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INFECTION PREVENTION AND CONTROL MANUAL
3.1 Indwelling Vascular Devices
CENTRAL VENOUS INFUSION AND PERIPHERAL INFUSION GUIDELINES
RATIONALE
The agency will promulgate procedures aimed at the prevention of vascular device- related
infections.
DEFINITIONS
INTRAVASCULAR DEVICES INCLUDE THE FOLLOWING:
Short Peripheral Venous Catheters, usually inserted into the veins of the forearm or hand.
Because of their short-term nature they are rarely associated with Blood Stream Infections
(BSI), but are frequently associated with a non-infective phlebitis.
Midline Catheters, inserted via antecubital fossa into basilic/cephalic vein. Associated with
lower rates of phlebitis than peripheral venous catheters, and lower rates of infection and
cost than central venous catheters.
Non-tunnelled Central Venous Catheters inserted into the internal jugular vein have shown
a higher rate of infection than those inserted into the subclavian vein. Multi-lumen CVCs
show a greater rate of infection than single lumen catheters.
Peripherally Inserted Central Venous Catheters may have lower infection rates than those
inserted into the subclavian area.
Tunnelled Central Venous Catheters surgically implanted for long-term access eg;
Hickmans, may have lower rates of infection.
RISK MANAGEMENT
Strict adherence to aseptic technique and hand washing remains the cornerstone of
prevention of IV catheter – related infections.
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EVIDENCE- BASED GUIDELINES
SELECTION OF CATHETER TYPE
 Use a single-lumen catheter unless multiple ports are essential for patient
management.

If TPN is being administered, use one central venous catheter or lumen
exclusively for that purpose.

Use a tunnelled catheter or an implantable vascular access device for patients
in whom long-term vascular access is anticipated.

Consider the use of an antimicrobial impregnated central venous catheter for
adult patients who require short term (< 10 days) central venous catheterisation
and who are at high risk of catheter-related blood stream infection.
SELECTION OF CATHETER INSERTION SITE
 In selecting an appropriate insertion site, assess the risks of infection against
the risks of mechanical complications.

Unless medically contraindicated, use the subclavian site in preference to the
jugular or femoral sites for non-tunnelled catheter placement.

Consider the use of peripherally inserted catheters as an alternative to
subclavian or jugular vein catheterisation.
OPTIMUM ASEPTIC TECHNIQUE DURING CATHETER INSERTION
 Use optimum aseptic technique, including sterile gown, gloves, and a large
sterile drape for insertion. Wearing of surgical mask by operator and patient has
also been recommended.
CUTANEOUS ANTISEPSIS
 Clean the skin with a single patient use application of an alcoholic chlorhexidine
gluconate skin preparation (preferably 2% chlorhexidine gluconate in 70%
isopropyl alcohol) prior to catheter insertion. Use an alcoholic povidone-iodine
solution for patients with a history of chlorhexidine sensitivity. Allow the
antiseptic to dry before inserting the catheter.

Do not apply organic solvents, eg; acetone, ether, to the skin prior to catheter
insertion.

Do not routinely apply antimicrobial ointment to the catheter placement site prior
to insertion.
CATHETER AND CATHETER SITE CARE
 Before accessing the system, disinfect the external surfaces of the catheter hub
and connection ports with a single use sachet of aqueous solution of
chlorhexidine gluconate or povidone-iodiness, contraindicated by the
manufacturer’s recommendations.

Use transparent dressing to cover the catheter site.
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
Do not apply antimicrobial ointment to CVC insertion sites as part of routine
catheter site care.

Routinely flush indwelling CVCs with an anticoagulant unless otherwise advised
by the manufacturer.
REPLACEMENT STRATEGIES
 Do not routinely replace non-tunnelled CVCs as a method to prevent catheterrelated infections.

Use wire-assisted catheter exchange to replace a malfunctioning catheter, or to
exchange an existing catheter if there is no evidence of infection at the catheter
site or proven catheter-related blood stream infection.

If catheter-related infection is suspected, but there is no evidence of infection at
the catheter site, remove the existing catheter and insert a new one over a wire
guide; if tests reveal catheter-related infection, the newly inserted catheter should
be removed and, if still required, a new catheter inserted at a different site.

Do not use wire assisted catheter exchange for patients with catheter-related
infection. If continued vascular access is required, remove the implicated catheter,
and replace it with another catheter at a different insertion site.

Replace all tubing when the vascular device is replaced.

Replace intravenous tubing and stopcocks no more frequently than at 72 hour
intervals, unless clinically indicated.

Replace intravenous tubing used to administer blood, blood products, or lipid
emulsions at the end of the infusion or within 24 hours of initiating the infusion.
PERIPHERAL VENOUS CATHETERS
 Evaluate the catheter site at each shift.
 Replace all peripheral cannula inserted under emergency conditions within 24
hours of insertion

Remove peripheral venous catheters if the patient develops signs of phlebitis,
infection or malfunctioning catheter.

In adults replace short peripheral venous catheters at least 72 – 96 hours.
PAEDIATRIC PATIENTS
 Leave peripheral venous catheters in place until IV therapy is completed unless a
complication (eg phlebitis or infiltration) occurs.
CVC’S, INCLUDING PICC’S
 Routine catheter replacement at scheduled intervals has not reduced the
incidence of catheter related blood stream infections. Routine replacement is not
necessary for catheters that are functioning and have no evidence of causing
local or systemic complications.
 Daily assessment of the need for continuing central access, and prompt removal
of unnecessary access is an important aspect of infection prevention
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ANTIBIOTIC PROPHYLAXIS
 Do not administer systemic antimicrobials routinely before insertion or during the
use of a central venous catheter to prevent catheter colonisation or bloodstream
infection.
REFERENCES:
Farr, B.M. Nosocomial Infections related to use of intravascular devices inserted for shortterm vascular access. Chapter 11 in Hospital Epidemiology and Infection Control, second
edition C. Glen Mayhall 1999 Lippincott, Williams and Wilkins.
Guidelines for the prevention of intravascular catheter related infection. Centres for Disease
Control.USA August 9 2002
Horvath R and Collignon P. Controlling intravascular catheter infections. Australian
Prescriber 2003(26):2:41-43
Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the
Healthcare Setting. Australian Government Department of Health and Ageing, 2004.
Pearson ML: Guidelines for Prevention of Intravascular Device-related Infection. HICPAC.
Infection Control and Hosp. Epidemiology. 1996; 17(7) 438-473.
Pratt RJ, Pellowe CM, WilsonJA, Loveday HP, et al. National evidence-based guidelines for
preventing healthcare-associated infections in NHS hospitals in England. J
Hos.Infect(2007)65S, S1-S64
Raad I. Hanna H., Nosocomial infections related to use of intravascular devices inserted for
long-term vascular access. Chapter 12 in Hospital Epidemiology and Infection Control,
second edition C. Glen Mayhall 1999 Lippincott, Williams and Wilkins.
Management of peripheral intravascular devices. Clinical Update. The Joanna Briggs
Institute for Evidence Based Nursing and Midwifery 2008, Adelaide. Australian Nurses
Journal. Sept. 08 Vol.16 Number 3.
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INFECTION PREVENTION AND CONTROL MANUAL
3.2 Indwelling Urinary Catheter
RATIONALE
The agency will use evidence-based procedures for the management of urethral catheters
and urinary drainage systems.
DEFINITIONS
Urethral catheters provide drainage of the urinary bladder when this is absolutely
necessary. A sterile, closed to air, drainage system provides some protection against
infection ascending into the bladder, and allows drainage of urine.
RISK MANAGEMENT
The presence of a urethral catheter presents several possible infection risks to the client.
Firstly, the presence of a foreign body within the urethra creates a bio-film between the
urethral mucosa and the catheter, in which micro-organisms can grow, and cause
ascending infection. Secondly, micro-organisms may ascend up the lumen of the catheter,
in air bubbles and due to back pressure. Micro-organisms introduced at the time of
catheterisation also contribute to infection potential.
Duration of catheterisation is strongly associated with the risk of infection, the longer the
catheter is in place, the higher the incidence of urinary tract infection.
50% of patients become infected by day 15 of catheterisation and almost 100% by
one month.
EVIDENCE-BASED GUIDELINES

Only use indwelling urethral catheters after considering alternative methods of
management.

The device should not be left indwelling unless absolutely necessary.

Choice of catheter material will depend on clinical experience, patient
assessment and anticipated duration of catheterisation.

Select the smallest gauge catheter that will allow free urinary outflow. A catheter
with a 10 ml balloon should be used. Urological patients may require larger
gauge sizes and balloons.

Catheterisation is an aseptic procedure. Ensure that staff are trained and
competent to perform urethral catheterisation.

Clean the urethral meatus prior to catheter insertion.

Use an appropriate sterile lubricant from a single dose container to minimise
urethral trauma and infection.
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
Connect indwelling urethral catheters to a closed urinary drainage system.

Ensure that the connection between the catheter and the urinary drainage is not
broken, except for good clinical reasons.

Obtain urine samples from a sample port, or aseptic needle aspiration.

If there is no balloon on the catheter (to hold it in place) the catheter should be
stabilised against movement.

Position urinary drainage bags below the level of the bladder on a stand that
prevents contact with the floor. Where such drainage cannot be maintained, eg.,
during moving and handling, clamp the urinary drainage bag tube and remove
clamp as soon as the bag can be maintained below the level of the bladder.

Empty the urinary drainage bag frequently enough to maintain urine flow and
prevent reflux, but avoid unnecessary emptying as this constitutes disruptions of
the closed system. Use a separate and clean container for each patient, and
avoid contact between the urinary drainage tap and container.

Do not add antiseptic or antimicrobial solutions into urinary drainage bags.

Do not change catheters unnecessarily or as part of routine practise.

Routine personal hygiene is all that is needed to maintain meatal hygiene.

Bladder irrigation, instillation and washout do not prevent infection.
INDICATIONS FOR USE
Indwelling urinary catheters should be inserted only when essential for the management of
the patient, and left in place only for as short a time as possible.
The main indications are:
to relieve urinary tract obstruction

to permit bladder drainage in patients with neurogenic bladder dysfunction or
retention

during urological investigations and procedures

to assist healing following surgery/trauma to the genitourinary tract

to measure urinary output accurately as part of critical fluid balance estimation
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CATHETER INSERTION
Staff responsible for insertion or management of indwelling urinary catheters must
understand the risks of infection and the rationale of procedures designed to prevent
infection and be trained in the correct techniques of aseptic catheter insertion and
management.
HOSPITAL POLICY

Male catheterisation must be performed by medical staff or a suitably trained
Registered Nurse

Female catheterisation can be performed by either a nursing or medical staff.
PREPARATION OF THE OPERATOR
Antiseptic hand hygiene, sterile gloves and gown should be used when inserting an
indwelling urinary catheter. This will prevent exogenous contamination and provide a barrier
to avoid exposure of staff to the patient’s urine.
HANDWASHING
An antiseptic hand wash solution should be used and the hands dried with a clean paper
towel.
SITE PREPARATION
The perineal area should be cleaned using mild soap and water prior to catheterisation. If
additional cleansing is required at the time of the procedure use 0.9% saline to cleanse
labia minora and urethral meatus using downward strokes.
A single use sachet of sterile lubricant or lignocaine jelly is used to minimise friction/pain on
insertion.
ASEPTIC TECHNIQUE
Catheterisation should be performed using an aseptic technique and sterile equipment to
minimise entry of microorganisms to the bladder during the procedure.
Discard catheter if it is accidentally contaminated during the procedure. Contamination
includes any contact with the perineal area other than the urethral meatus. The catheter
must be connected to the drainage bag maintaining asepsis.
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SELECTION OF CATHETER
The smallest catheter compatible with adequate function should be selected to minimise
urethral trauma. The anticipated length of time the catheter is likely to remain in situ, the
reason for catheterisation, and the patient’s tolerance to catheter material should be
considered.
A catheter that is too large may produce urethral irritation, leading to urethritis and possibly
to the development of urethral strictures. Pressure on blood vessels may produce tissue
necrosis.
SECURING THE CATHETER
Indwelling catheters should be secured to the thigh after insertion in such a manner as to
prevent unnecessary tension on the catheter within the urethra and urethral tract.
The catheter tubing and drainage bag should be positioned at all times to promote drainage
and prevent reflux of urine from the bag to the bladder.
Suitable drainage bag carriers should be used to hang the drainage bag on the bed or, for
ambulatory patient, to allow it to be carried.
Drainage systems must not be placed onto the floor.
DOCUMENTATION
The following data should be documented in the patients’ medical records:
date, time and reason for insertion

type and size catheter

volume of the balloon

re-catheterisation if necessary
MAINTENANCE OF CLOSED DRAINAGE
A closed drainage system should be maintained with as few disconnections as possible.
Interruption of the catheter and drainage system should be kept to a minimum and done
using strict aseptic technique. Hands should be washed before and after any manipulation
of the catheter system.
Avoid disconnection of the catheter and drainage system by irrigating only when absolutely
necessary and collecting specimens from the designated collection port.
If breaks in aseptic technique, disconnection or leakage occur, replace the system after
disinfecting the catheter-tubing junction with alcoholic chlorhexidine or aqueous povidone
iodine.
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REPLACEMENT OF CATHETERS
Do not change catheters arbitrarily.
The catheter may need to be removed or replaced only if problems such as obstruction,
malfunction or contamination are present. The catheter should be checked at least daily.
If re-catheterisation is necessary, replace the entire system using aseptic technique.
Long-term catheters can remain in place for up to 3 months.
REPLACEMENT OF CATHETER DRAINAGE BAG
Replace drainage bags, including leg bags at weekly intervals. Using strict aseptic
technique to minimise the risk of infection.
Overnight bags can be attached directly to the leg bag for overnight drainage. Each
morning the over night bag should be disconnected, emptied and washed with warm soapy
water. It should then be allowed to dry in a clean area.
Drainage bags should always be replaced when a new catheter is inserted.
EMPTYING OF THE CATHETER DRAINAGE BAG
Catheter bag emptying can be a major cross infection hazard if the procedure is not
exercised with extreme care. The drainage bag port can be a potential source of infection.
Wash hands before and after drainage bag emptying. The wearing of non-sterile gloves is
recommended.
Eye protection is recommended.
The urine should be emptied into a collecting receptacle and care should be taken to
prevent the drainage port from coming into contact with the collecting receptacle. Heat
disinfected or disposable collecting receptacles should be used.
BLADDER IRRIGATION
Irrigation of the bladder and/or catheter should only be performed when essential for the
management of the patient. The practice of bladder irrigation does not offset the potential
for micro organisms to enter the catheter system during the procedure.
The main indications are:



to prevent clot formation in the patient who has had prostatic surgery and studies;
to bathe the membranous lining of the bladder with prescribed drugs;
to irrigate the bladder with a prescribed fluid to remove debris from the bladder .
A sterile irrigant is used for all bladder irrigation. Irrigation is to be performed using strict
aseptic technique.
A three-way foley catheter should be used for continuous bladder irrigation
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PATIENT CARE AND MAINTENANCE OF DEVICES










Increased intake of fluids should be encouraged (unless medically contraindicated) to
facilitate the removal of micro-organisms and debris.
Perineal/vulval washing should be carried out regularly (twice daily), as well as after a
bowel motion.
Cleaning of the catheter and the insertion site should be carried out regularly (twice
daily) to avoid encrustation.
Closed drainage/collection systems should not be opened unless necessary.
The ports should be aseptically swabbed with an antimicrobial solution and allowed to
dry immediately before use in order to prevent the entry of micro-organisms into the
line.
The interruption of urine flow should be avoided, as should the interruption of routine
irrigation of urinary catheters.
Urine samples should be collected from the closed system with a syringe and needle
(after cleaning the port), not by breaking the connection between the catheter and the
drainage/collection system, and never from the drainage tap attached to the collection
container itself.
Before collecting urine samples or emptying the collection container, HCW’s should
wash their hands and then put gloves on. They should wash their hands after
removing the gloves.
The collection container should neither be raised above the level of the urethra nor
allowed to trail on the floor.
If there is a risk of urinary reflux when the patient is being moved, the tubing should
be clamped temporarily, then unclamped afterwards.
CULTURE FOR SUSPECTED CATHETER-RELATED INFECTION
Routine urine cultures are not required for patients with indwelling urinary catheters but
should be performed if there is any clinical evidence of urinary tract infection.
Catheterisation should never occur solely to obtain a urine specimen for culture because of
the risk of introducing organisms. If the patient is already catheterised, this is a valid
method of urine specimen collection.
Collect the urine specimen before the commencement of antibiotic therapy and before, not
after any irrigation procedure.
The specimen must be accompanied with a request slip detailing type of specimen (eg.
CSU, MSU) and accurate clinical notes to aid the laboratory with bacteriological
examination and sensitivity patterns.
COLLECTION OF CATHETER URINE SPECIMENS FOR CULTURE
Specimens of urine from catheterised patients must be aseptically obtained using an
aspiration technique to avoid contamination of the specimen. Specimens should never be
obtained by disconnecting the catheter from the drainage system. A closed system must be
maintained to avoid introducing pathogens.
Specimens must never be collected from the drainage bag. Such specimens only indicate
the microorganisms in the drainage bag and not in the urinary tract.
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METHOD OF COLLECTION

Wash hands with antiseptic preparation.

Clamp catheter tubing below sampling/aspiration port.

Put on clean gloves –sterile gloves are not necessary.

Disinfect port with 70% alcohol swab and allow 15 seconds to dry.

Aspirate 5-10 mls urine.

If a needle and syringe is used, transfer urine to sterile labelled container.

Disinfect port with 70% alcohol swab to remove any urine.

Remove clamp.

Send specimen to the laboratory immediately, together with a completed request
form noting this is a CSU.
The urine specimen must reach the laboratory for culture within 2 hours of collection to
avoid multiplication of possible contaminants.
When delay is inevitable refrigerate the urine at 4oC to retard the degeneration of cells and
multiplication of micro organisms. The urine will be suitable for culture for 24-48 hours if
kept at 4°C.
REFERENCES
Burke, J.P. and Zavasky, D. Nosocomial Urinary Tract Infections in Hospital Epidemiology
and Infection Control 2nd Edition by C. Glen Mayhall. Lippincott, Williams and Wilkins,
Philadelphia 1999.
Lee, G. and Bishop, P. Microbiology and Infection Control for Health Professionals.
Prentice Hall, Australia 1997.
Lewin, S. Urinary Tract Infections in Infectious Diseases – a Clinical Approach. Yung,
McDonald, Spelman, Street and Johnson, Cherry Print, Australia 2001.
Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the
Healthcare setting. Australian Government Department of Health and Ageing, 2004.
Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, et al. National evidence-based guidelines
for preventing healthcare-associated infections in NHS hospitals in England. J
Hosp.Infect(2007)65S, S1-S64
Wenzel RP. Prevention and control of nosocomial infections. 4th Edition Lippincott, Williams
and Wilkins Philadelphia 2003, pp 298-311
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