Chlorhexidine-based solutions should
be considered as a replacement for povidone-iodine (including alcohol-based)
formulations in efforts to prevent catheter-related infection.
Publication Types:
Comparative Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
PMID: 17954800 [PubMed - indexed for MEDLINE]
2: Curr Opin Crit Care. 2007 Oct;13(5):563-71.
Diagnosis and prevention of catheter-related infections.
Timsit JF.
Medical ICU, Hôpital Albert Michallon, Grenoble, France. [email protected]
PURPOSE OF REVIEW: To highlight the major advances in diagnosing and preventing
catheter-related infections published in research articles published between
March 2004 and May 2007. RECENT FINDINGS: The challenge remains to make the
diagnosis of catheter-related infection with good accuracy without catheter
removal. The differential time to obtain positive qualitative blood culture
appeared to be the most accurate available technique. Many catheter-related
bloodstream infections are preventable. Simple interventions are often useful and
multimodal programs are very efficacious, particularly in the intensive care
setting. For long-term catheter-related bloodstream infection prevention, patient
education appeared promising. Interesting evidence suggested that anticoagulant,
by decreasing the biofilm formation, could decrease the risk of infection. For
short-term central venous catheter-related infections research is ongoing on
antiseptic dressings. Antiseptic lock appeared promising for preventing long-term
central venous catheter bloodstream infections. SUMMARY: Nowadays, multimodal
programs of catheter infection prevention are efficacious. Levels of
catheter-related bloodstream infection of more than one or two per 1000
catheter-days are usually only found in the intensive care unit. It is a
prerequisite to evaluate the cost-effectiveness of new techniques of prevention.
As catheter-related bloodstream infections become rarer, strategies limiting
unnecessary removal of catheters need to be developed and tested.
Publication Types:
Review
PMID: 17762237 [PubMed - indexed for MEDLINE]
3: Nursing. 2007 Sep;37(9):14-5.
What you need to know about PICCs, part 2.
Guthrie D, Dreher D, Munson M.
Massachusetts General Hospital, Boston, USA.
PMID: 17728628 [PubMed - indexed for MEDLINE]
4: J Hosp Infect. 2007 Jun;65 Suppl 2:30-3.
Prevention of central venous catheter-related infections: what works other than
impregnated or coated catheters?
Mermel LA.
Division of Infectious Diseases, Department of Medicine, Rhode Island Hospital,
RI 028903, USA.
Catheter-related bloodstream infections (CRBSI) are a significant cause of
morbidity and excess hospital cost. Data from prospective, randomized trials
demonstrate that the risk of these infections can be minimized by simple
interventions. Changing the behaviour of healthcare workers who insert and care
for intravascular catheters is imperative. Creating a culture of patient safety
and assuring easy access to the products necessary to maintain strict asepsis
during catheter insertion, dressing changes, and when manipulating catheter hubs,
will enhance adherence to optimal practice and will reduce the risk posed to the
millions of patients in need of such devices.
Publication Types:
Review
PMID: 17540238 [PubMed - indexed for MEDLINE]
5: J Vasc Access. 2003 Apr-Jun;4(2):56-61.
A prospective, randomized trial comparing a transparent dressing and a dry gauze
on the exit site of long term central venous catheters of hemodialysis patients.
Le Corre I, Delorme M, Cournoyer S.
Microbiology-Infectology Department, Charles LeMoyne Hospital, Greenfield Park,
Quebec - Canada.
The objective of this study was to assess the risk of bacteremia, estimate the
cost and evaluate the quality of life by using a transparent dressing (TD) versus
(vs) a dry gauze (DG) on the exit site of long term central I.V. catheters (LTCC)
of hemodialysis patients. This 6-months preliminary study was conducted on 58
patients (pts) randomized to receive DG replaced 3 times/week (29 pts) or TD
replaced every 7 days (29 pts). Data on patients, conditions of the exit site,
local infection, bacteremia, quality of life and cost related to each type of
dressing were collected. Two pts in the DG group experienced bacteremia related
to their LTCC vs 1 pt in the group TD. A total of 7 (DG) vs 13 (TD) pts
experienced skin condition changes at the catheter exit site. Some skin
reactions, erythema and pruritus, did occur initially in the group TD and was due
in part to insufficient drying time of the skin preparation solution. The
estimated individual, weekly costs for using the DG was $7.60 vs $4.72 Canadian
dollars for the TD. The SF-36trade mark scores did not show a significant
difference between the 2 groups during the study (3.8 (PCS), 6.4 (MCS) at study
end). Although this study was statistically underpowered, it suggests that the
incidence of bacteremia was not increased with the use of a TD. Moreover, the use
of a TD allowed fewer dressing changes, lowered total treatment costs, with no
observed unfavorable impact on the quality of life and without significant local
complications of the exit site. Based on the positive results observed in this
pilot study, further study is warranted to examine the cost effectiveness of
long-term use of TD dressings on dialysis catheter exit sites.
PMID: 17642061 [PubMed - in process]
6: Curr Opin Infect Dis. 2007 Aug;20(4):360-9.
Prevention of intravascular catheter infection.
Eggimann P.
Department of Adult Intensive Care Medicine and Burn Centre, Centre Hospitalier
Universitaire Vaudois (CHUV), Lausanne, Switzerland. [email protected]
PURPOSE OF REVIEW: To review recent evidence supporting the guidelines for
preventing catheter-related and catheter-associated infections. RECENT FINDINGS:
A series of studies has confirmed, over the past few years, that education-based
preventive programmes can reduce these infections by one half to two thirds. The
evidence supporting some specific measures has increased for the optimal timing
for set replacement, for catheter-site dressing with chlorhexidine-impregnated
devices, and for the use of some coated or impregnated intravascular devices.
SUMMARY: Catheter-related and associated infections are largely preventable and
should not be viewed as an unaffordable tribute to technical medicine.
Improvements in existing techniques and new technologies should all be integrated
into a structured process of continuous improvement in the quality of care.
Publication Types:
Review
PMID: 17609594 [PubMed - indexed for MEDLINE]
7: Curr Opin Crit Care. 2007 Aug;13(4):411-5.
Prevention of catheter-related blood stream infection.
Byrnes MC, Coopersmith CM.
Department of Surgery, Washington University School of Medicine, St. Louis,
Missouri, USA.
PURPOSE OF REVIEW: Catheter-related blood stream infections are a morbid
complication of central venous catheters. This review will highlight a
comprehensive approach demonstrated to prevent catheter-related blood stream
infections. RECENT FINDINGS: Elements of prevention important to inserting a
central venous catheter include proper hand hygiene, use of full barrier
precautions, appropriate skin preparation with 2% chlorhexidine, and using the
subclavian vein as the preferred anatomic site. Rigorous attention needs to be
given to dressing care, and there should be daily assessment of the need for
central venous catheters, with prompt removal as soon as is practicable.
Healthcare workers should be educated routinely on methods to prevent
catheter-related blood stream infections. If rates remain higher than benchmark
levels despite proper bedside practice, antiseptic or antibiotic-impregnated
catheters can also prevent infections effectively. A recent program utilizing
these practices in 103 ICUs in Michigan resulted in a 66% decrease in infection
rates. SUMMARY: There is increasing recognition that a comprehensive strategy to
prevent catheter-related blood stream infections can prevent most infections, if
not all. This suggests that thousands of infections can potentially be averted if
the simple practices outlined herein are followed.
Publication Types:
Review
PMID: 17599011 [PubMed - indexed for MEDLINE]
8: Paediatr Nurs. 2007 May;19(4):39-44.
A care bundle for management of central venous catheters.
Smith M.
Paediatric Intensive Care Unit, Birmingham Children's Hospital.
Central venous catheters (CVCs) are an essential tool in paediatric intensive
care, providing a means to monitor patient haemodynamics and to administer
fluids, nutrition, blood products and medications. Because multiple factors
contribute to the high risk of catheter related infection, a multi-strategy
approach is required to prevent such infections. Using contemporary literature
and clinical audit findings a 'care bundle' was created for use within the PICU
at Birmingham Children's Hospital. This care bundle groups together best
practices in order to prevent catheter related bloodstream infection.
Publication Types:
Evaluation Studies
PMID: 17542322 [PubMed - indexed for MEDLINE]
9: J Infus Nurs. 2007 Mar-Apr;30(2):105-12; quiz 120-1.
Implementing evidence-based nursing practice in the pediatric intensive care
unit.
Morgan LM, Thomas DJ.
Nova Southeastern University, Miami, FL, USA. [email protected]
With the widespread use of central venous catheters in children, the incidence of
catheter-related bloodstream infections (CR-BSIs) is increasing. Current
evidence-based practice strategies to decrease CR-BSIs include using maximum
barrier techniques during insertion, practicing good hand hygiene, performing
skin antisepsis with 2% chlorhexidine, using a chlorhexidine-impregnated patch
(CIP) covered by a semipermeable polyurethane dressing, and promptly removing
catheters when no longer needed. Implementation of evidence-based practice
bundles, along with monthly monitoring of infection surveillance, has resulted in
significant decreases in the average rates of CR-BSIs per 1,000 catheter days in
many pediatric intensive care units.
PMID: 17413495 [PubMed - indexed for MEDLINE]
10: J Burn Care Res. 2007 Mar-Apr;28(2):222-30.
Standard operating procedures for the clinical management of patients enrolled in
a prospective study of Inflammation and the Host Response to Thermal Injury.
Silver GM, Klein MB, Herndon DN, Gamelli RL, Gibran NS, Altstein L,
McDonald-Smith GP, Tompkins RG, Hunt JL; The Inflammation and the Host Response
to Trauma, Collaborative Research Program.
Department of Surgery, Loyola University Stritch School of Medicine, Maywood,
Illinois 60153, USA.
As part of the National Institutes of General Medical Sciences (NIGMS)-funded
Inflammation and the Host Response to Injury study, participating investigators
created a database, a clinical data collection protocol, and web-based case
report form. To obtain high-quality clinical endpoints for correlation with
genomic data, a uniform approach to patient management between centers was
required. Standard operating procedures (SOPs) were generated to minimize
variability and promote a uniform standard of patient care. The SOPs are
necessary to enable validation of the clinical endpoints to be used for
comparison with genomic and proteomic information derived from samples of blood
and tissue obtained from thermally injured patients. Participating investigators
identified areas of potential practice variation and developed a set of SOPs
based on available data and sound clinical principles. In the absence of
sufficient clinical data to identify a single management strategy, SOPs were
designed to apply the best approach to management without interfering with local
standards of care. The data- collection instrument, or case report form, was
constructed concurrently with the SOPs. Wherever possible, the case report form
was modified to collect data that might resolve controversial management issues.
Modifications in management strategies that were necessary for children are
delineated as needed. Data queries and site visits were conducted to audit
compliance. SOPs for 10 areas of clinical care were developed. The institution of
the SOPs required minor changes in clinical practice patterns and personnel
training but did not require participating centers to procure new technology or
alter the utilization of clinical resources significantly. The SOPs represent
current management strategies applied to the study population to reduce variation
in patient management. The SOPs are easily adaptable to other burn-related
clinical protocols as well as to the routine daily management burn patients.
Publication Types:
Multicenter Study
PMID: 17351437 [PubMed - indexed for MEDLINE]
11: Intensive Care Med. 2007 Mar;33(3):466-76. Epub 2007 Jan 19.
Infectious complications of percutaneous central venous catheterization in
pediatric patients: a Spanish multicenter study.
García-Teresa MA, Casado-Flores J, Delgado Domínguez MA, Roqueta-Mas J,
Cambra-Lasaosa F, Concha-Torre A, Fernández-Pérez C; Spanish Central Venous
Catheter Pediatric Study Group.
Pediatric Intensive Care Unit, Hospital Niño Jesús, C/ Menéndez Pelayo, 65,
28009, Madrid, Spain.
OBJECTIVE: Analysis of infectious complications and risk factors in percutaneous
central venous catheters. DESIGN: One-year observational, prospective,
multicenter study (1998-1999). SETTING: Twenty Spanish pediatric intensive care
units. PATIENTS: Eight hundred thirty-two children aged 0-14 years. INTERVENTION:
None. MEASUREMENTS AND MAIN RESULTS: One thousand ninety-two catheters were
analyzed. Seventy-four (6.81%) catheter-related bloodstream infections (CRBSI)
were found. The CRBSI rate was 6.4 per 1,000 CVC days (95% CI 5.0-8.0). Risk
factors for CRBSI were weight under 8 kg (p < 0.001), cardiac failure (RR 2.69;
95% CI 1.95-4.38; p < 0.001), cancer (RR 1.66; 95% CI 0.97-2.78; p=0.05),
silicone catheters (RR 2.82; 95% CI 1.49-5.35; p = 0.006), guidewire exchange
catheterization (p=0.002), obstructed catheters (RR 2.67; 95% CI 1.63-4.39;
p<0.001), and more than 12 days' indwelling time (RR 5.9; 95% CI 3.63-9.41;
p<0.001). Multivariate Cox regression identified lower patient weight (HR 2.4;
95% CI 1.11-5.19; p=0.002), guidewire exchange catheterization (HR 2.2; 95% CI
1.07-4.54; p=0.049) and more than 12 days' indwelling time (HR 1.97; 95% CI
0.89-4.36; p=0.089) as significant independent predictors of CRBSI. Factors which
protected against infection were the use of povidone-iodine on hubs (HR 0.42; 95%
CI 0.19-0.96; p=0.025) and porous versus impermeable dressing (HR 0.41; 95% CI
0.23-0.74; p=0.004). Two children (0.24%) died from endocarditis following
catheter-related sepsis due to Stenotrophomonas maltophilia in one case and P.
aeruginosa in the other. CONCLUSIONS: Catheter-related sepsis is associated with
lower patient weight and more than 12 days' indwelling time, but not with the
insertion site. Cleaning hubs with povidone-iodine protects from infection.
Publication Types:
Multicenter Study
PMID: 17235512 [PubMed - indexed for MEDLINE]
12: Am J Infect Control. 2006 Dec;34(10):636-41.
Prospective cohort study of central venous catheters among internal medicine ward
patients.
Trick WE, Miranda J, Evans AT, Charles-Damte M, Reilly BM, Clarke P.
Department of Medicine, Stroger Hospital of Cook County and Rush Medical College,
1900 W. Polk Street, Chicago, IL 60612, USA. [email protected]
BACKGROUND: Central venous catheter (CVC) use is less well described for patients
outside the intensive care unit. We evaluated CVCs and the associated bloodstream
infection rate among patients admitted to the general medical service. METHODS:
We performed a prospective cohort study of patients who had a CVC on admission or
inserted during their stay on the general medical service in a public teaching
hospital, November 15, 2004, to March 31, 2005. RESULTS: We identified 106 CVCs,
52 were present on admission and 54 were inserted; there were 682 catheter-days.
The primary bloodstream infection rate was 4.4 per 1000 catheter-days (95% CI:
0.9-13): highest for catheters inserted in the emergency department compared with
those inserted on other units (24 vs 1.7 per 1000 catheter-days), P = .045. By
multivariable analysis, inadequate dressings were more likely among patients with
a body mass index > or =30 kg/m(2), adjusted odds ratio, 3.4 (95% CI: 1.4-8.0).
CONCLUSIONS: Many CVCs had previously been inserted in the emergency department
or intensive care unit; therefore, strategies to reduce bloodstream infections
that focus on ward insertion practices may not dramatically reduce bloodstream
infection rates. Intervention strategies should target improved dressing care and
consideration of early removal or replacement of catheters inserted in the
emergency department.
PMID: 17161738 [PubMed - indexed for MEDLINE]
13: J Hosp Infect. 2007 Jan;65(1):47-53. Epub 2006 Nov 30.
Pseudomonas aeruginosa and Pseudomonas putida outbreak associated with
contaminated water outlets in an oncohaematology paediatric unit.
Aumeran C, Paillard C, Robin F, Kanold J, Baud O, Bonnet R, Souweine B, Traore O.
CHU Clermont-ferrand, Hôpital Gabriel Montpied, Service d'Hygiène Hospitalière,
Clermont-Ferrand, France and Univ Clermont 1, UFR Médecine, EA 3843, Laboratoire
de Virologie, Clermont-Ferrand, France. [email protected]
This paper describes an outbreak of Pseudomonas aeruginosa and Pseudomonas putida
that occurred in an oncohaematology paediatric unit between January and April
2005. Eight children had nosocomial infections due to P. aeruginosa (N=5) or P.
putida (N=3), which were recovered from central venous catheter blood cultures
(N=4), the catheter exit site alone (N=2), or the catheter exit site and the
catheter tip (N=2). Subsequent investigation showed that contaminated water
outlets represented the possible source of spread. Studies of nursing and
environmental cleaning practices revealed two modes of catheter contamination. A
reduction in the size of the catheter dressing at the exit site gave less
protective cover during showers, and a detergent-disinfectant diluted with tap
water had contaminated perfusion bottles. Repetitive intergenic consensus
polymerase chain reaction indicated two discrete patterns for P. aeruginosa and
one for P. putida. The water network was chlorinated, and disposable seven-day
filters were fitted on all taps and showers. Due to the deleterious effects of
chlorination on the water network and the cost of the weekly filter change, a
water loop producing microbiologically controlled water was installed. In
addition, the concentration of the detergent-disinfectant was increased and
refillable sprayers were replaced with ready-to-use detergent-disinfectant
solution for high-risk areas. Following these measures, no Pseudomonas spp. have
since been isolated in clinical or environmental samples from the ward.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 17141370 [PubMed - indexed for MEDLINE]
14: Contrib Nephrol. 2007;154:84-96.
Hemodialysis catheter exit site care.
Astle CM.
WC McKenzie Center, University of Alberta Hospital, Edmonton, Canada.
Tunneled, cuffed central venous catheters are used extensively throughout the
hemodialysis patient population as a permanent arterio-venous access. One of the
major complications associated with these devices is infection. The strategies
aimed at reducing catheter-related infection include nurse-patient ratio, use of
barrier precautions, hand washing, ointments, dressings, and skin antiseptics.
The intent of this paper is to examine the types of skin antiseptics and compare
their effectiveness.
PMID: 17099303 [PubMed - in process]
15: Worldviews Evid Based Nurs. 2005;2(1):4-13; discussion 14-5.
A systematic review for effective management of central venous catheters and
catheter sites in acute care paediatric patients.
Lee OK, Johnston L.
Intensive Care Unit, The Royal Children's Hospital, The University of Melbourne,
School of Nursing, Parkville, Victoria, Australia 3051. [email protected]
BACKGROUND: Central venous catheters (CVCs) have provided many benefits in
modern-day medical practice; however, they also put patients at risk of
catheter-related complications. Numerous studies have been carried out in
relation to the management of central venous catheters with conflicting results.
While there were several systematic reviews of central venous catheter-related
issues, it is clear that there was no systematic review of CVC-related studies
specific to the paediatric population in the acute care setting. OBJECTIVE: To
present the best available evidence for effective management of central venous
catheters and catheter sites in the prevention and/or reduction of
catheter-related complications in hospitalised paediatric patients. METHODS: A
systematic review was undertaken according to the approach of the Centre for
Reviews and Dissemination (CRD; http://www.york.ac.uk/inst/crd). DATA SOURCE:
Literature was identified by electronic searching of Cochrane Library, MEDLINE,
CINAHL, HealthSTAR, and CancerLit; checking references of all review articles;
hand searching of key relevant journals and conference proceedings; and contact
with expert informants, medical suppliers, and pharmaceutical companies.
INCLUSION/EXCLUSION CRITERIA: The review included randomised and non-randomised
controlled trials conducted with hospitalised paediatric patients. Studies that
included mixed adult and paediatric populations and mixed hospitalised and home
care settings were excluded. DATA EXTRACTION: Two independent reviewers extracted
data onto a standard data extraction form, with differences resolved by
discussion. QUALITY ASSESSMENT: The quality assessment of retrieved studies
included: study design, the degree to which systematic bias was avoided or
minimised, the degree to which the assessment was "blind," the degree to which
follow up was completed. DATA SYNTHESIS: Quantitative pooling of studies was not
feasible due to the diversity of interventions and outcome measures between
similar studies. A narrative account of the study characteristics and results was
therefore undertaken. RESULTS: Thirty-eight randomised and quasi-randomised
controlled trials were retrieved for critical appraisal. Of these, 32 were
excluded from the review because the studies did not meet the inclusion criteria
and some lacked reporting of appropriate data. Six studies met the criteria with
interventions such as antibiotic flushes, antiseptic skin preparations, and
dressing materials. CONCLUSION: Quality of reporting was generally lacking.
Statistical pooling of results was not possible due to diversity in the reporting
of outcomes. There was no evidence to make recommendations on the degree of
barrier precautions and the type of aseptic technique to be used at the time of
catheter insertion in the paediatric population to prevent catheter-related
infection. There was insufficient evidence to support the routine use of an
antibiotic flushing solution. There was a lack of randomised controlled trial
(RCT) evidence on the benefit of heparin flushes, the use of in-line filters, the
frequency of fluid administration set changes, or the type of dressing to use and
the frequency of dressing changes. There was some evidence to suggest that
chlorhexidine lotion is superior to povidone iodine as a cutaneous antiseptic at
the catheter insertion site. However, no recommendation can be made for the use
of chlorhexidine in neonates less than 2 weeks old or in premature infants. This
systematic review concluded that there is an urgent need for well-designed
randomised controlled trials with sufficient power to determine the effectiveness
of various interventions in relation to management of CVCs.
Publication Types:
Review
PMID: 17040550 [PubMed - indexed for MEDLINE]
16: Int J Nurs Stud. 2007 Nov;44(8):1324-33. Epub 2006 Sep 25.
The effectiveness of a nurse-initiated intervention to reduce catheter-associated
bloodstream infections in an urban acute hospital: an intervention study with
before and after comparison.
Tsuchida T, Makimoto K, Toki M, Sakai K, Onaka E, Otani Y.
Department of Nursing, Graduate School of Nursing, Osaka University, 1-7
Yamadaoka, Suita city, Osaka 565-0871, Japan. [email protected]
BACKGROUND: Catheter care is considered to be important for prevention of
catheter-associated bloodstream infections (CABSIs) although epidemiological
evidence is sparse. OBJECTIVES: To identify problems associated with catheter
care and evaluate the effectiveness of nurse-initiated interventions to reduce
CABSIs. DESIGN: An intervention study with before and after comparison. SETTINGS:
CABSI surveillance was conducted in a 560-bed acute hospital located in a major
urban area in Japan. PARTICIPANTS: Patients were enrolled in this study from
April 2000 to December 2002 based on the following criteria: (1) adult
inpatients; and (2) those in whom central venous lines or Swan-Ganz catheters
were inserted for 2 days or longer. METHODS: In the first year, risk factors for
CABSI and problems associated with catheter care were identified by inspection of
the infection control nurse (ICN) or four trained link nurses, and the laboratory
results. In the subsequent 2 years, the following interventions based on the
surveillance results were implemented: (1) enhanced skin preparation by scrubbing
with regular bathing soap and tap water; (2) a new method for stabilisation of
the catheter inserted into the internal jugular vein, where additional dressing
was placed over the sterilised dressing; (3) educating the staff on maximal
sterile precautions by teaching staff members at their section meetings and
displaying posters; (4) use of a check list and observation of catheter insertion
by link nurses to monitor compliance; and (5) selection of a disinfectant that
requires shorter contact time and has longer residual effect. RESULTS: After
these interventions were implemented, the overall bloodstream infection (BSI)
rate declined from 4.0/1000 device-days to 1.1/1000 device-days (p<0.005).
CONCLUSIONS: We identified four problems-those related to skin preparation,
dressing, sterile precautions and disinfectant. We implemented a series of
interventions to reduce CABSIs; the overall CABSI rate decreased significantly.
PMID: 16996516 [PubMed - indexed for MEDLINE]
17: Nurs Stand. 2006 Aug 16-22;20(49):42-6.
The safe removal of central venous catheters.
Ingram P, Sinclair L, Edwards T.
The Royal Infirmary of Edinburgh, Edinburgh. [email protected]
Many nurses working in general wards and departments are caring for patients with
central venous catheters and are increasingly responsible for their removal. This
article outlines the basis of good practice and the possible complications,
focusing on air embolism.
Publication Types:
Review
PMID: 16939143 [PubMed - indexed for MEDLINE]
18: J Hosp Infect. 2006 Sep;64(1):56-62. Epub 2006 Jul 21.
A napkin-associated outbreak of Burkholderia cenocepacia bacteraemia in
haemodialysis patients.
Lo Cascio G, Bonora MG, Zorzi A, Mortani E, Tessitore N, Loschiavo C, Lupo A,
Solbiati M, Fontana R.
Dipartimento di Patologia, Sezione di Microbiologia, Università di Verona,
Verona, Italy. [email protected]
This article reports a catheter-related outbreak of bacteraemia involving 38
patients in two haemodialysis units in Verona. Burkholderia cepacia complex
strains were isolated from human blood and from an individually wrapped
disinfection napkin that was contained in a commercially available, sterile
dressing kit used to handle central venous catheters. Micro-organisms isolated
from blood cultures and from the napkin were identified by standard procedures
and confirmed as B. cenocepacia (genomovar III) by molecular analysis. Using
pulsed-field gel electrophoresis analysis, the clinical isolates were
indistinguishable or closely related to the B. cenocepacia isolated from the
napkin. In conclusion, this study found that a contaminated commercial napkin
soaked in quaternary ammonium, even when quality certified, was the source of
infection.
Publication Types:
Multicenter Study
Research Support, Non-U.S. Gov't
PMID: 16859809 [PubMed - indexed for MEDLINE]
19: J Infus Nurs. 2006 Jul-Aug;29(4):225-31.
Erratum in:
J Infus Nurs. 2006 Sep-Oct;29(5):242.
Summary of product trials for 10, 164 patients: comparing an intravenous
stabilizing device to tape.
Schears GJ.
Mayo Clinic, Rochester, Minnesota 55905, USA. [email protected]
Inadequate catheter securement is an underrecognized patient safety issue that
contributes significantly to catheter-related complications, including
dislodgment, occlusion, infiltration, and infection. Pooled data from prospective
product trials at 83 hospitals compared tape to a standard peripheral intravenous
(PIV) securement method with a PIV-specific catheter-stabilizing device
(StatLock). A 67% reduction (P<.001) in total patient complications was observed
in the stabilizing device group, as compared with the tape group. Also, the need
for unscheduled PIV restarts was reduced by 76% with the stabilizing device
(P<.001). An annual cost savings of $18,000 per hospital on PIV materials and a
combined savings of $277,000 on materials, complication costs, and nursing time
were estimated on the basis of these reduced complications. Newer
catheter-stabilizing technologies can help to reduce patient complications, for
an overall cost savings, and consequently reduce needlestick exposures for
healthcare providers by reducing restarts and prolonging dwell times.
Publication Types:
Comparative Study
Meta-Analysis
PMID: 16858255 [PubMed - indexed for MEDLINE]
20: Br J Nurs. 2006 Jun 22-Jul 12;15(12):650-4.
Central venous catheters: a review of skin cleansing and dressings.
Danks LA.
Vascular Surgery, Luke Ward, Guy's and St Thomas's Hospital, London.
Having central intravenous devices is an indispensable part of the total care for
high dependency patients, as they are used for administration of a wide range of
intravenous therapies and for haemodynamic monitoring. However, their use is
frequently complicated by a variety of local or systemic infections. Therefore,
all staff involved in the management of central venous catheters must base their
practice on what is agreed in the literature as being effective in reducing the
risk of hospital acquired infections. This article offers a literature-based
review of the management of central venous catheters, focusing on skin cleansing
and dressing types. Proper skin preparation prior to catheter insertion has been
shown to be essential in reducing infections.
Publication Types:
Review
PMID: 16835539 [PubMed - indexed for MEDLINE]
21: Adv Chronic Kidney Dis. 2006 Jul;13(3):225-44.
Avoiding trouble down the line: the management and prevention of hemodialysis
catheter-related infections.
Lok CE.
Department of Medicine, Division of Nephrology, University Health Network-Toronto
General Hospital and University of Toronto, Toronto, Ontario, Canada.
[email protected]
Over the last 2 decades, hemodialysis catheter use has increased. Annually,
approximately 30% of patients using a central venous catheter (CVC) experience a
septic or bacteremic episode and are subsequently at risk of its associated
long-term complications and mortality. Because of the serious clinical and
financial impact of hemodialysis catheter-related bacteremias (HCRIs),
standardized, validated definitions based on the hemodialysis patient population
are necessary in order to better diagnose, monitor, and report HCRI for patient
quality assurance and research purposes. The pathophysiology of HCRI involves a
complex interaction between a triad that consists of the host patient, the
infecting microorganism, and the vehicle catheter. Although the microorganism
contribution in the pathogenesis of HCRI is likely most important, certain
patient and catheter-related characteristics may be more amenable to
manipulation. The key to managing HCRI is on prophylaxis against the initial
microorganism catheter adherence and subsequent biofilm development. General and
specific prophylactic maneuvers directed at both an intravascular and
extraluminal route of microorganism entry are discussed including antibiotic- and
silver-impregnated catheters and dressings, subcutaneous access devices, and
topical prophylaxis at the exit site. In addition to systemic antibiotic use, the
3 methods of HRCI treatment using catheter salvage, guidewire exchange, and
concurrent antibiotic lock are compared. The outcome and complications of HCRI
may be serious and highlight the importance of careful, continual infection
surveillance. Although the use of a multidisciplinary hemodialysis infection
control team is desirable, staffing education and physician feedback have been
shown to improve adherence to infection control guidelines and reduce HCRI.
Publication Types:
Review
PMID: 16815229 [PubMed - indexed for MEDLINE]
22: Infect Control Hosp Epidemiol. 2006 Jul;27(7):662-9. Epub 2006 Jun 9.
Comment in:
Infect Control Hosp Epidemiol. 2007 Mar;28(3):370; author reply 370-1.
A multicenter intervention to prevent catheter-associated bloodstream infections.
Warren DK, Cosgrove SE, Diekema DJ, Zuccotti G, Climo MW, Bolon MK, Tokars JI,
Noskin GA, Wong ES, Sepkowitz KA, Herwaldt LA, Perl TM, Solomon SL, Fraser VJ;
Prevention Epicenter Program.
Department of Medicine, Washington University School of Medicine, Saint Louis, MO
63110, USA. [email protected]
BACKGROUND: Education-based interventions can reduce the incidence of
catheter-associated bloodstream infection. The generalizability of findings from
single-center studies is limited. OBJECTIVE: To assess the effect of a
multicenter intervention to prevent catheter-associated bloodstream infections.
DESIGN: An observational study with a planned intervention. SETTING: Twelve
intensive care units and 1 bone marrow transplantation unit at 6 academic medical
centers. PATIENTS: Patients admitted during the study period. INTERVENTION:
Updates of written policies, distribution of a 9-page self-study module with
accompanying pretest and posttest, didactic lectures, and incorporation into
practice of evidence-based guidelines regarding central venous catheter (CVC)
insertion and care. MEASUREMENTS: Standard data collection tools and definitions
were used to measure the process of care (ie, the proportion of nontunneled
catheters inserted into the femoral vein and the condition of the CVC insertion
site dressing for both tunneled and nontunneled catheters) and the incidence of
catheter-associated bloodstream infection. RESULTS: Between the preintervention
period and the postintervention period, the percentage of CVCs inserted into the
femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence
interval [CI], 0.61-0.88); the total proportion of catheter insertion site
dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95%
CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream
infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days
(relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied
among individual units. CONCLUSIONS: An education-based intervention that uses
evidence-based practices can be successfully implemented in a diverse group of
medical and surgical units and reduce catheter-associated bloodstream infection
rates.
Publication Types:
Multicenter Study
Research Support, N.I.H., Extramural
Research Support, U.S. Gov't, P.H.S.
PMID: 16807839 [PubMed - indexed for MEDLINE]
23: Br J Nurs. 2006 Apr 13-26;15(7):362, 364-8.
Central venous catheter infection in adults in acute hospital settings.
Jones CA.
King's College London.
As well as the human cost, central venous catheter (CVC)-related bloodstream
infections significantly inflate hospital costs, mainly through increased length
of stay in hospital, particularly in intensive care. This literature review
appraises recent research on measures used to minimize CVC-related infection and
compares it with current best practice. Randomized controlled trials and
systematic reviews published on the subject between 2000 and 2005 were reviewed,
concentrating on non-tunnelled, short-term CVCs in the acute hospital setting.
The new evidence mainly backs up current best practice. However, skin
disinfection could be improved by using alcoholic chlorhexidine followed by
aqueous povidone-iodine before CVC insertion. Also, alcoholic chlorhexidine is
the preferred solution for cleaning the hubs/connectors before accessing the CVC.
Good hand hygiene and quality control and education programmes are vital to
improve patient care. More research is needed to clarify the effectiveness of
certain interventions and technologies, such as antimicrobial CVCs.
Publication Types:
Review
PMID: 16723935 [PubMed - indexed for MEDLINE]
24: Crit Care Nurs Q. 2006 Apr-Jun;29(2):117-22.
Central venous access device infections in the critical care unit.
Tilton D.
Shawnee Mission Medical Center, Shawnee Mission, KS 66204, USA.
[email protected]
Central venous access devices are indispensable tools in caring for the gravely
ill patients in today's critical care units. Unfortunately, they are also one of
the major sources for nosocomial infections in the hospital setting. This article
explores the pathophysiology and risk factors related to central venous access
devices infections, and examine prevention strategies. The critical care nurse,
using evidence-based practice guidelines in the care of these lines, can be
instrumental in preventing catheter-related infections.
Publication Types:
Review
PMID: 16641647 [PubMed - indexed for MEDLINE]
25: Semin Pediatr Infect Dis. 2006 Jan;17(1):20-4.
Catheter-related bloodstream infections in the pediatric intensive care unit.
Newman CD.
Department of Pediatrics and Critical Care, Texas Children's Hospital, Houston,
TX 77030, USA. [email protected]
Catheter-related bloodstream infections (CRBSIs) are a significant complication
for children treated in the pediatric intensive care unit (PICU). This review
seeks to identify the epidemiology, risk factors, treatment, and prevention
strategies for CRBSIs in the PICU. Factors such as catheter type, insertion site,
number of lumens, indwelling time, and medications delivered all can influence
the rate of CRBSIs. Prevention strategies include use of full-barrier techniques
during insertion, use of chlorhexidine cleaning solutions during insertion and
dressing change, strict adherence to catheter-care protocols, and removal of
catheters as soon as possible after conclusion of therapy.
Publication Types:
Review
PMID: 16522502 [PubMed - indexed for MEDLINE]
26: Dermatology. 2006;212 Suppl 1:47-52.
Our method of povidone-iodine ointment and gauze dressings reduced
catheter-related infection in serious cases.
Fukunaga A, Naritaka H, Fukaya R, Tabuse M, Nakamura T.
Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan.
[email protected]
In experiment 1, we evaluated our method of catheter care at subclavian vein
insertion sites for the control of catheter-related infections in seriously ill
neurosurgical patients who needed prolonged catheter placement, compared with an
older method. In our method, the insertion site was prepared with 10%
povidone-iodine solution, followed by application of 10% povidone-iodine
ointment, and covered with sterile gauze and a transparent polyurethane dressing.
The older method was based on 1996 guidelines for the prevention of intravascular
device-related infections. Catheter colonization and mortality were both found to
be significantly reduced with our method (p = 0.0214, p = 0.0379, respectively).
In experiment 2, we evaluated whether a regimen of catheter care with 10%
povidone-iodine ointment was more effective than that without povidone-iodine
ointment for the prevention of infections. This suggested effectiveness of 10%
povidone-iodine ointment for reduction of infection. Our method of catheter care
was useful even in seriously ill neurosurgical patients.
PMID: 16490975 [PubMed - indexed for MEDLINE]
27: Nutr Clin Pract. 2006 Feb;21(1):56-61.
Erratum in:
Nutr Clin Pract. 2006 Apr;21(2):vi.
Techniques to prevent central venous catheter infections: products, research, and
recommendations.
Banton J.
University of Wisconsin Hospital and Clinics, 600 Highland Ave., Madison, WI
53792, USA. [email protected]
Central venous catheters (CVCs) are commonly used to deliver a variety of
therapies such as chemotherapy and parenteral nutrition. It is well known that
there are complications associated with CVCs; a major complication is
catheter-related bloodstream infection (CRBSI). Many strategies exist to prevent
CVC complications and CRBSI. This paper will focus on the fight against CRBSI
using 3 products at the catheter insertion site: 2% chlorhexidine, BioPatch, and
transparent split dressings. Lists of key recommendations from national
organizations for infection prevention are included.
Publication Types:
Review
PMID: 16439770 [PubMed - indexed for MEDLINE]
28: Nursing. 2006 Jan;36(1):20-1.
What you need to know about ports.
Rosenthal K.
ResourceNurse Continuing Education, Inc., Long Beach, NY, USA.
PMID: 16394992 [PubMed - indexed for MEDLINE]
29: JPEN J Parenter Enteral Nutr. 2006 Jan-Feb;30(1 Suppl):S7-12.
Anatomy and physiology of venous system vascular access: implications.
Grant JP.
Duke University Medical Center, Durham, North Carolina. 27710, USA.
[email protected]
Ideal characteristics for long-term vascular access that can be managed in the
home environment include a large vascular lumen in a high-flow blood system to
minimize risks of obstruction and phlebitis, ease of sterile dressing
maintenance, patient comfort, and longevity of the access site. Additionally,
adaptation to placement at the bedside or in the home, technical ease and safety
of placement, and minimal expense would be beneficial. With these considerations,
possible anatomical sites would include the external and internal jugular veins,
subclavian vein, cephalic vein, basilic vein, femoral vein, right atrial
appendage, and translumbar and transhepatic access to the inferior vena cava. Of
these, the internal jugular vein, subclavian vein, cephalic vein, basilic vein,
and femoral vein would seem best suited for long-term venous access.
Publication Types:
Review
PMID: 16387914 [PubMed - indexed for MEDLINE]
30: Biomaterials. 2006 Apr;27(11):2450-67. Epub 2005 Dec 6.
Drug/device combinations for local drug therapies and infection prophylaxis.
Wu P, Grainger DW.
Department of Chemistry, Colorado State University, Fort Collins, CO 80523-1872,
USA.
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.
Publication Types:
Review
PMID: 16337266 [PubMed - indexed for MEDLINE]
31: Nursing. 2005 Dec;35(12):54-6.
Caring for a nontunneled CVC site.
Hadaway LC.
Lynn Hadaway Associates, Inc., Milner, GA, USA.
Learn current recommendations for preventing catheter-related complications in an
adult.
PMID: 16331230 [PubMed - indexed for MEDLINE]
32: Infect Control Hosp Epidemiol. 2005 Aug;26(8):703-7.
Octenidine hydrochloride for the care of central venous catheter insertion sites
in severely immunocompromised patients.
Tietz A, Frei R, Dangel M, Bolliger D, Passweg JR, Gratwohl A, Widmer AE.
Division of Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
OBJECTIVE: To determine the efficacy and tolerability of octenidine
hydrochloride, a non-alcoholic skin antiseptic, for the care of central venous
catheter (CVC) insertion sites. DESIGN: Prospective, observational study.
SETTING: Bone marrow transplantation unit of a university hospital. PATIENTS: All
consecutive patients with a nontunneled CVC were enrolled prospectively after
informed consent. METHODS: Octenidine hydrochloride (0.1%) was applied for
disinfection at the CVC insertion site during dressing changes. The following
cultures were performed weekly as well as at the occurrence of any systemic
inflammatory response syndrome criteria: cultures of the skin surrounding the CVC
entry site, cultures of the three-way hub connected to the CVC, blood cultures,
and cultures of the CVC tip on removal. Enhanced microbiological methods (skin
swabs of a 24-cm2 standardized area, roll plate, and sonication of catheter tips)
were applied. RESULTS: One hundred thirty-five CVCs were inserted in 62 patients
during the study period and remained for a mean period of 19.1 days,
corresponding to 2,462 catheter-days. Bacterial density at the insertion site
declined substantially over time, and most cultures became negative 2 weeks after
insertion. Only 6 patients had a documented catheter-related bloodstream
infection. The incidence density was 2.39 catheter infections per 1,000
catheter-days. No side effects were noted with application of the antiseptic.
CONCLUSIONS: Disinfection with a skin antiseptic that contains octenidine
hydrochloride is highly active and well tolerated. It leads to a decrease in skin
colonization over time and may be a new option for CVC care.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 16156327 [PubMed - indexed for MEDLINE]
33: Crit Care Med. 2005 Sep;33(9):2022-7.
Comment in:
Crit Care Med. 2005 Sep;33(9):2133-4.
The effect of process control on the incidence of central venous
catheter-associated bloodstream infections and mortality in intensive care units
in Mexico.
Higuera F, Rosenthal VD, Duarte P, Ruiz J, Franco G, Safdar N.
General Hospital, Mexico City, Mexico.
PURPOSE: To ascertain the effect of an infection control program including
process control on intensive care unit (ICU) rates of intravascular device
(IVD)-associated bloodstream infection (BSI). SETTING: Two level III adult ICUs
in one public university hospital in Mexico: one medical surgical ICU and one
neurosurgical ICU. POPULATION STUDY: All adult patients admitted to study units
who had a central venous catheter (CVC) in place for at least 24 hrs. METHODS: A
prospective before/after trial in which rates of IVD-associated BSI are
determined during a period of active surveillance without process control (phase
1) were compared with rates of IVD-associated BSI after implementing an infection
control program applying process control (phase 2). RESULTS: Six hundred five
IVD-days were accumulated in phase 1, and 2824 IVD-days were accumulated during
phase 2. Compliance with CVC site care and hand hygiene improved significantly
from baseline during the study period: placing a gauze dressing over the catheter
insertion site (99.24% vs. 86.69%, respectively; relative risk [RR] = 1.14; 95%
confidence interval [CI] = 1.07-1.22; p = .0000), proper use of gauze for
vascular catheter insertion site (97.87% vs. 84.21%, respectively; RR = 1.16; 95%
CI = 1.09-1.24; p = .0000), documentation of the duration of the administration
set of the vascular catheter (93.85% vs. 40.69%, respectively; RR = 2.34; 95% CI
= 2.14-2.56; p = .0000), and hand hygiene before contact with the patient (84.9%
vs. 62%, respectively; RR = 1.37; 95% CI = 1.21-1.51; p = .0000). Overall rates
of IVD-associated BSI were lowered significantly from baseline rates after
implementation of process control (19.5 vs. 46.3 BSIs per 1000 IVD-days,
respectively; RR = 0.42; 95% CI = 0.27-0.66; p = .0001). Overall rates of crude
unadjusted mortality were lowered significantly from baseline rates (48.5% vs.
32.8% per 100 discharges, respectively; RR = 0.68; 95% CI = 0.50-0.31; p = .01).
CONCLUSION: Implementation of an infection control program utilizing education,
process control, and performance feedback was associated with significant
reductions in rates of IVD-associated BSI and mortality.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 16148475 [PubMed - indexed for MEDLINE]
34: Chest. 2005 Aug;128(2):489-95.
Risk of catheter-related bloodstream infection with peripherally inserted central
venous catheters used in hospitalized patients.
Safdar N, Maki DG.
Section of Infectious Diseases, Department of Medicine, University of Wisconsin
Medical School, Madison, USA.
BACKGROUND: Peripherally inserted central venous catheters (PICCs) are now widely
used for intermediate and long-term access in current-day health care, especially
in the inpatient setting, where they are increasingly supplanting conventional
central venous catheters (CVCs) placed percutaneously into the internal jugular,
subclavian, or femoral veins. Data on the risk of PICC-related bloodstream
infection (BSI) with PICCs used in hospitalized patients are limited. STUDY
OBJECTIVES: To determine the risk of PICC-related BSI in hospitalized patients.
STUDY DESIGN: Prospective cohort study using data from two randomized trials
assessing the efficacy of chlorhexidine-impregnated sponge dressing and
chlorhexidine for cutaneous antisepsis. METHODS: PICCs inserted into the
antecubital vein in two randomized trials during from 1998 to 2000 were
prospectively studied; most patients were in an ICU. PICC-related BSI was
confirmed in each case by demonstrating concordance between isolates colonizing
the PICC at the time of removal and from blood cultures by restriction-fragment
DNA subtyping. RESULTS: Overall, 115 patients had 251 PICCs placed. Mean duration
of catheterization was 11.3 days (total, 2,832 PICC-days); 42% of the patients
were in an ICU at some time, 62% had urinary catheters, and 49% had received
mechanical ventilation. Six PICC-related BSIs were identified (2.4%), four with
coagulase-negative staphylococcus, one with Staphylococcus aureus, and one with
Klebsiella pneumoniae, a rate of 2.1 per 1,000 catheter-days. CONCLUSION: This
prospective study shows that PICCs used in high-risk hospitalized patients are
associated with a rate of catheter-related BSI similar to conventional CVCs
placed in the internal jugular or subclavian veins (2 to 5 per 1,000
catheter-days), much higher than with PICCs used exclusively in the outpatient
setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed
and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A
randomized trial of PICCs and conventional CVCs in hospitalized patients
requiring central access is needed. Our data raise the question of whether the
growing trend in many hospital hematology and oncology services to switch from
use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs
are more vulnerable to thrombosis and dislodgment, and are less useful for
drawing blood specimens. Moreover, PICCs are not advisable in patients with renal
failure and impending need for dialysis, in whom preservation of upper-extremity
veins is needed for fistula or graft implantation.
Publication Types:
Research Support, Non-U.S. Gov't
Review
PMID: 16100130 [PubMed - indexed for MEDLINE]
35: Pediatr Infect Dis J. 2005 Aug;24(8):676-9.
Chlorhexidine-impregnated dressing for prevention of colonization of central
venous catheters in infants and children: a randomized controlled study.
Levy I, Katz J, Solter E, Samra Z, Vidne B, Birk E, Ashkenazi S, Dagan O.
Department of Pediatric Infectious Diseases, Schneider Children's Medical Center
of Israel, Petah Tiqva, Israel. [email protected]
BACKGROUND: Infections of short term, nontunneled, intravascular catheters are
often caused by migration of organisms from the insertion site. The aim of this
study was to evaluate the effectiveness and safety of a chlorhexidine
gluconate-impregnated dressing for the reduction of central venous catheter (CVC)
colonization and CVC-associated bloodstream infections in infants and children
after cardiac surgery. METHODS: This prospective, randomized, controlled study
was conducted in the pediatric cardiac intensive care unit of a tertiary care
pediatric medical center. Patients 0-18 years of age who were admitted to the
pediatric cardiac intensive care unit during a 14-month period and required a CVC
for >48 hours were randomized to receive a transparent polyurethane insertion
site dressing (control group) or a chlorhexidine gluconate-impregnated sponge
(Biopatch) dressing covered by a transparent polyurethane dressing (study group).
The main outcome measures were rates of bacterial colonization, rates of
CVC-associated bloodstream infections and adverse events. RESULTS: Seventy-one
patients were randomized to the control group and 74 to the study group. There
were no significant between group differences in age, sex, Pediatric Risk of
Mortality score or cardiac severity score. CVC colonization occurred in 21
control patients (29%) and 11 (14.8%) study patients (P = 0.0446; relative risk,
0.6166; 95% confidence interval, 0.3716-1.023). Bloodstream infection occurred in
3 patients (4.2%) in the control group and 4 patients (5.4%) in the study group.
Local redness was noted in 1 control patient and 4 study group patients.
CONCLUSIONS: The chlorhexidine gluconate-impregnated sponge is safe and
significantly reduces the rates of CVC colonization in infants and children after
cardiac surgery.
Publication Types:
Clinical Trial
Randomized Controlled Trial
PMID: 16094219 [PubMed - indexed for MEDLINE]
36: J Hosp Infect. 2005 Oct;61(2):139-45.
Impact of central venous catheter type and methods on catheter-related
colonization and bacteraemia.
Moretti EW, Ofstead CL, Kristy RM, Wetzler HP.
Department of Anesthesiology, Duke University Medical Center, P.O. Box 3094 DUMC,
Erwin Road, Durham, NC 27710, USA. [email protected]
A prospective, randomized, controlled, multi-centre clinical trial was performed
to test the effectiveness of an antimicrobial central venous catheter (CVC) made
of polyurethane integrated with silver, platinum and carbon black (Vantex).
Adults expected to require a CVC for more than 60 h were eligible, and were
randomized to receive the test or control catheter. All CVCs were inserted with
new venipunctures using full aseptic technique. Following catheter removal, the
distal tip and an intracutaneous segment were removed and cultured using
semiquantitative and quantitative methods. Peripheral blood samples were obtained
and cultured to confirm cases of catheter-related bloodstream infection (CRBSI).
Bacterial and fungal organisms were identified by standard microbiological
methods. Catheter placement was performed primarily in the intensive care unit
(50%) or operating theatre (42%). Complete data could be evaluated for 539
patients (77%). The mean duration of CVC placement was 149.3h (six days). There
were no significant differences in colonization or bacteraemia rates between the
test and control catheters. The overall colonization rate was not particularly
low (24.5%), and yet CVC-related bacteraemia occurred in only 1.4% of patients,
and CRBSI occurred in only one patient from the control group (0.2%). Insertion
site and dressing change frequency were significantly associated with the
colonization rate. Although CVCs with antimicrobial features have been associated
with a decrease in catheter-related colonization and bacteraemia, this study
demonstrated that infection rates may depend more on non-catheter-related
factors, such as adherence to infection control standards, selection of insertion
site, duration of CVC placement, and dressing change frequency. As microbial
resistance increases, clinicians should make maximal use of these processes to
reduce catheter-related infections.
Publication Types:
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
PMID: 16026898 [PubMed - indexed for MEDLINE]
37: Pediatrics. 2005 Jun;115(6):1602-6.
Evaluation of a unique, nurse-inserted, peripherally inserted central catheter
program.
Gamulka B, Mendoza C, Connolly B.
Vascular Access Program, Hospital for Sick Children, Toronto, Ontario, Canada.
[email protected]
BACKGROUND: Concerns regarding the safety and success of peripherally inserted
central catheters (PICCs) placed at the bedside in the pediatric population
initially precluded the development of a nurse-inserted PICC program at our
pediatric center. Previously, all PICCs were inserted by interventional
radiologists (IRs) with fluoroscopic guidance. A new nurse-inserted PICC program
was initiated with collaboration between PICC nurses and IRs. METHODS: Three
nurses participated in the project. Patients who met preestablished selection
criteria were approached. All insertions were performed with sterile technique on
the fluoroscopy table, with IRs available to support the PICC nurse. Veins were
accessed visually or through palpation. Final tip position was confirmed in all
cases with contrast material administration and fluoroscopy. Additional
fluoroscopy was performed only if placement difficulties were encountered. All
patients were monitored prospectively. RESULTS: Ninety-nine patients (age: 3-18
years; average age: 13.6 years) met the selection criteria. Two patients
underwent primary insertion by an IR. The remaining 97 patients underwent an
insertion attempt by a nurse. Sixty-nine PICCs (71.1%) were placed successfully
by a nurse, 15 (15.5%) required minor assistance from an IR, and 13 (13.4%) were
inserted by an IR after an unsuccessful nurse attempt. No insertion complications
were noted. Insertion difficulties included difficulty advancing the catheter
(19.6%), difficulty cannulating the vein (6.2%), and tip malposition (2.1%).
Postinsertion complications occurred for 27.8% of PICCs, and 13.4% required
removal before the end of therapy. CONCLUSION: This novel, pediatric
nurse-inserted PICC program has a good safety profile, high success rate, and low
postprocedural complication rate.
Publication Types:
Evaluation Studies
Research Support, Non-U.S. Gov't
PMID: 15930222 [PubMed - indexed for MEDLINE]
38: Pediatrics. 2005 Jun;115(6):1513-8.
Is bloodstream infection preventable among premature infants? A tale of two
cities.
Aly H, Herson V, Duncan A, Herr J, Bender J, Patel K, El-Mohandes AA.
Department of Newborn Services, George Washington University Hospital, 900 23rd
St NW, Suite G2092, Washington, DC 20037, USA. [email protected]
BACKGROUND: Bloodstream infection (BSI) is a significant cause of morbidity and
death encountered in the NICU. The rates of BSIs vary significantly in NICUs
across the nation. However, no attempt has been made to correlate this variation
with specific infection-control practices and policies. We experienced a
significant increase in BSIs in the NICU at the George Washington University
Hospital and were seeking additional precautionary measures to reduce BSI rates.
Our objective was to review policies and practices associated with lower
infection rates nationally and to test their reproducibility in our unit. DESIGN
AND METHODS: Data on BSI rates in 16 NICUs were reviewed. The BSI rate at
Connecticut Children's Medical Center (CCMC) was the lowest among those reviewed.
A team from George Washington University Hospital conducted a site visit to CCMC
to examine their practices. Differences in the aseptic precautions used for
intravenous line management were noted at CCMC, where a closed medication system
is used. This system was applied at George Washington University Hospital
starting January 1, 2001. Infection rates among low birth weight infants (<2500
g) at George Washington University Hospital in the period from January 1998 to
December 2000 (group 1) were compared with those in the period from January 2001
to December 2003 (group 2). Comparisons between the 2 cohorts were made with
Fisher's exact test, the Kruskal-Wallis test, and Student's t test. Multivariate
analysis was used to control for differences in birth weight, gestational age,
central line days, and ventilator days. Analyses were repeated for the subgroup
of very low birth weight infants (<1500 g). RESULTS: A total of 536 inborn low
birth weight infants were included in this retrospective study (group 1, N = 169
infants; group 2, N = 367). The incidence of sepsis decreased significantly from
group 1 to group 2 (25.4% and 2.2%, respectively). The reduction of sepsis
observed in association with the new practice was statistically significant after
controlling for birth weight, central line days, and ventilator days in a
multiple regression model (regression coefficient: 0.95 +/- 0.29). The odds ratio
of reduction in sepsis after implementation of the new practice was 2.6 (95%
confidence interval: 1.5-4.5). The central line-related BSI rate decreased from
15.17 infections per 1000 line days to 2.1 infections per 1000 line days. The
study included 233 very low birth weight infants, ie, 90 in group 1 and 143 in
group 2. The rate of BSIs decreased significantly from group 1 to group 2 (46.7%
and 5.6%, respectively). The decrease in sepsis rate remained significant in a
multiple regression model (regression coefficient: 1.42 +/- 0.35). The odds ratio
of decreased sepsis in relation to the new policy application among the very low
birth weight infants was 4.15 (95% confidence interval: 2.1-8.3). CONCLUSION:
Applying the closed medication system was associated with reduced BSI rates in
our unit. This protocol was easily reproducible in our environment and showed
immediate results. Serious attempts to share data can potentially optimize
outcomes and standardize policies and practices among NICUs.
Publication Types:
Comparative Study
PMID: 15930211 [PubMed - indexed for MEDLINE]
39: AACN Clin Issues. 2005 Apr-Jun;16(2):185-98; quiz 272-4.
Pediatric catheter-related bloodstream infections: latest strategies to decrease
risk.
Kline AM.
Department of Pediatric Critical Care, Children's Memorial Hospital, Chicago, IL
60614, USA.
Central venous catheters are often mandatory devices when caring for critically
ill children. They are required to deliver medications, nutrition, and blood
products, as well as for monitoring hemodynamic status and drawing laboratory
samples. Any foreign object that is introduced to the body is at risk for
infection. Central venous catheters carry a particularly high risk of infection
and these infections can be life threatening. Advanced practice nurses possess
the power to influence catheter-related line infections in their critical care
units. Understanding current recommendations for catheter material selection,
site selection, site preparation, and site care can affect rates of
catheter-related bloodstream infections. This article discusses risk factors for
developing catheter-related bloodstream infections in critically ill children, as
well as measures to decrease incidence of catheter-related bloodstream
infections, including a review of recommendations from the Centers for Disease
Control and Prevention.
Publication Types:
Review
PMID: 15876887 [PubMed - indexed for MEDLINE]
40: Neurosurgery. 2005 May;56(5):E1161; discussion E1161.
Erratum in:
Neurosurgery. 2005 Jul;57(1):180.
Near-miss injection of an anesthetic agent into a cerebrospinal fluid external
ventricular drain: special report.
Drake JM, Crawford MW.
Division of Neurosurgery, Hospital for Sick Children, University of Toronto,
Toronto, Ontario, Canada. [email protected]
OBJECTIVE AND IMPORTANCE: Human error has been increasingly recognized as a cause
of patient morbidity and mortality. One method of error prevention is the
reporting of a near-miss event. We report that intravenous anesthetic agents were
nearly injected into the external ventricular drainage (EVD) of a patient during
an emergency shunt procedure. CLINICAL PRESENTATION: A 3-year-old male patient
with multiple cerebrospinal fluid shunts and shunt infection had an external
ventricular drain catheter tunneled to exit just inferior to the left clavicle
during a previous procedure. The exit site was covered by an occlusive dressing.
This particular system, the Codman external drainage system II collection bag and
tubing set (Codman & Shurtleff, Inc., Raynham, MA), contains two access ports (a
three-way stoppered port and an angled rubber stoppered injection port). At
induction of anesthesia, the EVD system was mistaken for a central venous line
and was nearly injected with propofol and rocuronium. Fortunately, the error was
quickly recognized and the patient came to no harm. INTERVENTION AND TECHNIQUE: A
modified EVD system has recently been released that does not include the
three-way port, and features an embedded bright green stripe in the tubing to
distinguish it from intravenous tubing. CONCLUSION: We recommend using caution
when tunneling EVDs to sites that might be confused with central venous access
sites. EVD system tubing should be designed so it can be easily distinguished
from intravenous tubing, and it should be clearly labeled as an EVD line.
Publication Types:
Case Reports
PMID: 15854270 [PubMed - indexed for MEDLINE]
41: Minerva Anestesiol. 2005 May;71(5):197-206.
Effect of different sterile barrier precautions and central venous catheter
dressing on the skin colonization around the insertion site.
[Article in English, Italian]
Carrer S, Bocchi A, Bortolotti M, Braga N, Gilli G, Candini M, Tartari S.
Anesthesia and Resuscitation Unit, San Luca Hospital, 45027 Trecenta, (Rovigo),
Italy.
AIM: The purpose of this prospective, randomized, controlled study was the
comparison of maximal sterile barrier (consisting of mask, cap, sterile gloves,
gown, large drape) vs control precautions (mask, cap, sterile gloves, small
drape) and of transparent polyurethan film vs gauze dressing for use on central
venous (CVC) nontunneled catheters, inserted via the jugular vein. Skin
colonization at the insertion site (defined by quantitative skin cultures
performed at the time of insertion and in days 2 and 5) was used as a primary
endpoint. Catheter tip colonization was also assessed through qualitative culture
and CVC related sepsis was defined by the isolation of the same organism from the
catheter tip and the blood, with clinical sepsis of no other apparent source.
METHODS: Eighty-two consecutive patients were enrolled, admitted to a mixed
medical-surgical ICU, aged 72+/-12 years, 58% male, SAPS II 42+/-13. One-hundred
and seven CVCs were studied (presenting 750 catheter in situ days); CVCs were in
place for a mean period of 6.9+/-4.7 days and 5 episodes of central
catheter-related bloodstream infection were detected (6.6 per 1000 catheter
days). RESULTS: A multiple logistic regression detected an increased risk of skin
colonization in male gender (OR=2.5) and control precautions (OR=3.4) and no
difference with regard to age, dressing and diagnostic group. CONCLUSIONS:
Maximal sterile barrier proved to be an effective and recommended practice.
However surveillance skin cultures revealed the common and changing nature of
colonization of skin at the insertion site.
Publication Types:
Clinical Trial
Randomized Controlled Trial
PMID: 15834348 [PubMed - indexed for MEDLINE]
42: J Pediatr Surg. 2005 Mar;40(3):523-7.
Gastroschisis: ward reduction compared with traditional reduction under general
anesthesia.
Davies MW, Kimble RM, Cartwright DW.
Grantley Stable Neonatal Unit, Royal Women's Hospital, Brisbane, Queensland,
4029, Australia. [email protected]
BACKGROUND/PURPOSE: In gastroschisis it is proposed that gut reduction may be
achieved without intubation or general anesthesia (GA) through ward reduction.
The authors aimed to determine if ward reduction decreased morbidity and duration
of treatment. METHODS: Infants born from January 1, 1995, to December 31, 2001,
with gastroschisis were managed with either reduction under GA in the operating
theatre (OT group)--up to September 1999, or ward reduction (when eligible) in
the neonatal unit without GA/ventilation (ward reduction [WR] group)--from
September 1999. RESULTS: Of the 37 infants, 31 were eligible for ward
reduction-15 from the OT group, 16 from the WR group. All infants in the OT group
had at least 1 episode of ventilation and 1 GA: 62% of infants in the WR group
avoided ventilation (P = .0002) and 81% avoided GA (P < .0001). Infants who had
ward reduction had significantly shorter durations of ventilation and oxygen
therapy. Septicemia occurred in 31% of the WR group and 7% of the OT group (P =
.17). Infants who had ward reduction left intensive care 16 days earlier (P =
.02) and tended to reach full enteral feeds 8 days sooner (P = .06) and be
discharged from hospital 15 days earlier (P = .05). CONCLUSIONS: Infants who had
ward reduction do better in terms of avoiding GA/ventilation, establishing feeds,
and going home earlier. A randomized, controlled trial comparing the 2 approaches
is feasible, safe, and worthwhile.
Publication Types:
Comparative Study
Evaluation Studies
PMID: 15793729 [PubMed - indexed for MEDLINE]
43: J Am Soc Nephrol. 2005 May;16(5):1456-62. Epub 2005 Mar 23.
Randomized, controlled trial of topical exit-site application of honey
(Medihoney) versus mupirocin for the prevention of catheter-associated infections
in hemodialysis patients.
Johnson DW, van Eps C, Mudge DW, Wiggins KJ, Armstrong K, Hawley CM, Campbell SB,
Isbel NM, Nimmo GR, Gibbs H.
Department of Renal Medicine, Level 2, Ambulatory Renal and Transplant Services
Building, University of Queensland at Princess Alexandra Hospital, Ipswich Road,
Woolloongabba, Brisbane, Queensland 4102, Australia.
[email protected]
The clinical usefulness of hemodialysis catheters is limited by increased
infectious morbidity and mortality. Topical antiseptic agents, such as mupirocin,
are effective at reducing this risk but have been reported to select for
antibiotic-resistant strains. The aim of the present study was to determine the
efficacy and the safety of exit-site application of a standardized antibacterial
honey versus mupirocin in preventing catheter-associated infections. A
randomized, controlled trial was performed comparing the effect of thrice-weekly
exit-site application of Medihoney versus mupirocin on infection rates in
patients who were receiving hemodialysis via tunneled, cuffed central venous
catheters. A total of 101 patients were enrolled. The incidences of
catheter-associated bacteremias in honey-treated (n = 51) and mupirocin-treated
(n = 50) patients were comparable (0.97 versus 0.85 episodes per 1000
catheter-days, respectively; NS). On Cox proportional hazards model analysis, the
use of honey was not significantly associated with bacteremia-free survival
(unadjusted hazard ratio, 0.94; 95% confidence interval, 0.27 to 3.24; P = 0.92).
No exit-site infections occurred. During the study period, 2% of staphylococcal
isolates within the hospital were mupirocin resistant. Thrice-weekly application
of standardized antibacterial honey to hemodialysis catheter exit sites was safe,
cheap, and effective and resulted in a comparable rate of catheter-associated
infection to that obtained with mupirocin (although the study was not adequately
powered to assess therapeutic equivalence). The effectiveness of honey against
antibiotic-resistant microorganisms and its low likelihood of selecting for
further resistant strains suggest that this agent may represent a satisfactory
alternative means of chemoprophylaxis in patients with central venous catheters.
Publication Types:
Clinical Trial
Comparative Study
Randomized Controlled Trial
PMID: 15788475 [PubMed - indexed for MEDLINE]
44: Intensive Crit Care Nurs. 2005 Apr;21(2):99-109. Epub 2004 Dec 8.
Infection control issues in central venous catheter care.
Theaker C.
Nursing Research Unit, Department of Nursing and Quality, 3rd Floor Britten Wing,
Royal Brompton and Harefield NHS Trust, Sydney Street, London SW3 6NP, UK.
[email protected]
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.
Publication Types:
Review
PMID: 15778074 [PubMed - indexed for MEDLINE]
45: Am J Infect Control. 2005 Mar;33(2):83-7.
Impact of an educational program and policy changes on decreasing
catheter-associated bloodstream infections in a medical intensive care unit in
Brazil.
Lobo RD, Levin AS, Gomes LM, Cursino R, Park M, Figueiredo VB, Taniguchi L,
Polido CG, Costa SF.
Infection Control Hospital Committee, Hospital das Clínicas, Department of
Infectious Diseases, University of São Paulo, Brazil.
BACKGROUND: Central venous catheter-associated bloodstream infections (CVC-BSI)
are a frequent cause of morbidity and mortality in intensive care settings. Many
strategies have been used to decrease the risk of CVC-BSI; however, few studies
have explored the educational intervention as an approach to reduce the CVC-BSI
rates. OBJECTIVE: The purpose of this study was to determine the impact of an
educational program targeted to specific points observed during CVC care
practices on decreasing CVC-BSI in a medical intensive care unit. METHODS: An
educational program was developed by a multidisciplinary task force to highlight
correct practices for CVC care. Relative risk ratios, 95% confidence intervals,
and P values were determined for all primary and secondary outcomes. The chi 2
linear test for trends of CVC-BSI rates was performed during the study period and
the following year. RESULTS: Forty-eight primary bloodstream infections occurred
in 2450 catheter-days (20 per 1000 catheter-days) in the 16 months before the
intervention. After the educational intervention and policy changes such as
standardized povidone-iodine use during dressing care, the number of CVC-BSI
dropped to 16 in 1381 catheter-days (11 per 1000 catheter-days), a decrease of
40%. The rate of CVC-BSI remained almost the same, 22 in 1701 catheter-days (12
per 1000 catheter-days), during the following year after the educational
intervention (P = .07). The distribution of pathogens was different comparing the
pre- and postintervention period. Staphylococcus aureus was the most common
pathogen in preintervention, decreasing significantly during the study period (P
= .02). The adhesion to the overall catheter care policy improved significantly
in the postintervention period (P < .01). CONCLUSION: A multiple approach
included an educational strategy, targeted to specific problems observed during a
careful evaluation of CVC care practices, and policy changes can decrease rates
of CVC-BSI. However, despite the good results, our rates are still high, and
reinforcement of CVC care practices will be continued.
Publication Types:
Evaluation Studies
PMID: 15761407 [PubMed - indexed for MEDLINE]
46: J Adv Nurs. 2004 Nov;48(3):247-56.
Central venous catheters: a survey of ICU practices.
Rickard CM, Courtney M, Webster J.
School of Nursing, Queensland University of Technology, Brisbane, Queensland,
Australia. [email protected]
AIM: This paper describes the current infection control practices for CVC care
and compares these to evidence-based practice guidelines. BACKGROUND: Intensive
care patients with central venous catheters (CVCs) are at risk of
catheter-related infection, which increases morbidity, mortality and health care
costs. Infection control practices, including care of intravenous administration
sets and catheter sites, are undertaken by nurses in an attempt to avoid
infection. Although practice guidelines are available, infection control
practices may vary between practitioners and institutions; however, current
practice has not been formally surveyed. METHOD: A prospective, cross-sectional
descriptive survey was carried out. Intensive care units (n = 14) in Australia
were surveyed about their infection control policies for CVC care. Results were
tabulated and compared with evidence-based practice guidelines. RESULTS: A wide
variety of responses was received about duration of administration set use for
standard, parenteral nutrition and propofol (lipid-based anaesthetic) infusions;
ad hoc administration set connection technique; dressing frequency, materials and
solutions; and barrier precautions used during procedures. There was inconsistent
adherence to the guidelines. CONCLUSION: There is variation in the infection
control approach to CVC care. Greater adherence to existing Centers for Disease
Control Guidelines would assist in the standardization of best practice and
facilitate evidence-based care.
Publication Types:
Multicenter Study
PMID: 15488038 [PubMed - indexed for MEDLINE]
47: Infect Control Hosp Epidemiol. 2004 Aug;25(8):696-8.
Povidone-iodine ointment and gauze dressings associated with reduced
catheter-related infection in seriously ill neurosurgical patients.
Fukunaga A, Naritaka H, Fukaya R, Tabuse M, Nakamura T.
Department of Neurosurgery, Saiseikai Kanagawaken Hospital, Yokohama City, Japan.
Povidone-iodine ointment and gauze covered by transparent dressings were compared
with transparent dressings alone in historical controls (both changed twice
weekly) in neurosurgical patients needing catheter placement for prolonged
periods. Colonization and bloodstream infection were both reduced with the new
method (P < .01 and P = .062, respectively).
Publication Types:
Clinical Trial
Comparative Study
Controlled Clinical Trial
PMID: 15357164 [PubMed - indexed for MEDLINE]
48: Infect Control Hosp Epidemiol. 2004 Aug;25(8):668-74.
Cost-benefit analysis of chlorhexidine gluconate dressing in the prevention of
catheter-related bloodstream infections.
Crawford AG, Fuhr JP Jr, Rao B.
Department of Health Policy, Jefferson Medical College, Suite 115, 1015 Walnut
Street, Philadelphia, PA 19107, USA.
OBJECTIVES: To compare the costs with the benefits of using chlorhexidine
gluconate dressings on central venous catheters and to determine the
effectiveness of these dressings in reducing local infections and
catheter-related bloodstream infections (CRBSIs), costs, and mortality. DESIGN:
Cost-benefit analysis using randomized, controlled trial data on chlorhexidine
dressing prevention of local infection and CRBSI, data on cost of chlorhexidine
dressing versus standard treatment, data on averted cost of treating local
infection and CRBSI, and data on mortality attributable to CRBSI. Decision
analysis evaluated averted CRBSI treatment cost per patient resulting from
chlorhexidine dressing use. Sensitivity analyses demonstrated net benefit of
chlorhexidine dressing, varying baseline rate of CRBSI, incremental cost of
treating CRBSI, and number of catheters, and evaluated mortality preventable
through chlorhexidine dressing use, varying baseline rate of CRBSI, number of
catheters, and mortality attributable to CRBSI. PATIENTS AND SETTING: Patients of
all Philadelphia area hospitals and one Philadelphia academic medical center.
RESULTS: Estimated potential annual U.S. net benefits from chlorhexidine dressing
use ranged from $275 million to approximately $1.97 billion. Cost-benefit
findings persisted in sensitivity analyses varying baseline rate of CRBSI,
incremental cost of treating CRBSI, and overall number of catheters used.
Preventable mortality analyses showed potential decreases of between 329 and
3,906 U.S. deaths annually as a result of nationwide use of chlorhexidine
dressing. CONCLUSIONS: Chlorhexidine dressings would reduce costs, local
infections and CRBSIs, and deaths. Use of chlorhexidine dressings should be
considered to prevent infections among patients with catheters.
Publication Types:
Clinical Trial
Comparative Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
PMID: 15357159 [PubMed - indexed for MEDLINE]
49: Infect Control Hosp Epidemiol. 2004 Aug;25(8):641-5.
Candida parapsilosis bloodstream infection in pediatric oncology patients:
results of an epidemiologic investigation.
Posteraro B, Bruno S, Boccia S, Ruggiero A, Sanguinetti M, Romano Spica V,
Ricciardi G, Fadda G.
Institute of Microbiology, Largo F Vito, 1-00168 Rome, Italy.
OBJECTIVE: To investigate an outbreak of Candida parapsilosis bloodstream
infections (BSIs) involving three patients admitted to a pediatric oncology unit
between April and June 2002. METHODS: After the third case was documented,
cultures were performed of the hands of all medical and paramedical staff members
in the pediatric oncology unit and of environmental surfaces in the rooms
occupied by the three patients. Electrophoretic karyotyping with pulsed-field gel
electrophoresis and arbitrarily primed polymerase chain reaction were used to
assess the genetic relatedness among C. parapsilosis isolates. RESULTS: The three
cases of C. parapsilosis BSI were diagnosed based on blood cultures performed
during a 38-day period. Evidence of prior C parapsilosis colonization of the
gastrointestinal tract was present in only the first case. Each patient had an
indwelling central venous catheter (CVC), which was promptly removed, and
semiquantitative catheter tip cultures also revealed C. parapsilosis. None of the
30 environmental cultures performed was positive for C. parapsilosis, but the
fungus was isolated from the hands of 6 of the 20 nurses tested. Both molecular
typing methods revealed identical DNA fingerprinting patterns for all 13 patient
isolates (7 from blood, 3 from CVC tips, and 3 from the gastrointestinal tract)
and for 5 of the 6 recovered from the nurses' hands. CONCLUSIONS: These findings
suggest the possibility of cross-infection with a single C. parapsilosis strain
that was transmitted (probably during CVC dressing changes) by nurses whose hands
were colonized with it. The role of previous gastrointestinal colonization in the
first case cannot be excluded.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 15357154 [PubMed - indexed for MEDLINE]
50: Chest. 2004 Jul;126(1):90-4.
Micrococcus-associated central venous catheter infection in patients with
pulmonary arterial hypertension.
Oudiz RJ, Widlitz A, Beckmann XJ, Camanga D, Alfie J, Brundage BH, Barst RJ.
Division of Cardiology, Research & Education Institute, Harbor-UCLA Medical
Center, Torrance, CA 90502, USA. [email protected]
STUDY OBJECTIVES: To determine the incidence of catheter-related infection in
patients with pulmonary arterial hypertension (PAH) receiving epoprostenol (EPO),
and to note an etiologic role for Micrococcus spp, which is rarely reported as a
pathogen in the medical literature. DESIGN: Observational study. SETTING: Two PAH
specialty treatment centers, Harbor-UCLA Medical Center (Torrance, CA), and the
College of Physicians and Surgeons, Columbia University (New York, NY). PATIENTS:
A total of 192 patients with PAH receiving continuous therapy with IV EPO.
INTERVENTIONS: From 1987 to 2000, 192 patients with PAH received infusions of EPO
via central venous catheter. Catheter care included regular dressing changes with
dry gauze using a sterile procedure, without the use of flushes. Patients were
asked to report on known infections and treatments, and symptoms. All infections
were verified by a telephone call to the patient, care provider, and microbiology
laboratory whenever possible. MEASUREMENTS AND RESULTS: There were 335,285
catheter days (mean +/- SD, 1,325 +/- 974 catheter days). There were 88 clinical
catheter infections with 51 blood culture-positive infections, necessitating
catheter removal in 38 instances. The following pathogens were isolated:
Staphylococcus aureus (25); Micrococcus spp (14); mixed flora (3);
coagulase-negative Staphylococcus spp (2); Corynebacterium spp (2); Serratia
marcessens (1); Enterobacter spp (1); Pseudomonas aeruginosa (1); enterococci
(1); and unidentified Gram-positive cocci (1). The catheter infection rate was
0.26 per 1,000 catheter days. CONCLUSIONS: The use of long-term therapy with
continuous EPO appears to be associated with a low incidence of catheter-related
infections. Micrococcus spp were the second most common etiologic agent.
Caregivers managing patients with PAH must be aware of the risk of catheter
infection, as it may contribute to the morbidity and mortality associated with
the use of EPO. When isolated, Micrococcus spp should not be viewed as a
contaminant, but rather as a true pathogen that may require therapeutic
intervention.
PMID: 15249447 [PubMed - indexed for MEDLINE]
51: Am J Infect Control. 2004 May;32(3):142-6.
Using maximal sterile barriers to prevent central venous catheter-related
infection: a systematic evidence-based review.
Hu KK, Lipsky BA, Veenstra DL, Saint S.
Northwest Health Services Research and Development Program, Department of
Medicine, University of Washington and VA Puget Sound HCS, 1660 South Columbian
Way, HSR&D (152), Seattle, WA 98108, USA.
BACKGROUND: Catheter-related infections cause increased morbidity, mortality, and
health care costs. Infection control experts advocate using maximal sterile
barriers to reduce the incidence of these infections. Low compliance rates
suggest that clinicians are not convinced or are not aware that available data
support adopting this more cumbersome, time-consuming, and relatively more
expensive technique. Accordingly, we conducted a systematic, evidence-based
review of the medical literature to determine the value of maximal sterile
barriers. DATA SOURCES: We used multiple computerized databases, reference lists
of identified articles, and queries of prominent investigators. STUDY SELECTION:
We selected studies comparing infectious outcomes using maximal sterile barriers
versus using less stringent sterile barrier techniques during central venous
catheter insertion. DATA SYNTHESIS: We found only 3 primary research studies.
Although each study suggests maximal sterile barriers may reduce infectious
complications, the evidence supporting this conclusion is incomplete. The only
randomized controlled trial limited enrollment to ambulatory oncology patients.
These 3 studies differed notably in their patient populations, research designs,
and health care settings. CONCLUSION: The medical literature suggests maximal
sterile barriers are advantageous in at least one setting and may be useful in
others. While we believe the available evidence does support the use of maximal
sterile barriers during routine insertion of central venous catheters,
prospective studies and economic analyses would better clarify its value.
Publication Types:
Research Support, U.S. Gov't, Non-P.H.S.
Research Support, U.S. Gov't, P.H.S.
Review
PMID: 15153925 [PubMed - indexed for MEDLINE]
52: Crit Care. 2004 Jun;8(3):157-62. Epub 2003 Sep 29.
Clinical review: new technologies for prevention of intravascular
catheter-related infections.
Cicalini S, Palmieri F, Petrosillo N.
2nd Infectious Diseases Unit, Istituto Nazionale per le Malattie Infettive
Lazzaro Spallanzani, IRCCS, Rome, Italy. [email protected]
Intravascular catheters have become essential devices for the management of
critically and chronically ill patients. However, their use is often associated
with serious infectious complications, mostly catheter-related bloodstream
infection (CRBSI), resulting in significant morbidity, increased duration of
hospitalization, and additional medical costs. The majority of CRBSIs are
associated with central venous catheters (CVCs), and the relative risk for CRBSI
is significantly greater with CVCs than with peripheral venous catheters.
However, most CVC-related infections are preventable, and different measures have
been implemented to reduce the risk for CRBSI, including maximal barrier
precautions during catheter insertion, catheter site maintenance, and hub
handling. The focus of the present review is on new technologies for preventing
infections that are directed at CVCs. New preventive strategies that have been
shown to be effective in reducing risk for CRBSI, including the use of catheters
and dressings impregnated with antiseptics or antibiotics, the use of new hub
models, and the use of antibiotic lock solutions, are briefly described.
Publication Types:
Research Support, Non-U.S. Gov't
Review
PMID: 15153233 [PubMed - indexed for MEDLINE]
53: Infect Control Hosp Epidemiol. 2004 Mar;25(3):266-8.
Unnecessary use of central venous catheters: the need to look outside the
intensive care unit.
Trick WE, Vernon MO, Welbel SF, Wisniewski MF, Jernigan JA, Weinstein RA.
Division of Healthcare Quality Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia, USA.
We developed criteria for justifiable CVC use and evaluated CVC use in a public
hospital. Unjustified CVC-days were more common for non-ICU patients compared
with ICU patients. Also, insertion-site dressings were less likely to be intact
on non-ICU patients. Interventions to reduce CVC-associated bloodstream
infections should include non-ICU patients.
Publication Types:
Evaluation Studies
Research Support, U.S. Gov't, P.H.S.
PMID: 15061422 [PubMed - indexed for MEDLINE]
54: Arch Surg. 2004 Feb;139(2):131-6.
The impact of bedside behavior on catheter-related bacteremia in the intensive
care unit.
Coopersmith CM, Zack JE, Ward MR, Sona CS, Schallom ME, Everett SJ, Huey WY,
Garrison TM, McDonald J, Buchman TG, Boyle WA, Fraser VJ, Polish LB.
Department of Surgery, Washington University School of Medicine, St Louis, MO,
USA. [email protected]
HYPOTHESIS: The success of an educational program in July 1999 that lowered the
catheter-related bloodstream infection (CRBSI) rate in our intensive care unit
(ICU) 3-fold is correlated with compliance with "best-practice" behaviors.
DESIGN: Before-after trial. SETTING: Surgical ICU in a referral hospital.
PATIENTS: A random sample underwent bedside audits of central venous catheter
care (n = 187). All ICU admissions during a 39-month period (N = 4489) were
prospectively followed for bacteremia. INTERVENTIONS: On the basis of audit
results in December 2000, a behavioral intervention was designed to improve
compliance with evidenced-based guidelines of central venous catheter management.
MAIN OUTCOME MEASURES: Compliance with practices known to decrease CRBSI.
Secondary outcome was CRBSI rate on all ICU patients. RESULTS: Multiple
deficiencies were identified on bedside audits 18 months after the previous
educational program. After the implementation of a separate behavioral
intervention in July 2001, a second set of bedside audits in December 2001
demonstrated improvements in documenting the dressing date (11% to 21%; P<.001)
and stopcock use (70% to 24%; P<.001), whereas nonsignificant trends were
observed in hand hygiene (17% to 30%; P>.99) and maximal sterile barrier
precautions (50% to 80%; P =.29). Appropriate practice was observed before and
after the behavioral intervention in catheter site placement, dressing type,
absence of antibiotic ointment, and proper securing of central venous catheters.
Thirty-two CRBSIs occurred in 9353 catheter-days 24 months before the behavioral
intervention compared with 17 CRBSIs in 6152 catheter-days during the 15 months
after the intervention (3.4/1000 to 2.8/1000 catheter-days; P =.40). CONCLUSIONS:
Although a previous educational program decreased the CRBSI rate, this was
associated with only modest compliance with best practice principles when bedside
audits were performed 18 months later. A behavioral intervention improved all
identified deficiencies, leading to a nonsignificant decrease in CRBSIs.
Publication Types:
Comparative Study
Evaluation Studies
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.
PMID: 14769568 [PubMed - indexed for MEDLINE]
55: J Infus Nurs. 2004 Jan-Feb;27(1):37-44.
Evaluation of a no-dressing intervention for tunneled central venous catheter
exit sites.
Olson K, Rennie RP, Hanson J, Ryan M, Gilpin J, Falsetti M, Heffner T, Gaudet S.
Cross Cancer Institute, Edmonton, Alberta. [email protected]
This study tested whether central venous catheter (CVC)-related sepsis could be
reduced by removing a hypothesized reservoir for pathogens, the CVC exit site
dressing. Seventy-eight individuals with cancer, stratified for gender (37 men
and 41 women) and transplant status, with newly inserted CVCs were recruited and
randomly assigned to receive either a gauze dressing or no dressing, once their
catheter insertion site had healed (3 weeks). Because there was no difference in
CVC-related septic episodes based on gender or transplant status, the
stratification was not maintained for remaining analyses. Although there was no
significant difference in CVC-related septic episodes (P =.28) or
rehospitalization rates (P =.41) because of CVC-related sepsis between the
dressing and no-dressing group, individuals in the dressing group developed
CVC-related sepsis sooner (P =.02) than did individuals in the no-dressing group.
Publication Types:
Clinical Trial
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
PMID: 14734986 [PubMed - indexed for MEDLINE]
56: J Vasc Surg. 2004 Jan;39(1):73-8.
Management of infected prosthetic dialysis arteriovenous grafts.
Ryan SV, Calligaro KD, Scharff J, Dougherty MJ.
Section of Vascular Surgery, Pennsylvania Hospital, 700 Spruce Street,
Philadelphia, PA 19106, USA.
BACKGROUND: Hemodialysis access is one of the most common vascular procedures
that is performed by vascular and general surgeons. Prosthetic arteriovenous
graft (AVG) infections pose potentially life-threatening septic and bleeding
complications, as well as loss of dialysis access. Strategies employed to
preserve some grafts, prevent morbidity in those with major infections, and
maintain access are presented. METHODS: Between July 1, 1995 and August 1, 2002,
1441 AVG procedures were performed at a single institution. Fifty-one (3.5%)
prosthetic AVG infections in 45 patients were identified. Twenty-seven graft
infections occurred at a prior incision for placement or revision of a graft. The
other 24 infections were located within the body of the graft, and 14 of these
were documented to be at a recent puncture site for hemodialysis access. The most
common presentation (47% [24/51]) was an exposed graft or a draining sinus tract.
Management included total graft excision (TGE) when patients presented with
sepsis or the entire graft was bathed in pus; subtotal graft excision (SGE), when
all of the graft was removed except an oversewn small cuff of prosthetic material
on an underlying patent artery; and partial graft excision (PGE), when only a
limited infected portion of the graft was removed and a new graft was rerouted
through adjacent sterile tissue to maintain patency of the original graft.
RESULTS: None of the 45 patients died or developed hand ischemia. A uniformly
successful outcome was achieved in all patients who were treated with TGE (13/13:
8 vein patches, 4 primary closure, 1 arterial ligation) or SGE (15/15). However,
these treatments necessitated placement of a central venous catheter for
temporary dialysis access and a new AVG later. All of these 28 wounds healed by
secondary intention, including all 15 cases in which an oversewn cuff of
prosthetic material remained. Graft patency and wound healing were achieved in
74% (17/23) of infections treated with PGE, and placement of a temporary dialysis
access catheter and new AVG were avoided. The 6 failures of PGE ultimately
required TGE because of nonhealing wounds, but there were no acute hemorrhagic or
septic events. CONCLUSIONS: Systemic sepsis caused by prosthetic AVG infections
mandates TGE. SGE and PGE can be safely employed in selected patients with
infected prosthetic AVGs. SGE maintains patency of the underlying artery and
avoids a difficult and time-consuming dissection. PGE offers the advantage of
minimizing extensive dissection of well-incorporated uninfected graft segments
and allows continued dialysis access at the incorporated portion of the graft.
PMID: 14718819 [PubMed - indexed for MEDLINE]
57: J Adv Nurs. 2003 Dec;44(6):623-32.
Central venous catheter dressings: a systematic review.
Gillies D, O'Riordan E, Carr D, O'Brien I, Frost J, Gunning R.
Research Development Unit, School of Nursing, Family and Community Health,
University of Western Sydney, Paranatta Campus, Building ER, Penrith South DC,
New South Wales 1797, Australia. [email protected]
BACKGROUND: Gauze and tape or transparent polyurethane film dressings such as
Tegaderm, Opsite or Opsite IV3000 are the most common types of dressing used to
secure central venous catheters (CVCs). Currently, there are no clear guidelines
as to which type of dressing is the most appropriate. AIMS: To identify whether
there are any differences between gauze and tape and/or transparent polyurethane
film dressings in the incidence of CVC-related infection, catheter-related
sepsis, catheter security, tolerance to dressing material, dressing condition and
ease of application in hospitalized patients. METHODS: The Cochrane Controlled
Trials Register and Medline, Embase and CancerLit databases were searched to
identify any controlled trials comparing the effects of gauze and tape and/or
transparent polyurethane dressings on CVCs. Additional references were sought
from published and non-published literature. Twenty-three studies were reviewed.
Data were extracted independently from each paper by two members of the review
team and results compared. Differences were resolved either by consensus or
referral to a third person. Authors were contacted for missing information.
RESULTS: Of the 23 studies reviewed, 15 were excluded. Of the remaining eight,
data were available for meta-analysis from six studies. Of the six included
studies, two compared gauze and tape with Opsite IV3000, two compared Opsite with
Opsite IV3000, one compared Tegaderm with Opsite IV3000, and one compared
Tegaderm with Opsite. CONCLUSIONS: There was no evidence of any difference in the
incidence of infectious complications between any of the dressing types compared
in this review. Each of these comparisons was based on no more than two studies
and all of these studies reported data from a small patient sample. Therefore it
is unlikely that any of these comparisons would have had sufficient power to
detect any differences between groups.
Publication Types:
Meta-Analysis
Review
PMID: 14651685 [PubMed - indexed for MEDLINE]
58: Intensive Care Med. 2004 Jan;30(1):62-7. Epub 2003 Nov 26.
The pathogenesis of catheter-related bloodstream infection with noncuffed
short-term central venous catheters.
Safdar N, Maki DG.
Section of Infectious Diseases, Department of Medicine, Medical School,
University of Wisconsin, Madison, WI 53792, USA.
OBJECTIVE: Short-term, noncuffed, percutaneously inserted central venous
catheters (CVCs) are widely used and cause more than 250,000 bloodstream
infections (BSIs) in hospitals each year in the United States. We report a
prospective study undertaken to determine the pathogenesis of CVC-related BSI.
DESIGN AND SETTING: Prospective cohort study in a university hospital 24-bed
medical-surgical intensive care unit. PATIENTS AND PARTICIPANTS: Patients
participating in two randomized trials during 1998-2000-one studying the efficacy
of a 1% chlorhexidine-75% alcohol solution for cutaneous antisepsis and the other
a novel chlorhexidine-impregnated sponge dressing-formed the study population;
CVC-related BSIs were considered to be extraluminally acquired if concordance was
identified solely between isolates from catheter segments, skin, and blood
cultures and intraluminally acquired if concordance was demonstrated only between
hub or infusate and blood culture isolates, as confirmed by DNA subtyping of
isolates from blood and catheter sites or infusate. RESULTS: Of 1,263 catheters
(6075 CVC days) prospectively studied, 35 (2.7%) caused BSI (5.9 per 1000 CVC
days); 27 were caused by coagulase-negative staphylococci. Overall, 45% of
infections were extraluminally acquired, 26% were intraluminally derived, and the
mechanism of infection was indeterminate in 29%. In the pooled control groups of
the two trials, 25 CVC-related BSIs occurred (7.0 per 1000 CVC days), of which
60% of infections were extraluminally acquired, 12% were intraluminally derived
and 28% were indeterminate. In contrast, CVC-related BSIs in the treatment groups
were most often intraluminally derived (60%, p=0.006). CONCLUSIONS: Most
catheter-related BSIs with short-term percutaneously inserted, noncuffed CVCs
were extraluminally acquired and derived from the cutaneous microflora.
Strategies achieving successful suppression of cutaneous colonization can
substantially reduce the risk of catheter-related BSI with short-term CVCs.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 14647886 [PubMed - indexed for MEDLINE]
59: Cochrane Database Syst Rev. 2003;(4):CD003827.
Gauze and tape and transparent polyurethane dressings for central venous
catheters.
Gillies D, O'Riordan L, Carr D, Frost J, Gunning R, O'Brien I.
School of Nursing, Family and Community Health, College of Social and Health
Sciences, University of Western Sydney,Parramatta Campus, Building ER, Locked Bag
1797, Penrith South DC, New South Wales, Australia, NSW 1797.
[email protected]
BACKGROUND: Central venous catheters facilitate venous access, allowing the
intravenous administration of complex drug treatments, blood products and
nutritional support, without the trauma associated with repeated venepuncture.
However, central venous catheters are associated with a risk of infection. Some
studies have indicated that the type of dressing used for central venous
catheters may affect the risk of infection. Gauze and tape or transparent
polyurethane film dressings such as Tegaderm, Opsite or Opsite IV3000 are the
most common types of dressing used to secure central venous catheters. Currently,
it is not clear which type of dressing is the most appropriate. OBJECTIVES: To
compare gauze and tape and transparent polyurethane central venous catheter
dressings in terms of catheter related infection, catheter security, tolerance to
dressing material and dressing condition in hospitalised adults and children.
SEARCH STRATEGY: The Cochrane Wounds Group Specialised Trials Register (October
2002), the Cochrane Controlled Trials Register (4th Quarter 2002) and the
databases; MEDLINE (1966-December 2002, CINAHL (1982-October 2002) and EMBASE
(1980-December 2002) were searched to identify any randomised controlled trials
comparing the effects of gauze and tape and/or transparent polyurethane dressings
for central venous catheter sites. Additional references were identified from
bibliographies of published literature and were also sought from other sources.
SELECTION CRITERIA: All randomised controlled trials evaluating the effects of
dressing type (i.e. gauze and tape and/or transparent polyurethane dressings) on
central venous catheter related infection, catheter security, tolerance to
dressing material and dressing condition in hospitalised patients. DATA
COLLECTION AND ANALYSIS: Twenty-three studies were reviewed. Data was extracted
from each paper by two members of the review team independently and results then
compared. Differences were resolved either by consensus or by referral to a third
member of the review team. Authors were contacted for missing information. MAIN
RESULTS: Of the 23 studies reviewed, 14 were excluded. Nine studies were
included. Data was only available for meta-analysis from six of the nine included
studies. Of the six included studies with available data, two compared gauze and
tape with Opsite IV3000, two compared Opsite with Opsite IV3000, one compared
gauze and tape with Tegaderm, and one compared Tegaderm with Opsite. There was no
evidence of any difference in the incidence of infectious complications between
any of the dressing types compared in this review. Each of these comparisons was
based on no more than two studies and all of these studies reported data from a
small patient sample. Therefore it is probable that the finding of no difference
between dressing types is due to the lack of adequate data. REVIEWER'S
CONCLUSIONS: There is a high level of uncertainty regarding the risk of infection
with the central venous catheter dressings identified in this review. Therefore,
at this stage it appears that the choice of dressing for central venous catheters
can be based on patient preference. To identify the most appropriate central
venous catheter dressings, further research is necessary. It is paramount that
any future studies investigating this issue must be rigorously performed
randomised controlled trials.
Publication Types:
Meta-Analysis
Review
PMID: 14583995 [PubMed - indexed for MEDLINE]
60: Clin J Oncol Nurs. 2003 May-Jun;7(3):289-98.
Central venous catheter site care for blood and marrow transplant recipients.
Zitella L.
Stanford University Medical Center, 300 Pasteur Drive, H3249, MC5623, Stanford,
CA 94305, USA. [email protected]
Treatment-induced neutropenia, long central venous catheter (CVC) dwell times,
and the use of immunosuppressive agents place blood and marrow transplant
recipients at high risk for CVC infection. The most common causative organisms of
CVC infection are ubiquitous skin flora of hospitalized patients. A great deal of
research on CVC care, including dressing change procedures and frequency, has
been conducted; however, variations in study design, patients studied, and
terminology used to define CVC infection limit the generalizability of the
findings. This article reviews significant studies of CVC care and infection
rates and describes the findings of a survey of CVC care practices of Blood and
Marrow Stem Cell Transplant Special Interest Group members of the Oncology
Nursing Society.
Publication Types:
Review
PMID: 12793335 [PubMed - indexed for MEDLINE]
61: Prof Nurse. 2003 Apr;18(8):441-4.
Reducing the risks of device-related infection caused by staphylococci.
Kiernan M.
Southport and Ormskirk NHS Trust, Southport, Merseyside.
Many patients require the administration of therapy via intravenous lines, which
increases their risk of acquiring an infection in hospital. It it vital for
nurses to be aware of such risks and to minimise them by taking precautions when
inserting and removing i.v. devices, as well as in removing or changing
dressings. Nurses should also be able to recognise signs of infection should this
occur.
Publication Types:
Review
PMID: 12715534 [PubMed - indexed for MEDLINE]
62: Clin J Oncol Nurs. 2003 Mar-Apr;7(2):218-21, 241.
Central line sepsis.
Peterson KK.
Deaconess Billings Clinic, Billings, MT, USA. [email protected]
Since 1980, the placement of central venous access devices has become routine,
and these catheters have been of great benefit in the treatment of patients with
cancer. Unfortunately, central venous catheters have not been without
complications. Central line sepsis has been reported to be one of the most
frequently occurring complications, and although it is extremely costly to treat,
more importantly, this condition is potentially life threatening to patients.
Developing strategies that would prevent central line catheter infections has
been a continual challenge for healthcare providers. Studies have been conducted
on the use of catheters with antiseptic coatings, antimicrobial coatings,
impregnated antimicrobial cuffs, prophylactic antibiotic therapy, antibiotic
locks, use of antithrombolytics, different exit site dressings, and the use of
various disinfectants for cleansing catheter exit sites. Healthcare providers,
including oncology nurses, need to be knowledgeable concerning potential sources
of infection and factors that may lead to central line sepsis (Chaiyakunapruk,
Veenstra, Lipsky, & Saint, 2002; Darouiche et al., 1999; Little & Palmer, 1998;
Veenstra, Saint, Saha, Lumley, & Sullivan, 1999). They need to advocate for the
use of sterile technique during catheter insertion and aseptic technique when
routine maintenance is provided and be aware of the standard treatments for and
potential outcomes of central line catheter infections. In addition, oncology
nurses should be encouraged to support and participate in controlled, randomized
studies that may provide scientific-based practices that decrease the number of
catheter-related infections in the future.
Publication Types:
Case Reports
PMID: 12696220 [PubMed - indexed for MEDLINE]
63: Am J Infect Control. 2003 Feb;31(1):34-9.
Evaluation of infectious complications of the implantable venous access system in
a general oncologic population.
Chang L, Tsai JS, Huang SJ, Shih CC.
Infection Control Committee, Koo-Foundation Sun, Yat-Sen Cancer Center, Taiwan,
Republic of China.
OBJECTIVES: This study was conducted to evaluate the infectious morbidity
associated with 2 common types of implantable port systems used in a cancer
center in Taiwan. METHODS: This study is retrospective and descriptive. Five
hundred seventy-two patients who received implantable ports at the cancer center
between January 1994 and December 1998 were included. The following 4 types of
catheter-related infections were defined in this study: bloodstream, pocket,
exit-site, and tunnel. Semiquantitative methods (rolling plate) were used for
cultures of removed catheters. RESULTS: The average duration for ports after
placement in patients was 358 days (range, 1-1742 days), and the median duration
was 242 days. The port-related infection rate was 5.6% in 586 ports and 0.15 per
1000 device-days. Our data indicate that when a port is in use, more frequent
dressing changes of the needle exit site (every 3 days vs every 7 days) appear to
have no significant impact on the catheter-related infection rate (5.2% vs 7.3%,
P =.3). Our observation also indicates that if the catheter is used for total
parenteral nutrition (TPN), the patient has a significantly increased chance of
developing an infection from the Candida species (71% vs 8%, P =.005).
Furthermore, the catheters associated with infections caused by the Candida
species had a shorter catheter life (median, 44 days). CONCLUSIONS: Infection is
the most common complication of venous port system use among cancer patients.
According to our data, it is safe and cost-effective to change exit-site needles
and transparent dressings every 7 days. It is clearly demonstrated by our study
that patients with ports used for the administration of TPN had a significantly
greater chance of developing infection from the Candida species. Further
investigation is needed to compare the relative advantages of using ports versus
other devices for the administration of TPN in cancer patients.
Publication Types:
Evaluation Studies
PMID: 12548255 [PubMed - indexed for MEDLINE]
64: Infect Control Hosp Epidemiol. 2002 Dec;23(12):730-2.
Weekly transparent dressing changes linked to increased bacteremia rates.
Curchoe RM, Powers J, El-Daher N.
Unity Health System, Rochester, New York, USA.
BACKGROUND: In 2000, the rate of primary bloodstream infections (BSIs) was double
that in 1999 for intensive care unit (ICU) patients with triple lumen catheters,
pulmonary artery catheters, or both. In December 1999, changes in products and
practices related to site care were implemented as a cost-saving initiative.
OBJECTIVE: To determine the factors contributing to an increase of BSIs after
cost-saving measures for site care had been introduced. DESIGN: Epidemiologic
study involving prospective identification of infection. SETTING: A community
teaching hospital. PARTICIPANTS: Patients in a 20-bed, medical-surgical ICU
identified as having triple lumen catheters, pulmonary artery catheters, or both
and a primary BSI during 2000 and 2001. METHODS: Alcohol swab sticks were
reintroduced and the frequency of transparent dressing changes and site care was
increased. Inservice presentations were conducted on aseptic technique and
posters were placed reviewing site care protocol for physicians and nurses.
RESULTS: The incidence of primary BSIs decreased significantly (P = .003) during
a 3-month intervention and this decrease was sustained through the following 12
months. CONCLUSIONS: Prolonging the interval between the change of transparent
dressings from 3 times weekly to once weekly and switching from alcohol swab
sticks to pads was associated with an increase in BSIs, which was controlled
after returning to the original policy.
Publication Types:
Comparative Study
PMID: 12517015 [PubMed - indexed for MEDLINE]
65: Infect Control Hosp Epidemiol. 2002 Dec;23(12):725-9.
Comment in:
Infect Control Hosp Epidemiol. 2002 Dec;23(12):713-5.
An outbreak of bloodstream infections in an outpatient hemodialysis center.
Price CS, Hacek D, Noskin GA, Peterson LR.
Department of Medicine, Denver Health Medical Center, and the University of
Colorado Health Sciences Center, Denver, Colorado, USA.
OBJECTIVES: Investigate and control an increase in bloodstream infections (BSIs)
in an outpatient hemodialysis center. PATIENTS AND DESIGN: A retrospective cohort
study was conducted for patients receiving dialysis at the center from February
2000 to April 2001. A case-control study compared microbiological data for all
BSIs that occurred during the study period with those for BSIs that occurred
during a baseline period January 1999 to January 2000). BSI rates before and
after a 1-month intervention (May 2001) were assessed. A case was defined as a
new BSI during the study period. RESULTS: The outbreak was polymicrobial, with
approximately 30 species. The baseline BSI rate was 0.7 per 100 patient-months.
From February 2000 to April 2001, the BSI rate increased to 4.2 per 100
patient-months. Overall, 75% of the BSIs were associated with central venous
catheters (CVCs), but CVC use did not fully explain the increase in BSIs. In
January 2000, when the center changed ownership, prepackaged CVC dressing kits
and biweekly infection control monitoring were discontinued. Beginning in May
2001, staff were educated on CVC care, chlorhexidine replaced povidone-iodine for
cutaneous antisepsis, gauze replaced transparent dressings, antimicrobial
ointments containing polyethylene glycol at CVC exit sites were discontinued, and
patients with CVCs were educated on cutaneous hygiene. After the intervention
period, by October 2001, rates decreased to less than 1 BSI per 100
patient-months. CONCLUSIONS: Proper cutaneous antisepsis and access site care is
crucial in preventing BSIs in patients receiving hemodialysis. Infection control
programs, staff and patient education, and use of optimal antisepsis agents or
prepackaged kits are useful toward this end.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 12517014 [PubMed - indexed for MEDLINE]
66: Medicine (Baltimore). 2002 Nov;81(6):466-79.
A review of risk factors for catheter-related bloodstream infection caused by
percutaneously inserted, noncuffed central venous catheters: implications for
preventive strategies.
Safdar N, Kluger DM, Maki DG.
Department of Medicine, University of Wisconsin Medical School and University of
Wisconsin Hospitals and Clinics, Madison, 53792, USA.
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.
Publication Types:
Review
PMID: 12441903 [PubMed - indexed for MEDLINE]
67: Clin Radiol. 2002 Sep;57(9):850-2.
Totally implanted venous access device removal in interventional radiology.
Murthy R, Wesley BA, Coldwell DM.
Department of Diagnostic Radiology, University of Maryland Medical System,
Division of Vascular and Interventional Radiology, Baltimore 21201, USA.
PURPOSE: To demonstrate that totally implanted venous access device (TIVAD)
removal in the out-patient interventional radiology (IR) recovery room is safe
and effective. MATERIALS AND METHODS: Fifty-seven TIVADs were removed in 56
patients using a standard cut-down technique. Forty-one devices (72%) in 40
patients without signs of pocket infection were closed with primary intention
with sub-cuticular absorbable or simple non-absorbable sutures, depending on
operator preference. All patients were followed up to assess for bleeding or
infection. Sixteen devices (28%) in 16 patients with suspected pocket infection
were allowed to heal by secondary intention. These patients were managed with
antibiotics and dressing changes until healing was complete. Catheter tips were
sent for culture and sensitivity. RESULTS: TIVADs were removed intact in all 57
cases. There were no cases of air embolism, uncontrolled hemorrhage, retained
foreign body or catheter fragmentation. No bleeding or infectious complications
were noted in those patients who were allowed to heal with primary intention.
Wound closure was accomplished in all patients who were allowed to heal with
primary or secondary intention. CONCLUSION: TIVAD removal in an out-patient
recovery room by an interventional radiology team is safe and feasible, providing
a possible alternative venue for this procedure.
Publication Types:
Evaluation Studies
PMID: 12384113 [PubMed - indexed for MEDLINE]
68: Acta Chir Belg. 2002 Aug;102(4):256-8.
What really affects the incidence of central venous catheter-related infections
for short-term catheterization?
Giles Y, Aksoy M, Tezelman S.
Department of General Surgery, Istanbul Medical Faculty, Turkey.
Central venous catheterization is one of the important sepsis reasons in surgical
patients. In this randomized controlled study, the effect of the frequency and
type of catheter site care, as well as age, coexisting malignancy or diabetes
mellitus, total parenteral nutrition administration and antibiotics use, on
central venous catheter infection was investigated. Seventy-two single-lumen
polyurethane catheters were included. In group I (n: 33), a transparent occlusive
dressing was applied to the insertion site and not removed for 7 days unless
there were signs of local infection. In group II (n: 39), daily site care was
done with povidone-iodine 10% solution and a new sterile gauze was applied.
Chi-square, linear correlation and multiple regression tests were used for
statistical analysis. Mean duration of catheters was 8 +/- 4 days. There was no
catheter-related sepsis. Ten (13.9%) patients had positive catheter tip cultures
of whom three had site infection as well. The incidence of site and tip
infections were not significantly different in group I and II (p > 0.05). Site
infection and age younger than 60 years significantly increased the rate of tip
infection (p: 0.004 and p: 0.02 respectively). Total parenteral nutrition
administration was associated with higher rate of tip infection (p: 0.06).
Coexisting malignancy or diabetes mellitus, duration of catheter and antibiotics
use did not have any significant effect on the rate of central venous catheter
infections (p > 0.05). In conclusion, we observed that the frequency of insertion
site care and the type of dressing applied to the site had no significant effect
on the rate of CVC infection. Insertion site infection was the most significant
factor increasing the incidence of catheter tip infection. The use of the CVC for
total parenteral nutrition facilitated tip infection as well.
Publication Types:
Clinical Trial
Comparative Study
Randomized Controlled Trial
PMID: 12244905 [PubMed - indexed for MEDLINE]
69: J Crit Care. 2002 Jun;17(2):114-21.
Applying the science to the prevention of catheter-related infections.
O'Grady NP.
Warren Magnusen Clinical Center, National Institutes of Health, Bethesda, MD
20892, USA.
BACKGROUND: Catheter-related bloodstream infection (CR-BSI) remains a leading
cause of nososcomial infection, despite the fact that many CR-BSIs are
preventable. Simple principles of infection control and the use of novel devices
to reduce these infections are not uniformly implemented. OBJECTIVE: To review
and summarize the evidence that promotes strategies to prevent CR-BSIs. DATA
SOURCES: The Medline database and bibliographies of review articles and book
chapters were searched for relevant articles. STUDIES INCLUDED: In vitro and in
vivo laboratory-based studies, controlled clinical trials, prospective
interventional trials, and epidemiologic investigations. OUTCOME MEASURES:
Reduction in CR-BSI, catheter colonization, tunnel infection, or local site
infection. SYNTHESIS: The recommended prevention strategies with strong
supportive evidence include educating and training of health care providers who
insert and maintain catheters; using full barrier precautions during central
venous catheter insertion; using a 2% chlorhexidine preparation for skin
antisepsis; eliminating the practice of scheduled replacement of central venous
catheters for prevention of infection; and using antiseptic/antibiotic
impregnated short-term central venous catheters. CONCLUSION: Simple interventions
can reduce the risk for serious catheter-related infection. Health care provider
awareness and adherence to these prevention strategies is critical to reducing
the risk for CR-BSI, improving patient safety, and promoting quality health care.
Copyright 2002, Elsevier Science (USA). All rights reserved.
Publication Types:
Review
PMID: 12096374 [PubMed - indexed for MEDLINE]
70: Arch Intern Med. 2002 Apr 22;162(8):871-8.
Comment in:
Arch Intern Med. 2002 Oct 28;162(19):2253-4.
Intravascular catheter-related infections: new horizons and recent advances.
Raad II, Hanna HA.
Department of Infectious Diseases, Infection Control, and Employee Health, The
University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX
77030, USA. [email protected]
BACKGROUND: Central venous catheters have become essential devices for the
management of critically and chronically ill patients; however, their use is
often complicated by catheter-related bloodstream infections (CRBSIs), many of
which could be prevented. METHODS: This report is based on a literature review of
more than 100 published articles in intravascular catheter-related infections.
This review focuses on the most recent advances in the methods of diagnosis of
CRBSI as they relate to its pathogenesis and on novel preventive techniques and
approaches to management. RESULTS: Catheter-related bloodstream infections may be
diagnosed by different methods, including simultaneous quantitative blood
cultures, with the central blood culture yielding at least 5-fold colony-forming
units greater than the peripheral blood culture, and simultaneous blood cultures,
whereby the catheter-drawn blood culture becomes positive at least 2 hours before
the peripheral blood culture. Novel preventive techniques include the use of
ionic silver, an anticoagulant/antimicrobial flush solution, a new aseptic hub,
and antimicrobial impregnation of catheters and dressings. Management of CRBSIs
should be based on whether the infection is complicated or uncomplicated.
CONCLUSIONS: Novel technologies that have been proved to aid in the diagnosis and
prevention of CRBSIs should be considered in clinical practice. The management
approach should be based on the type of microorganism causing the infection and
on whether the infection is complicated or uncomplicated.
Publication Types:
Review
PMID: 11966337 [PubMed - indexed for MEDLINE]
71: Nurs Times. 2001 May 10-16;97(19):34-6.
Central venous catheters: some common clinical questions.
Simcock L.
Meyerstein Institute of Oncology, Middlesex Hospital, London.
PMID: 11957479 [PubMed - indexed for MEDLINE]
72: Nurs Times. 2001 Apr 12-18;97(15):36-9.
Preventing infections associated with central venous catheters.
Pratt R, Pellowe C, Harper P, Loveday H, Robinson N.
Richard Wells Research Centre, Thames Valley University, London.
CR-BSI is one of the most serious complications in an already seriously ill
patient. Incorporation of these recommendations into local protocols and routine
clinical practice will help to bring about a significant reduction in the
incidence of CR-BSI in all NHS acute care trusts. The evidence base will be
reviewed in 2002.
Publication Types:
Review
PMID: 11954368 [PubMed - indexed for MEDLINE]
73: Clin Infect Dis. 2002 May 1;34(9):1232-42. Epub 2002 Apr 2.
The promise of novel technology for the prevention of intravascular
device-related bloodstream infection. I. Pathogenesis and short-term devices.
Crnich CJ, Maki DG.
Section of Infectious Diseases, Department of Medicine, University of Wisconsin
Medical School, Madison, WI, USA.
Intravascular devices (IVDs) are widely used for vascular access but are
associated with substantial risk of development of IVD-related bloodstream
infection (BSI). The development of novel technologies, which are based on an
understanding of pathogenesis, promises a quantum reduction in IVD-related
infections in an era of growing nursing shortages. Infections of short-term IVDs
(that is, those in place <10 days), including peripheral venous catheters,
noncuffed and nontunneled central venous catheters (CVCs), and arterial
catheters, derive mainly from microorganisms colonizing the skin around the
insertion site, which most often gain access extraluminally. More-effective
cutaneous antiseptics, such as chlorhexidine, a chlorhexidine-impregnated sponge
dressing, CVCs with an anti-infective coating, anti-infective CVC hubs, and novel
needleless connectors, have all been shown to reduce the risk of IVD-related BSI
in prospective randomized trials. The challenge for the future will be to
identify new preventative technologies and to begin to adapt more widely those
technologies already shown to be efficacious and cost-effective.
Publication Types:
Research Support, Non-U.S. Gov't
Review
PMID: 11941550 [PubMed - indexed for MEDLINE]
74: J Chemother. 2001 Nov;13 Spec No 1(1):234-8.
The prevention of central venous catheter-related sepsis.
Elliott TS.
University Hospital Birmingham NHS Trust, UK.
[email protected]
Intravascular catheters continue to be a major source of sepsis which range from
localised inflammation at the site of insertion to septicaemia. There are two
main approaches which have been taken in an attempt to prevent these infections.
These can be divided into the patient and the catheter. Approaches for prevention
with patients include improved aseptic techniques, appropriate choice of
antiseptic skin preparations, use of semi-occlusive dressings and cleaning
schedules when using the devices. Catheters have also been developed to reduce
the incidence of these infections. These include the production of polymers with
smooth, anti-adhesive coatings, eg Hydromer, and more recently the introduction
of devices which are either coated with antiseptics or antimicrobials. The
antimicrobial coatings include antibiotics such as rifampicin and doxycycline or
antiseptics, for example benzalkonium chloride or chlorhexidine. The efficacy of
these approaches will be reviewed based on both laboratory and clinical studies.
The treatment of intravascular catheter-related sepsis depends primarily on
establishing the diagnosis. When the diagnosis has been made treatment ranges
from the use of antimicrobials alone to removal of the device. More recent
approaches have included the use of antibiotic locks within the catheters.
Treatment schedules will also be reviewed.
Publication Types:
Review
PMID: 11936372 [PubMed - indexed for MEDLINE]
75: EDTNA ERCA J. 2001 Apr-Jun;27(2):81-2.
Maintaining an optimum haemocatheter exit site.
Wittich E.
Renal Unit, Worcester UK.
As a result of crusty growths over some haemocatheter exit sites, it was decided
to explore why these crusty scabs occur and how they could be eradicated. It is
concluded that a haemocatheter exit site requires a dressing, which will maintain
an optimum environment, and avoid contamination from Staphylococcus aureus.
Inadine (Johnson & Johnson) a povidine iodine product, applied before the final
dressing of Tielle (Johnson & Johnson Medical), a hydropolymer adhesive dressing
creates an ideal environment for healing.The haemocatheter exit site can also be
inspected at each dialysis session, but can in fact be left insitu for seven
days.
PMID: 11868754 [PubMed - indexed for MEDLINE]
76: Semin Dial. 2001 Nov-Dec;14(6):432-5.
Acute dialysis catheters.
Oliver MJ.
Division of Nephrology, Department of Medicine, Sunnybrook and Women's College
Health Sciences Centre, Toronto, Ontario, Canada. [email protected]
Acute dialysis catheters are non-cuffed, non-tunnelled catheters used for
immediate vascular access. They are primarily used for acute renal failure in
bed-bound patients and for short-term use in patients with malfunction of
permanent access. Long-term use of acute catheters is not recommended, but does
occur with acceptable infection rates in dialysis centers where tunnelled, cuffed
catheters are not available. Most acute catheters are made of polyurethane, but
silicone catheters are now available with larger lumen sizes capable of
delivering blood flow rates over 300 ml/min. Acute catheters should be inserted
in the internal jugular or femoral vein under ultrasound guidance to minimize
complications. Subclavian catheters cause stenosis, thrombosis, and perforation
of vessels. Intermittent catheter malfunction still occurs, particularly for
left-sided internal jugular catheters and catheters placed in women. Blood flow
may improve with lumen reversal, intraluminal t-PA, or guidewire exchange.
Limiting duration of use and dressing catheter exit sites with dry gauze and
antiseptic ointments can prevent catheter-related infections.
Publication Types:
Review
PMID: 11851928 [PubMed - indexed for MEDLINE]
77: Intensive Care Med. 2002 Jan;28(1):18-28. Epub 2001 Nov 29.
Central venous catheter use. Part 2: infectious complications.
Polderman KH, Girbes AR.
Department of Intensive Care, VU University Medical Center, PO Box 7057, 1007 MB
Amsterdam, The Netherlands. [email protected]
Central venous catheters (CVCs) are used with increasing frequency in the
intensive care unit and in general medical wards. Catheter infection, the most
frequent complication of CVC use, is associated with increased morbidity,
mortality, and duration of hospital stay. Risk factors in the development of
catheter colonisation and bloodstream infection include patient factors
(increased risk associated with malignancy, neutropenia, and shock) and
treatment-related factors (increased risk associated with total parenteral
nutrition, ICU admission for any reason, and endotracheal intubation). Other risk
factors are prolonged catheter indwelling time, lack of asepsis during CVC
insertion, and frequent manipulation of the catheter. The most important factor
is catheter care after placement. Effects of CVC tunnelling on infection rates
depend to a large extent on indwelling time and the quality of catheter care. Use
of polyurethane dressings can increase the risk of colonisation compared to
regular gauze dressing. Thrombus formation around the CVC tip increases the risk
of infection; low-dose anticoagulants may decrease this risk. New developments
such as CVC impregnation with antibiotics may reduce the risk of infection.
Reducing catheter infection rates requires a multiple-strategy approach.
Therefore, ICUs and other locations where CVCs are used should implement strict
guidelines and protocols for catheter insertion, care, and maintenance.
Publication Types:
Review
PMID: 11818995 [PubMed - indexed for MEDLINE]
78: Tumori. 2001 Sep-Oct;87(5):308-11.
Long-term infusional systems: complications in cancer patients.
Coccaro M, Bochicchio AM, Capobianco AM, Di Leo P, Mancino G, Cammarota A.
Department of Medical Oncology, Ospedale Oncologico Regionale, Centro di
Riferimento Oncologico della Basilicata (CROB), Rionero In Vulture (PZ), Italy.
[email protected]
Long-term central vein catheters have found clinical application in different
fields of medicine and particularly in oncology. In fact, the continuous infusion
of some drugs has become the standard treatment in a wide variety of cancers, but
central vein catheters are not without risks. The authors report their experience
with central vein catheters. From January 1,1998, to December 31, 1999, 98
central vein catheters were placed in neoplastic patients. Seventy-seven (78.6%)
Groshong and 16 (16.3%) Port-a-cath catheters were used. The central vein
catheters were placed under local anesthesia. Before placement of the central
vein catheters, the patients were checked by chest X-ray and neck
ultrasonography. The procedure was performed under fluoroscopic control. The
central vein catheters were flushed periodically with normal saline solution and
sodium heparin. Sterile transparent adhesive dressings were used to occlude the
operative site. The median follow-up of patients was 9 catheter months (range,
1-24 months). There were a few early and late clinically evident complications.
The early complications were dislodgement in 5 cases (5.1%).The late
complications were: fibrin sleeve in 1 case (1.1%), thrombosis in 2 cases (2.1%)
and skin infection in 4 cases (4.1%). The low prevalence of major complications
related to implants and management of these supports an increased use in
oncology.
PMID: 11765179 [PubMed - indexed for MEDLINE]
79: J Infus Nurs. 2001 Jul-Aug;24(4):249-54.
Controversial issues in the care and maintenance of vascular access devices in
the long-term/subacute care client.
Sterba KG.
American Pharmaceutical Services, 14450 Trinity Boulevard, Suite 200, Fort Worth,
TX 76155. [email protected]
The aging population provides a unique challenge for the initiation and
maintenance of infusion therapy. This article will highlight three common but
controversial issues that have been observed by this author in the
long-term/subacute care realm of infusion therapy: 1) the failure to maintain a
sterile dressing over the catheter insertion site; 2) the use of heparin to
maintain patency of the peripheral infusion device; and 3) the routine
replacement of peripheral i.v. catheters. Several factors that contribute to the
controversies will be discussed, along with some associated negative and positive
outcomes.
Publication Types:
Review
PMID: 11507788 [PubMed - indexed for MEDLINE]
80: Pediatrics. 2001 Jun;107(6):1431-6.
Comment in:
Evid Based Nurs. 2002 Jul;5(3):73.
A randomized trial comparing povidone-iodine to a chlorhexidine
gluconate-impregnated dressing for prevention of central venous catheter
infections in neonates.
Garland JS, Alex CP, Mueller CD, Otten D, Shivpuri C, Harris MC, Naples M,
Pellegrini J, Buck RK, McAuliffe TL, Goldmann DA, Maki DG.
St. Joseph's Hospital, Milwaukee, WI 53210, USA. [email protected]
Neonates who require a central venous catheter (CVC) for prolonged vascular
access experience high rates of catheter-related bloodstream infection (CRBSI).
PURPOSE: A multicenter randomized clinical trial was undertaken to ascertain the
efficacy of a novel chlorhexidine-impregnated dressing (Biopatch Antimicrobial
Dressing) on the CVC sites of neonates for the prevention of catheter tip
colonization, CRBSI, and bloodstream infection (BSI) without a source. Setting.
Six level III neonatal intensive care units. Patients Studied. Neonates admitted
to study units who would require a CVC for at least 48 hours. METHODS: Eligible
infants were randomized before catheter placement to 1 of the 2 catheter site
antisepsis regimens: 1) 10% povidone-iodine (PI) skin scrub, or 2) a 70% alcohol
scrub followed by placement of a chlorhexidine-impregnated disk over the catheter
insertion site. A transparent polyurethane dressing (Bioclusive Transparent
Dressing) was used to cover the insertion site in both study groups. Primary
study outcomes evaluated were catheter tip colonization, CRBSI, and BSI without
an identified source. RESULTS: Seven hundred five neonates were enrolled in the
trial, 335 randomized to receive the chlorhexidine dressing and 370 to skin
disinfection with PI (controls). Neonates randomized to the antimicrobial
dressing group were less likely to have colonized CVC tips than control neonates
(15.0% vs 24.0%, relative risk [RR]: 0.6 95% confidence interval [CI]: 0.5-0.9).
Rates of CRBSI (3.8% vs 3.2%, RR: 1.2, CI: 0.5-2.7) and BSI without a source
(15.2% vs 14.3%, RR: 1.1, CI: 0.8-1.5) did not differ between the 2 groups.
Localized contact dermatitis from the antimicrobial dressing, requiring crossover
into the PI treatment group, occurred in 15 (15.3%) of 98 exposed neonates
weighing </=1000 g. No neonates in the PI group developed contact dermatitis.
CONCLUSION: The novel chlorhexidine-impregnated dressing, replaced weekly, was as
effective as cutaneous disinfection with 10% PI and redressing the site every 3
to 7 days for preventing CRBSI and BSI without a source in critically ill
neonates requiring prolonged central venous access. The risk of local contact
dermatitis under the chlorhexidine dressing limits its use in low birth weight
infants who require prolonged central access during the first 2 weeks of life.
Publication Types:
Clinical Trial
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.
PMID: 11389271 [PubMed - indexed for MEDLINE]
81: Emerg Infect Dis. 2001 Mar-Apr;7(2):197-9.
New technologies to prevent intravascular catheter-related bloodstream
infections.
Mermel LA.
Brown University School of Medicine and Rhode Island Hospital, Providence, Rhode
Island, USA. [email protected]
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.
Publication Types:
Review
PMID: 11294705 [PubMed - indexed for MEDLINE]
82: Nurs Times. 2000 Apr 6-12;96(14):49-50.
Management of a central venous catheter.
Hatchett R.
Heart Hospital, London.
PMID: 11276673 [PubMed - indexed for MEDLINE]
83: Assist Inferm Ric. 2000 Apr-Jun;19(2):112-9.
[Comparison of two different protocols on change of medication in central venous
catheterization in patients with bone marrow transplantation: results of a
randomized multicenter study]
[Article in Italian]
Rasero L, Degl'Innocenti M, Mocali M, Alberani F, Boschi S, Giraudi A, Arnaud MT,
Zucchinali R, Paris MG, Dallara R, Thaler S, Perobelli G, Parfazi S, De Lazzer T,
Peron G.
Care of central venous catheter (CVC) in patients undergoing bone marrow
transplantation (BMT) raises significant problems related to the high risk of
local infections, to the immunodeficient status, which in itself is a
predisposing factor for systematic blood stream infections. Although frequent
changes of CVC dressing might theoretically reduce the incidence of infections,
they are also accompanied by significant skin toxicity and patient discomfort. No
study has yet addressed these points. The objective of this study was to compare
two different time interval protocols for CVC dressing, in order to assess the
effects on local infections and toxicity. In a multicentre study, 339 bone marrow
transplant (BMT) patients with a tunnelled CVC (group A, 230 pts) or a non
tunnelled one (Group B, 169 patients) were randomly allocated to receive CVC
dressing changes every 5 or 10 days if belonging to group A or 2 or 5 days if in
group B. Transparent impermeable polyurethane dressings were used for all
patients. The rate of local infection at the site of CVC insertion was assessed
by microbiological assay every 10 days, while severity of skin toxicity was
measured according to the ECOG scale. Sixty-five per cent of enrolled patients
were finally evaluable. Patients (in both groups) receiving CVC dressing changes
at longer intervals did not show a significant increase in the rate of local
infections, while those who received dressing every two days had a significant
increase in local skin toxicity. Longer intervals were accompanied by a reduction
in costs. The results of this study demonstrate that the increase in time
interval between CVC dressing changes in BMT patients did not increment the risk
of local infections, while significantly reducing patients discomfort and costs.
Publication Types:
Clinical Trial
Comparative Study
English Abstract
Multicenter Study
Randomized Controlled Trial
PMID: 11107366 [PubMed - indexed for MEDLINE]
84: Anaesth Intensive Care. 2000 Oct;28(5):475-90.
Can we achieve consensus on central venous catheter-related infections?
Fraenkel DJ, Rickard C, Lipman J.
Royal Brisbane Hospital, Queensland.
Central venous catheter-related bacteraemia is a substantial and preventable
source of iatrogenic morbidity and mortality. A single episode of
catheter-related bacteraemia has an estimated cost of A$50,000, with an
attributable mortality between 10 and 35%. Catheter colonization is diagnosed
with standard culture techniques. Diagnostic criteria for catheter-related
bacteraemia include the results of cultures from the catheter tip, the peripheral
blood and other possible sites of infection. The presence of clinical symptoms
and subsequent defervescence may assist in making the diagnosis. This review
explores the existing definitions of catheter-related infections and proposes a
new and more rigorous classification with criteria for definite, probable and
possible catheter-related bacteraemia. The authors hope that this classification
will enhance the interpretation of the literature and the planning of new
investigations. Infection rates can be reduced by appropriate site selection,
adequate skin preparation, sterile technique and appropriate dressings. Decreased
manipulation of administration sets, with more careful technique and less
frequent set replacement, may reduce hub contamination. Infection rates increase
with the duration in situ of the catheter, however are not reduced by regular
scheduled catheter replacement or guide-wire exchanges. A range of antimicrobial
catheter materials and coatings are under investigation, some of which are
effective in reducing the rate of catheter-related bacteraemia.
Chorhexidine-silver sulphadiazine and rifampicin-minocycline are the best studied
combinations to date. Further developments are expected, although none are likely
to be as effective as not inserting or removing the central venous catheter when
it is not required.
Publication Types:
Review
PMID: 11094662 [PubMed - indexed for MEDLINE]
85: Am J Kidney Dis. 2000 Jul;36(1):199-204.
An outbreak of Burkholderia cepacia bacteremia in hemodialysis patients: an
epidemiologic and molecular study.
Kaitwatcharachai C, Silpapojakul K, Jitsurong S, Kalnauwakul S.
Division of Nephrology and the Division of Infectious Disease, Department of
Medicine, Faculty of Medicine, Prince of Songkla University, Thailand.
[email protected]
The risk of blood stream infections increases in patients undergoing chronic
hemodialysis. Outbreaks of infection are usually caused by contamination of the
water supply, water treatment, distribution system, or dialyzer reprocessing. We
report an outbreak of subclavian catheter-related Burkholderia cepacia bacteremia
in nine patients undergoing hemodialysis. Using randomly amplified polymorphic
DNA (RAPD) analysis, the bacterial isolates were clonally identical to
Burkholderia cepacia isolated from residue of the diluted chlorhexidine-cetrimide
solution used to disinfect the transfer forceps. These forceps were used to pick
up cotton balls and gauze for dressing the subclavian catheter. Antibiotic
therapy failed to cure the infections, and all patients required catheter
removal. Pathology showed numerous bacilli embedded in the biofilm on the inner
surface of the removed catheters. In conclusion, our study showed that
contaminated chlorhexidine-cetrimide solution was the source of a bacteremic
outbreak in nine patients who developed catheter-related Burkholderia cepacia
infection.
Publication Types:
Research Support, Non-U.S. Gov't
PMID: 10873892 [PubMed - indexed for MEDLINE]
86: Nurs Clin North Am. 2000 Jun;35(2):385-93.
Selection and implementation of a transparent dressing for central vascular
access devices.
Woods SS, Nass J, Deisch P.
Critical Care Clinical Nurse Specialist, Center for Advanced Nursing Practice,
BryanLGH Medical Center, Lincoln, NE, USA.
The selection of new central venous access devices (CVADs), line dressing, and
nursing clinical practices was guided by the Center for Advanced Nursing
Practice's Evidence-Based Practice Model. The model's evidence-triggered,
evidence-supported, evidence-observed, and evidence-based phases provided
structure that guided a systematic process in which best practice was
incorporated into the clinical setting, based on clinician insights, evaluation
of authoritative literature, and examination of three CVAD dressings as an
intervention using various study methods. This article discusses study findings,
recommendations, and implications for nursing practice. CVAD dressing integrity
has clinical practice applicability in multiple settings along the care
continuum.
Publication Types:
Review
PMID: 10873250 [PubMed - indexed for MEDLINE]
87: Australas J Dermatol. 2000 May;41(2):112-6.
Human immunodeficiency virus-related primary cutaneous aspergillosis.
Stanford D, Boyle M, Gillespie R.
Department of Dermatology, Royal Newcastle Hospital, New South Wales, Australia.
[email protected]
A 31-year-old Caucasian man with AIDS developed a crusted violaceous plaque under
adhesive tape near a central venous catheter insertion site. Histological
examination demonstrated a ruptured hair follicle containing collections of
fungal hyphae typical of Aspergillus spp. A culture of the biopsy material grew
Aspergillus fumigatus. The patient responded to removal of the catheter and the
occlusive dressing, in addition to itraconazole therapy. Aspergillosis must be
considered in the differential diagnosis of cutaneous lesions in human
immunodeficiency virus-infected patients, in particular when the lesion occurs
under adhesive tape or an occlusive dressing.
Publication Types:
Case Reports
PMID: 10812707 [PubMed - indexed for MEDLINE]
88: Nursing. 2000 Apr;30(4):24.
Changing a central venous catheter dressing.
McConnell EA.
PMID: 10797712 [PubMed - indexed for MEDLINE]
89: J Hosp Infect. 2000 Mar;44(3):241-3.
Evidence for a self-fulfilling hypothesis: chlorhexidine dressing for reduction
of microbial colonization of the skin with central venous catheters.
Schierholz JM, Beuth J, Pulverer G.
Publication Types:
Letter
PMID: 10706809 [PubMed - indexed for MEDLINE]
90: Haematologica. 2000 Mar;85(3):275-9.
Comparison of two different time interval protocols for central venous catheter
dressing in bone marrow transplant patients: results of a randomized, multicenter
study. The Italian Nurse Bone Marrow Transplant Group (GITMO).
Laura R, Degl'Innocenti M, Mocali M, Alberani F, Boschi S, Giraudi A, Arnaud MT,
Zucchinali R, Paris MG, Dallara R, Thaler S, Perobelli G, Parfazi S, De Lazzer T,
Peron G.
Bone Marrow Transplant Unit, Division of Hematology, Azienda Ospedaliera Careggi,
50134 Florence, Italy. [email protected]
BACKGROUND AND OBJECTIVE: Care of central venous catheter (CVC) in patients
undergoing bone marrow transplantation (BMT) raises significant problems related
to the high risk of local infections due to the immunodeficient status, which in
itself is a predisposing factor for systemic blood-stream infections. Although
frequent changes of CVC dressing might theoretically reduce the incidence of
infections, they are also accompanied by significant skin toxicity and patient
discomfort. No study has yet addressed these points. The objective of this study
was to compare two different time interval protocols for CVC dressing in order to
assess the effects on local infections and toxicity. DESIGN AND METHODS: In a
multicenter study, 399 bone marrow transplant (BMT) patients with a tunneled CVC
(Group A, 230 pts) or a non-tunneled one (Group B, 169 pts) were randomly
allocated to receive CVC dressing changes every 5 or 10 days, if belonging to
Group A, or 2 or 5 days, if in Group B. Transparent, impermeable polyurethane
dressings were used for all patients. The rate of local infections at the site of
CVC insertion was assessed by microbiological assays every 10 days, while the
severity of skin toxicity was measured according to the ECOG scale. RESULTS:
Sixty-five per cent of enrolled patients were finally evaluable. Patients (in
both Groups) receiving CVC dressing changes at longer intervals did not show a
significant increase in the rate of local infections, while those who received
dressing every 2 days had a significant increase in local skin toxicity. Longer
intervals were accompanied by a reduction in costs. INTERPRETATION AND
CONCLUSIONS: The results of this study demonstrate that the increase in time
interval between CVC dressing changes in BMT patients did not raise the risk of
local infections, while significantly reducing patient discomfort and costs.
Publication Types:
Clinical Trial
Comparative Study
Multicenter Study
Randomized Controlled Trial
PMID: 10702816 [PubMed - indexed for MEDLINE]