catheter related infxts jan
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Catheter-related bloodstream infections in intensive care units:a systematic review with meta-analysis
Prabha Ramritu, Kate Halton, David Cook, Michael Whitby & Nicholas Graves
Accepted for publication 28 August 2007
Correspondence to N. Graves:
e-mail: [email protected]
Prabha Ramritu MN RN
Project Officer
The Centre for Healthcare Related Infection
Surveillance & Prevention, Princess
Alexandra Hospital, Brisbane, Qld, Australia
Kate Halton MSc
Project Officer
The Centre for Healthcare Related Infection
Surveillance & Prevention, Princess
Alexandra Hospital, Brisbane, Qld, Australia
Institute of Biomedical and Health
Innovation, Brisbane, Qld, Australia
David Cook MBBS PhD
Medical Officer
Intensive Care Unit, Princess Alexandra
Hospital, Brisbane, Qld, Australia
Michael Whitby FRACP MPH
Director of Infectious Diseases
The Centre for Healthcare Related Infection
Surveillance & Prevention, Princess
Alexandra Hospital, Brisbane, Qld, Australia
Nicholas Graves PhD
Senior Research Fellow in Health Economics
The Centre for Healthcare Related Infection
Surveillance & Prevention, Princess
Alexandra Hospital, Brisbane, Qld, Australia
Institute of Biomedical and Health
Innovation, Brisbane, Qld, Australia
R A M RI T U P . , H A L T O N K . , C O O K D . , W H I T B Y M . & G R AV E S N . ( 2 0 08 )R A M RI T U P . , H A L T O N K . , C O O K D . , W H I T B Y M . & G R AV E S N . ( 2 0 08 ) Catheter-
related bloodstream infections in intensive care units: a systematic review with
meta-analysis. Journal of Advanced Nursing 62(1), 321
doi: 10.1111/j.1365-2648.2007.04564.x
AbstractTitle. Catheter-related bloodstream infections in intensive care units: a systematic
review with meta-analysis.Aim. This paper is a report of a systematic review and meta-analysis of strategies,
other than antimicrobial coated catheters, hypothesized to reduce risk of catheter-
related bloodstream infections and catheter colonization in the intensive care unit
setting.
Background. Catheter-related bloodstream infections occur at a rate of 5 per 1000
catheter days in the intensive care unit setting and cause substantial mortality and
excess cost. Reducing risk of catheter-related bloodstream infections among inten-
sive care unit patients will save costs, reduce length of stay, and improve outcomes.
Methods. A systematic review of studies published between January 1985 and
February 2007 was carried out using the keywords catheterization central venous
with combinations of infection*, prevention* and bloodstream*. All included
studies were screened by two reviewers, a validated data extraction instrument was
used and data collection was completed by two blinded independent reviewers. Risk
ratios for catheter-related bloodstream infections and catheter colonization were
estimated with 95% confidence intervals for each study. Results from studies of
similar interventions were pooled using meta-analyses.
Results. Twenty-three studies were included in the review. The strategies that
reduced catheter colonization included insertion of central venous catheters in the
subclavian vein rather than other sites, use of alternate skin disinfection solutions
before catheter insertion and use of Vitacuff in combination with polymyxin, neo-
mycin and bacitracin ointment. Strategies to reduce catheter-related bloodstream
infection included staff education multifaceted infection control programmes and
performance feedback.Conclusion. A range of interventions may reduce risks of catheter-related blood-
stream infection, in addition to antimicrobial catheters.
Keywords: bloodstream infection, central venous catheters, intensive care unit,
meta-analysis, nursing, prevention, systematic review
R E V I E W P A P E RJAN
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Introduction
Catheter-related bloodstream infections (CRBSI) occur at a
rate of 50 per 1000 catheter days in the intensive care unit
(ICU) setting (McLaws & Taylor 2003, Anonymous, 2004).
The mortality attributable to these infections may be as high
as 246% and length of stay is extended by between 7 and
191 days; the cost per case has been estimated to be
$US4888 (c. 2448) and 16,356 (c. 11,139) (Orsi et al.
2002, Rosenthal et al. 2003a). Reducing risk of CRBSI
among ICU patients will save costs, reduce length of stay and
improve mortality and morbidity.
The risk of CRBSI in the ICU setting depends on many
factors. Although many relate to patient diagnosis and
underlying health state, others are associated with discre-
tionary decisions made by healthcare professionals. Many
studies have focused on the use of anti-microbial catheters
to reduce rates in this clinical context and a number of
meta-analyses have been published that describe the effec-tiveness of different types of anti-microbial catheters for
the ICU setting (Veenstra et al. 1999, Marin et al. 2000,
Mermel 2000, Walder et al. 2002, Geffers et al. 2003).
However, a multitude of other interventions used at various
points in the catheter insertion and management pathway
are available. There are currently no systematic reviews
summarizing the evidence for these other interventions
specifically in relation to their effectiveness in the adult
ICU setting, or attempting to bring this information together
in one coherent summary (Halton & Graves 2007).
The review
Aim
The aim of the review was to evaluate strategies, other than
antimicrobial coated catheters, hypothesized to reduce risk of
CRBSI and catheter colonization in the ICU setting.
Design
A systematic review was conducted according to the methods
described by the Centre for Reviews and Dissemination,University of York (Centre for Reviews and Dissemination,
2001).
Search methods
Databases and search terms
A search was conducted of the following electronic data-
bases for research published between January 1985 and
February 2007: MEDLINE; Cumulative Index of Nursing
and Allied Health Literature (CINAHL); Current Contents;
Current Contents Connect; Australian Medical Index; Bio-
logical Abstracts; EMBASE; Science Citation; National
Library of Medicine; PubMed; Dissertation Abstracts;
Database of Review of Abstracts of Effectiveness; Cochrane
Library; Health Services Technology (National Health
Service, United Kingdom and United States of America);
National Clearing House (Agency for Healthcare Research
and Quality); Center for Disease Control guideline and
reports; Bandolier and Clinical Evidence (Wales BMJ
Publishing group). The broad MeSH search term, cathe-
terization central venous with combinations of keywords
infection*, prevention* and bloodstream* was used. The
reference lists of all relevant guidelines, systematic reviews,
and full articles of all studies included were hand-checked
for additional studies. Details of the inclusion and exclu-
sion criteria are presented in Table 1. Observational and
randomized controlled trial (RCT) designs were included.Studies were included if a definition of CRBSI was pro-
vided that required the isolation of the same organism from
the culture of a catheter segment and peripheral blood
cultures. Catheter colonization results were reported if the
study used a recognized definition of a positive catheter
colonization of either 15 colony forming units (CFU) by
semi-quantitative culture (Maki et al. 1977) or 103 CFU/
mL by quantitative technique from culture of the distal end
of the catheter (Brun-Buisson et al. 1987).
Table 1 Inclusion and exclusion criteria
Inclusion criteria
Full report of observational study or randomized controlled trial
Investigate short-term (
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Search outcome
Five hundred and sixty-nine abstracts were reviewed and 513
excluded. The remaining 56 articles were read in full and
judged explicitly against the inclusion criteria. Twenty-seven
were excluded and 29 met the inclusion criteria. Complete
data sets were obtained from twenty-three studies, published
between 1985 and February 2007: 13 RCTs, two trials and
nine observational cohort studies, see Table 2. Six were
excluded as part of the quality assessment exercise because
we could not obtain all the necessary data despite attempts to
contact the authors, see Table 3 for all exclusion criteria. The
process is illustrated by Figure 1.
Quality appraisal
Validated data extraction instruments for experimental and
observational studies chosen for clarity, comprehensiveness
and use in previous central venous catheter (CVC)-related
reviews [specifically the Evidence-based Practice Infection
Control (EPIC) project] were pilot tested and used (Prattet al. 2001). This instrument and the Scottish Intercollegiate
Guidelines Network (SIGN) checklist were used to assess
study quality (SIGN 2001). As in the EPIC project, studies
were grouped into three quality categories (Pratt et al. 2001):
category 1, well-designed study, findings can be generalized
to most hospitals; category 2, acceptable experimental study,
conclusions may be generalized and in absence of category 1
evidence, study accepted into review; category 3, study
methodology fatally flawed and rejected from review. Details
of the data extracted are provided in Appendix 1.
Data abstraction
All studies were screened by two reviewers using the abstract
or full paper. Data were extracted independently by two
reviewers (PR and either NG or DC or KH), blinded to the
author, date of publication and author affiliations, with
inconsistencies resolved by consultation. If required, corre-
sponding authors were contacted by e-mail, twice in 4 weeks,
to obtain missing information or clarify ambiguity.
Synthesis
For each study, the risk ratios (RR) with 95% confidence
intervals (CI) were calculated for the outcomes of CRBSI andcatheter colonization. A RR is a measure of relative risk
derived from two proportions. Relative risk is the risk of
developing a disease relative to exposure. Data from studies
investigating the same intervention were pooled. The DerSi-
monian & Laird method was used to calculate summary RR
with 95% CI for both outcomes via a random effects model
(Petitti 2000), normally distributed errors were assumed. This
method incorporates an assumption that the different studies
are estimating different, yet related, treatment effects. Sta-
tistical heterogeneity was assessed using the MantelHaenzel
test statistic. Studies brought together in any systematic
review will differ and these differences are known as statis-
tical heterogeneity. STATASTATA 9TM software package (StataCorp,
College Station, TX, USA) was used for all the statistical
analysis. No sensitivity or subgroup analysis was undertaken
due to the small number of studies anticipated to be available
for any one type of intervention.
Results
Study characteristics and a summary of results are presented
in Tables 3 and 4. Studies were grouped into eight categories:
site of CVC insertion; choice of skin disinfectant; catheter
replacement at a new site vs. exchange over a guidewire;
connectors and hubs; attachable cuffs; number of lumens on
the CVC; educational programme to increase healthcare
professional awareness of strategies to prevent infection; andcombined interventions. All 23 reported rates of CRBSI and
16 studies reported catheter colonization. The range of
definitions used in the studies are summarized in Table 5.
Site of insertion (two studies)
Short-term non-tunnelled CVC are inserted into the internal
jugular, subclavian, femoral or axillary veins and the risk of
CRBSI is believed to vary by site. One RCT (Merrer et al.,
2001) found a higher proportion of catheters inserted in the
femoral vein were colonized compared to the subclavian (RR
64; 95% CI: 19212; P < 0001) but there was no
difference in CRBSI rates (RR 2 02; 95% CI: 019221;
P = 06). A prospective comparative open study (Martin et al.
1998) found a similar colonization rate for internal jugular
vs. axillary vein (RR 106; 95% CI: 034332; P = 05) and
no significant difference in the CRBSI rate (RR 0 42; 95% CI:
004398; P = 041).
Skin disinfectant solutions (three studies)
The skin can be a source of CRBSI, with skin flora believed to
migrate along the subcutaneous insertion tract. The use ofskin disinfectants prior to insertion and ongoing management
of the catheter may be an important risk reducing strategy.
Three studies compared different types of skin disinfectants.
One RCT (Maki et al. 1991) compared 2% aqueous
chlorhexidine (Chl) gluconate to 10% povidone iodine (PI)
and 70% isopropyl alcohol. The 2% aqueous Chl solution
compared to 10% PI reduced colonization by 69% (RR 031;
95% CI: 017088; P = 001) but there was no statistically
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Table2
Studycharacteristics
Strategy&Author
Year
Studydesign
Setting(no.
ICUs)
Interventions
Sample
size
Participants
Durationof
study(months)
Mean
age(years)
%
Males
Siteofinsertion
Merrer
2001
RCT
M,
S(8)
Subclavianvs.
femoral
136
134
59
7
61
9
6270
93
2
Martin
1998
OBS
Mixed(1)
Axillaryvs.
internaljugular
62
79
54
59
7975
24
Insertionsiteskindisinfectings
olution
Humar
2000
RCT
M/S;M,
NS(4)
10%
PIvs.
0
5%
Chl
117
125
62
2
58
3
615
625
12
Maki
1991
RCT
S(1)
10%PIvs.
70%
alcoholvs.
2%
Chl
77
32
67
53
53
51
NRNRNR
7
Parienti
2004
CORT
M
(2)
5%
PI/70%
ethanolvs.
10%
aqueousPI
106*
117
54
4
61
5
NRNR
12
Catheterreplacement
Bach
1992
RCT
CS(1)
Newsitevs.
guidewireexchange
80
79
68
64
6661
NR
Devices:connectors
Luna
2000
RCT
ICU(1)&surgicalunits
Standardhubvs.
SegurLock
27*
24*
NR
NR
NRNR
18
Leon
2003
RCT
M,
S(7)
Standardhubvs.
SegurLock
114
116
59
6
58
1
649
586
15
Lucet
2000
RCT
M,
S(3)
Hubprotectionboxandstandardhub
vs.
needle-lessclosedconnectorwithmultiflohub
37
40
NR
NR
NRNR
3
Yebenes
2004
RCT
Mixed(1)
Standard3-waystopcockvs.
disinfecta
ble
needle
freeconnector
139*
139*
58
7
55
3
755
705
NR
Devices:cuff
Flowers
1989
RCT
S(1)
Nocuff&PNBvs.
vitacuff&PNB
29*
26*
49
1
42
5
812
790
9
Hasaniya
1996
NRT
S(2)
Nocuffvs.
vitacuff
64
90
47
57
NRNR
13
Lumens
Gupta
1995
RCT
NR(1)
Singlevs.
double
25
25
NR
NR
NRNR
12
Gil
1989
OBS
M
(1)
Singlevs.
triple
63*
157*
NR
NR
NRNR
15
Hilton
1988
OBS
Mixed(4)
Singlevs.
triple
99*
309*
NR
NR
NRNR
6
Farkas
1992
RCT
M/S(1)
Singlevs.
triple
51
54
63
5
65
5
NRNR
22
P. Ramritu et al.
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Table2
(Continued)
Strategy&Author
Year
Studydesign
Setting(no.
ICUs)
Interv
entions
Sample
size
Participants
Durationof
study(months)
Mean
age(years)
%
Males
Educationalprogramme
Warren
2003
OBS
M,S
(2)
Preintervention(nodetails)vs.
interventioneduc
ation,
posters,factsheetspostedinICU;10-pageself-study
modulecompleted
674
541
71
71
5252
29
Multipleinterventions
Bonawitz
1991
RCT
S(1)
Gp1
cuff&CVCremovedat3days
Gp2
cuff&CVCremovedat7days
Gp3
nocuff&CVCremovedat3days
Gp4
nocuff&CVCremovedat7days
40*
35*
45*
39*
NR
NR
NR
NR
NRNRNRNR
14
Cobb
1992
RCT
M,
S(2)
Gp1
CVCreplacedevery3days+insertionatnewsite
Gp2
CVCreplacedevery3days+exchangeoverguidewire
Gp3
CVCreplacedwhenclinically
indic
ated+insertionatnewsite
Gp4
CVCreplacedwhenclinically
indic
ated+exchangeoveraguidewire
35
40
41
44
57
59
55
59
685059 52
16
Civetta
1996
OBS
Trauma(1)
Phase
1:PIforskinpreparation
Ph2:
triplelumenChg/ssdCVCs
Phase
3chlorhexidineskincleanser,changeincriteria
forg
uidewireexchange;extensionofsafeperio
d
forc
atheterextensionfrom2to4days
147
34
156
NR
NR
NR
NRNRNR
15
Lobo
2005
OBS
M
(1)
Phase
1pretest,
observationofCVC
Phase
2effectofeducationprogram,
standardizedcathetercarepractices
Phase
3monthlyCRBSIratefeedback,
provision
ofCRBSI
preventionguidetoallmedicalresidents
316
190
266
NR
NR
NR
NRNR NR
23
Higuera
2005
OBS
M/SNS(2)
Phase
1activesurveillancewithoutprocesscontrol
Phase
2infectioncontroleducationprogram;process
controlofCVCcare;compliancewithinfection
controlpracticesandCVCcare
132
338
44
3
45
9
45
5
48
2
11
Rosenthal
2003
OBS
M/SC(4)
Phase
1surveillanceofCRBSIrates
Phase
2trainingandeducation
Phase
3performancefeedbackoncompliance
with
infectioncontrolprogrammeandCVCcare
NR
NR
NR
71
71
71
48
8
53
6
53
6
28
CRBSI,
catheter-relatedbloodstreaminfection;ICU,
intensivecareunit;C
VC,
centralvenouscatheter;NR,
notrepo
rted;RCT,
randomizedcontrolledtrial;O
BS:cohortobservational
study;CORT,
cross-overunit-randomizedtrial;NRT,
non-randomizedtrial;M,
medical;M/S,
medical/surgical;C,cardiac;S,surgical;CS,cardiacsurgical;NS,neuro-surgical.
*NumberofCVCsreportedon
ly.
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significant reduction for CRBSI (RR 023; 95% CI: 003
192; P = 014). Compared to the 70% alcohol solution the
2% Chl showed no statistically significant difference in
colonization (RR 038; 95% CI: 011133; P = 011) or
CRBSI rates (RR 024; 95% CI: 002254; P = 024).
Another RCT (Humar et al. 2000) compared 10% PI
solution with 05% tincture of Chl solution and found no
difference in rates of colonization or CRBSI (RR 0 8; 95% CI:
052126; P = 022; RR 107; 95% CI: 027417; P = 06
respectively). The third study (Parienti et al. 2004) used a
cross-over unit-randomized trial to compare 10% aqueous PI
solution with 5% PI in 70% ethanol based aqueous solution.
Colonization rates were significantly lower for alcoholic PI
(RR 038; 95% CI: 022 to 065; P < 0001) but there was
no significant difference in CRBSI rate (RR 03; 95% CI:
00324; P = 021).
Catheter replacement on new site vs. exchange over
guidewire (one study)
Catheters can be replaced by inserting a replacement
catheter in a new site, or by replacing the catheter over
a guide wire in the same insertion site. The one RCT
included in this review that looked at this intervention
found no significant difference in colonization rates withguidewire exchange relative to new site replacement (RR
037; 95% CI: 01135; P = 010) and no cases of CRBSI
were observed (Bach et al. 1992).
Use of devices: connectors (four studies)
Central venous catheter hubs may be a source of intralu-
minal catheter colonization and CRBSI due to frequent
manipulation and use of a PI connection shield might
reduce risk. Two RCTs (Lucet et al. 2000, Leon et al.
2003) compared the rate of CRBSI observed with use of a
Segur-Lock (Inibsa Laboratories, Barcelona, Spain) connec-
tor relative to that observed under use of a standard hub.
Luna (Luna et al. 2000) included patients from ICU and
surgical units and data from ICU participants only are
included in the analysis. The pooled findings of these two
studies indicated a non-significant reduction in risk of
CRBSI with Segur-Lock, see Figure 2 (RR 027; 95% CI:
007105). Lucet et al. (2000) compared antiseptic impreg-
nated hub protection boxes to needle-less closed connectors
in a RCT, and reported a non-significant difference in risk
of catheter colonization and CRBSI (RR 1 25; 95% CI:
0662
37; P = 0
3 and RR 0
96; 95% CI: 0
0614
99;
P = 074, respectively). The fourth RCT (Yebenes et al.
2004) compared a disinfectable needle-free connector to the
standard three-way stopcock. The rates of CRBSI and
catheter colonization were lower in the needle-free connec-
tor group, with this difference approaching statistical
significance for CRBSI (RR 014; 95% CI: 002114;
P = 003), but not for catheter colonization (RR 0 69; 95%
CI: 0316; P = 037).
Use of devices: cuffs (two studies)
A biodegradable collagen cuff impregnated with bacterici-
dal silver ions (Vitacuff; Vitaphore Corp, Menlo Park, CA,
USA) has been suggested to prevent CVC colonization from
skin organisms migrating along the subcutaneous tract.
One RCT (Flowers et al. 1989) and one non-randomized
trial (Hasaniya et al. 1996) investigated triple-lumen
catheters with an attachable cuff (Vitacuff) relative to
catheters with no cuff. In the RCT, colonization rates with
Table 3 Reasons for excluding studies following full review
Excluded papers Reasons for exclusion
Roberts & Cheung (1998) Definition of CRBSI was not clear.
Berenholtz et al. (2004) Insufficient information
on inclusion criteria
Carrer et al. (2005) Insufficient information
on inclusion criteria
Coopersmith et al. (2002) Insufficient information
on inclusion criteria
Warren et al. (2004) Insufficient information
on inclusion criteria
Badley et al. (1996) Insufficient data on proven CRBSI
to calculate rate of CRBSI in the
three comparison groups
CRBSI, catheter-related bloodstream infection.
Search strategy
569 abstracts for review
513 rejected
27 excluded
(did not meet inclusion criteria)
6 excluded
(complete data sets not available)
56 articles for further review
29 included for full review
23 included
Figure 1 Search strategy and study selection.
P. Ramritu et al.
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Table4
Summaryresultsofincludedstudies(groupedtogetheraccording
topreventativestrategyexamined)
Preventativestrategy/Author
Year
Intervention
Proportionofcoloniza
tionRR(95%
CI)
ProportionofCRBS
IRR(95%
CI)
Siteofinsertion
Merrer
2001
Subclavianvs.
femoral
3/136
19/134
RR(usingfemoralsite
)6
4
(1
92
1
2,
P
1CVC
allowed
Multipleinterventions
Bonawitz
1991
SC;IJ
M
S,SG,
SGl
,C,
M
NS
Ga
uzepad
&
Opsite
2-3
Gps1&33
Gps2&47
Yes
Cobb
1992
SC,
IJ
3
M,
SG,SG
l,SD
10%PI
G,
AO
2
Gp13
Gp23
Gp36
Gp47
Yes
Civetta
1996
NR
3
M,C,S
G,SGl
Phase1:PI
Phase2:4%
chl
SG
/AO
PRN,
3
Phase
14
5
Phase
35
4
Yes
Lobo
2005
SCmostly
NS
SG,S
Gl,LD,
C,M
PI
G
PRN,
daily
NS
NS
Higuera
2005
NS
S
Fullbarrier
precaution
sometime
s
NS
G
NS
7
3*
NS
Rosenthal
2003
NS
S
NS
NS
G
NS
7
07*
NS
NS,notspecified;NR,
notrepo
rted;CVC,
centralvenouscatheter;A,
axillary;F.
femoral;IJ,
internaljugular;J,jugular;NR,
notreported;S,supraclavicular;SC,
subclavian;NC,
non-
coatedCVCs;Chg/ssd,
chlorhexidinegluconate/silversulfadiazinecoated
CVCs;M,
multiple;S,standard;SP,
standardpolyurethaneCVC;D,
drapes;LD,lar
gedrape;MBP,
maximal
barrierprecaution;SD,
steriledrape;LSD,
largesteriledrape;G.
gown;SG.
sterilegown;SGl,sterilegloves;Gl,gloves;M,
mask;C,
cap;Alc,
alcohol;AlcPI.alcoholicpovidoneiodine;Aq
PI,aqueouspovidoneiodine;AO
,antibiotic/antimicrobialointment;Chlg,chlorhexidinegluconate;Chl,chlorhexidine;I,iodinetincture;PI,povidoneiodine;SSD,s
tandardsteriledressing;
TSD,
transparentsteriledressing;TPU,
transparentpolyurethanedressing;
SG,
sterilegauze;G,
gauze;THD,
transparenthydrocolloiddressing;SPU,
standardpo
lyurethanedressing;AO,
antiseptic/antimicrobialointmentappliedoninsertionsite;PRN,
changed
asrequired;SP,
studysitepreference.
*Informationobtainedfromau
thorsviae-mail.
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error and bias can be minimized at all stages of the research.
Other limitations of the available evidence include the
inadequate power of many of the studies to detect a real
difference in CRBSI and colonization rates. Where possible
we combined evidence in meta-analyses, but the small
number of studies available for which we could pool datastill precluded the provision of statistical support for the
effectiveness of interventions. For example, colonization rates
were lower but did not reach significance at the 5% level for a
number of interventions such as 10% PI vs. 05% Chl
(Humar et al. 2000) and new site vs. guidewire exchange for
CVC replacement (Bach et al. 1992). We suggest future
studies be designed with a sample size large enough to detect
a real difference or to inform a subsequent meta-analysis.
The appraisal of evidence for reducing catheter coloniza-
tion and CRBSI is further complicated by the fact that a
number of different interventions are used concurrently inthe insertion and ongoing management of CVC. Unless all
studies investigating a particular intervention control for the
effect of these co-interventions it will be difficult to determine
the interventions that are most effective in reducing coloni-
zation and CRBSI, and if we can expect to achieve this effect
in other settings. As shown in Table 7, there was much
clinical heterogeneity in the studies and important confound-
ing data was often not provided for some co-interventions
such as site of insertion, use of barrier precautions and type
of disinfecting solution. Other problems arise from the
findings being influenced by the absence of a consistent
definition for CRBSI, see Table 5, and inconsistent catheter
management protocols across studies. In short, we still do
not have a full understanding of the most effective ways to
prevent CRBSI in the ICU context although this review and
others can help to indicate where some of the largest gaps in
our knowledge lie.
Conclusion
Interventions other than antimicrobial catheters may be
useful for reducing risks of CRBSI in the ICU setting.
Infection control is typically nurse-led within a wider multi-
disciplinary team and nurses play a key role in the care of ICU
patients, including assisting with the insertion and daily
management of CVCs. Nurse awareness and implementation
of appropriate risk reducing strategies is important. Thisreview is relevant to evidence-based nursing practice in many
international settings. It highlights the strength of evidence
underlying each intervention and the recent trend to use a
combination of most effective interventions to manage the
care of CVC. The strategies we recommend are relatively
low-cost, pose minimal risks for patients and constitute good
nursing practice. Finally, good decision-making requires that
the cost-effectiveness of all interventions be assessed and
compared, but understanding their effectiveness is an impor-
tant first step.
Acknowledgements
Financial support for the study was provided by the National
Health & Medical Research Council of Australia.
Author contributions
PR and NG were responsible for the study conception and
design and PR, DC and NG were responsible for the drafting
of the manuscript. PR, KH, DC and NG performed the data
collection and PR performed the searches and data analysis.
MW and NG obtained funding. PR, KH, DC and NG madecritical revisions to the paper. KH provided statistical advice.
DC, MW and NG supervised the study.
References
Anonymous (2004) National Nosocomial Infections Surveillance
System. National Nosocomial Infections Surveillance (NNIS) Sys-
tem report, data summary from January 1992 through June 2004,
What is already known about this topic
Catheter-related bloodstream infection arising in the
intensive care unit setting is a serious clinical and
economic problem.
Antimicrobial catheters are effective at reducing risk of
catheter-related bloodstream infection in the intensive
care unit setting.
Less is known about the effectiveness of other risk
reducing strategies.
What this paper adds
There is some evidence for strategies other than anti-
microbial catheters, such as staff education, multifac-
eted infection control programmes and performance
feedback.
This quality of this evidence is mixed and studies are
characterized by small samples. These interventions may be less costly and easier to
implement than widespread use of antimicrobial
catheters, but further work to model the cost-effec-
tiveness of all strategies is required.
P. Ramritu et al.
18 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
-
8/3/2019 Catheter Related Infxts JAN
17/20
issued October 2004. American Journal of Infection Control 32,
470485.
Bach A., Stubbig K. & Geiss H. (1992) Infectious risk of replacing
venous catheters by the guide-wire technique. Zentralblatt fur
Hygiene und Umweltmedizin 193, 150159.
Badley A., Steckelberg J., Wollan P. & Thompson R. (1996)
Infectious rates of central venous pressure catheters: comparison
between newly placed catheters and those that have been changed.
Mayo Clinic Proceedings 71, 838846.Berenholtz S., Pronovost P., Lipsett P., Hobson D., Earsing K., Farley
J., Milanovich S., Garrett-Mayer E., Winters B., Rubin H.,
Dorman T. & Perl T. (2004) Eliminating catheter-related blood-
stream infections in the intensive care unit. Critical Care Medicine
32, 20142020.
Bonawitz S., Hammell E. & Kirkpatrick J. (1991) Prevention of
central venous catheter sepsis: a prospective randomized trial.
American Surgeon 57, 618623.
Brun-Buisson C., Abrouk F., Legrand P., Huet Y., Larabi S. & Rapin
M. (1987) Diagnosis of central venous catheter-related sepsis.
Archives of Internal Medicine 147, 873877.
Carrer S., Bocchi A., Bortolotti M., Braga N., Gilli G., Candini M. &
Tartari S. (2005) Effect of different sterile barrier precautions and
central venous catheter dressing on the skin colonization around
the insertion site. Minerva Anestesiologica 71, 197206.
Centre for Reviews and Dissemination (2001) Undertaking
Systematic Reviews of Research on Effectiveness: CRDs Guidance
for Those Carrying out or Commissioning Reviews. CRD Report
Number 4, 2nd edn. University of York, York.
Centres for Disease Control and Prevention (2002) Guidelines for the
prevention of intravascular catheter-related infections. MMWR
51(RR10), 126.
Civetta J., Hudson-Civetta J. & Ball S. (1996) Decreasing catheter-
related infection and hospital costs by continuous quality
improvement. Critical Care Medicine 24, 16601665.
Cobb D., High K., Sawyer R., Sable C., Adams R., Lindley D., Prvett
T., Schwenzer K. & Farr B. (1992) A controlled trial of scheduledreplacement of central venous and pulmonary-artery catheters.
[comment]. New England Journal of Medicine 327, 10621068.
Coopersmith C., Rebmann T., Zack J., Ward M., Corcoran R.,
Schallom M., Sona C., Buchman T., Boyle W., Polish L. & Fraser
V. (2002) Effect of an education program on decreasing catheter-
related bloodstream infections in the surgical intensive care unit.
Critical Care Medicine 30, 5964.
Farkas J., Liu N., Bleriot J., Chevret S., Goldstein F. & Carlet J.
(1992) Single-versus triple-lumen central catheter-related sepsis:
a prospective randomized study in a critically ill population.
American Journal of Medicine 93, 277282.
Flowers R., Schwenzer K., Kopel R., Fisch M., Tucker S. & Farr B.
(1989) Efficacy of an attachable subcutaneous cuff for the pre-
vention of intravascular catheter-related infection. A randomized,
controlled trial. JAMA 261, 878883.
Gastmeier P. & Geffers C. (2006) Prevention of catheter-related
bloodstream infections: analysis of studies published between 2002
and 2005. Journal of Hospital Infection 64, 326335.
Geffers C., Zuschneid I., Eckmanns T., Ru den H. & Gastmeier P.
(2003) The relationship between methodological trial quality and
the effects of impregnated central venous catheters. Intensive Care
Medicine 29, 403409.
Gil R., Kruse J., Thill-Baharozian M. & Carlson R. (1989) Triple- vs.
single-lumen central venous catheters: a prospective study in a
critically ill population. Archives of Internal Medicine 149, 1139
1143.
Gupta S., Batra Y., Puri G., Panigrahi D. & Roy S. (1995) Infection
rates in single- and double-lumen central venous catheters in cri-
tically ill patients. National Medical Journal of India 8, 114117.
Halton K. & Graves N. (2007) Economic evaluation and catheter-
related bloodstream infections. Emergency Infectious Disease 13,815823.
Harris A., Lautenbach E. & Prebencevich E. (2005) A systematic
review of quasi-experimental study designs in the fields of infection
control and antibiotic resistance. Clinical Infectious Diseases 41,
7782.
Hasaniya N., Angelis M., Brown M. & Yu M. (1996) Efficacy of
subcutaneous silver-impregnated cuffs in preventing central venous
catheter infections. Chest109, 10301032.
Higuera F., Rosenthal V., Duarte P., Ruiz J., Franco G. & Safdar N.
(2005) The effect of process control on the incidence of central
venous catheter-associated bloodstream infections and mortality
in intensive care units in Mexico. Critical Care Medicine 33, 2022
2027.
Hilton E., Haslet T., Borenstein M., Tucci V. & Isenberg H. (1988)
Central venous infections: single- versus triple-lumen catheters:
influence of guidewires on infection rates when used for replace-
ment of catheters. American Journal of Medicine 84, 667672.
Humar A., Ostromecki A., Direnfeld J., Marshall J., Lazar N.,
Houston P., Boiteau P. & Conly J. (2000) Prospective randomized
trial of 10% povidone-iodine versus 0.5% tincture of chlorhex-
idine as cutaneous antisepsis for prevention of central venous
catheter infection. Clinical Infectious Diseases 31, 10011007.
Leon C., Alvarez Lerma F.,Ruiz Santana S.,Gonzalez V., De La Torre
M., Sierra R., Leon M. & Rodrigo J. (2003) Antiseptic chamber-
containing hub reduces central venous catheter-related infection: a
prospective, randomized study. Critical Care Medicine 31, 1318
1324.Lobo R., Levin A., Gomes L., Cursino R., Park M., Figueiredo V.,
Taniguchi L., Polido C. & Costa S. (2005) Impact of an educa-
tional program and policy changes on decreasing catheter-asso-
ciated bloodstream infections in a medical intensive care unit in
Brazil. American Journal of Infection Control 33, 8387.
Lucet J., Hayon J., Bruneel F., Dumoulin J. & Joly-Guillou M. (2000)
Microbiological evaluation of central venous catheter administra-
tion hubs. Infection Control and Hospital Epidemiology 21, 40
42.
Luna J., Masdeu G., Perez M., Claramonte R., Forcadell J., Barra-
china F. & Panisello M. (2000) Clinical trial evaluating a new hub
device designed to prevent catheter-related sepsis. European Jour-
nal of Clinical Microbiology and Infectious Diseases 19, 655662.
Maki D., Weise C. & Sarofin H. (1977) A semiquantitative culture
method for identifying intravenous catheter-related infection. New
England Journal of Medicine 296, 13051309.
Maki D., Ringer M. & Alvarado C. (1991) Prospective randomised
trial of povidone-iodine, alcohol, and chlorhexidine for prevention
of infection associated with central venous and arterial catheters.
Lancet338, 339343.
Marin M., Lee J. & Skurnick J. (2000) Prevention of nosocomial
bloodstream infections: effectiveness of antimicrobial-impregnated
JAN: REVIEW PAPER Catheter-related bloodstream infections in intensive care units
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 19
-
8/3/2019 Catheter Related Infxts JAN
18/20
and heparin-bonded central venous catheters. Critical Care
Medicine 28, 33323338.
Martin C., Bruder N., Papazian L., Saux P. & Gouin F. (1998)
Catheter-related infections following axillary vein catheterization.
Acta Anaesthesiologica Scandinavica 42, 5256.
McLaws M. & Taylor P. (2003) The hospital infection standardised
surveillance (HISS) programme: analysis of a two-year pilot.
Journal of Hospital Infection 53, 259267.
Mermel L. (2000) Prevention of intravacular catheter-related infec-tions. Annals Internal Medicine 132, 391402.
Merrer J., De Jonghe B., Golliot F., Lefrant J., Raffy B., Barre E.,
Rigaud J., Casciani D., Misset B., Outin Bosquet C., Brun-Buisson
C., Nitenberg G. & French Catheter Study Group (2001)
Complications of femoral and subclavian venous catheterization in
critically ill patients - A randomized controlled trial. JAMA 286,
700707.
Orsi G., Stefano L. & Noah N. (2002) Hospital-acquired, labora-
tory-confirmed bloodstream infection: increased hospital stay and
direct costs. Infection Control and Hospital Epidemiology 23,
190197.
Parienti J., Du Cheyron D., Ramakers M., Malbruny B., Leclercq
R., Le Coutour X. & Charbonneau P. (2004) Alcoholic povi-
done-iodine to prevent central venous catheter colonization: a
randomized unit-crossover study. Critical Care Medicine 32,
708713.
Petitti D. (2000) Meta-analysis, Decision Analysis, and Cost-Effec-
tiveness Analysis: Methods for Quantitative Synthesis in Medicine.
Oxford Univeristy Press, Oxford.
Pratt R., Pellowe C., Loveday H., Robinson N., Smith G., Barrett S.,
Davey P., Harper P., Loveday C., Mcdougall C., Mulhall A.,
Privett S., Smales C., Taylor L., Weller B. & Wilcox M. (2001) The
Epic project. Developing national evidence based guidelines for
preventing hospital acquired infections associated with the use of
central venous catheters. Technical report Part A & B. Journal of
Hospital Infections 47(Suppl), S3S82.
Rijnders B. & Van Wijngaerden E. (2002) Catheter-tip colonizationas a surrogate end point in clinical studies on catheter-related
bloodstream infection: how strong is the evidence? Clinical In-
fectious Diseases 35, 10531058.
Roberts B. & Cheung D. (1998) Biopatcha new concept in anti-
microbial dressings for invasive devices. Australian Critical Care
11, 1619.
Rosenthal V., Guzman S. & Migone O. (2003a) The attributable
cost, length of stay, and mortality of central line-associated
bloodstream infection in intensive care departments in Argentina: a
prospective, matched analysis. American Journal of Infection
Control31, 475480.
Rosenthal V., Guzman S., Pezzotto S. & Crnich C. (2003b) Effect ofan infection control program using education and performance
feedback on rates of intravascular device-associated bloodstream
infections in intensive care units in Argentina. American Journal of
Infection Control 31, 405409.
Scottish Intercollegiate Guidelines Network (2001) SIGN 50: A
Guideline Developers Handbook. Royal College of Physicians
of Edinburgh, Edinburgh. Available at http://www.sign.ac.uk.
accessed on 5 February 2007.
Veenstra D., Saint S., Saha S., Lumley T. & Sullivan S. (1999) Effi-
cacy of antiseptic-impregnated central venous catheters in pre-
venting catheter-related bloodstream infection: a meta-analysis.
JAMA 281, 261267.
Walder B., Pittet D. & Tramer M. (2002) Prevention of bloodstream
infections with central venous catheters treated with anti-infective
agents depends on catheter type and insertion time: evidence from
a meta-analysis. Infection Control and Hospital Epidemiology 23,
748756.
Warren D., Zack J., Cox M., Cohen M. & Fraser V. (2003) An
educational intervention to prevent catheter-associated blood-
stream infections in a nonteaching, community medical center.
Critical Care Medicine 31, 19591963.
Warren D., Zack J., Mayfield J., Chen A., Prentice D., Fraser V. &
Kollef M. (2004) The effect of an education program on the in-
ciderce of central venous catheter-associated bloodstream infection
in a medical ICU. Chest126, 16121618.
Yebenes J., Vidaur L., Serra-Prat M., Sirvent J., Batlle J., Motje M.,
Bonet A. & Palomar M. (2004) Prevention of catheter-relatedbloodstream infection in critically ill patients using a disinfectable,
needle-free connector: a randomized controlled trial. American
Journal of Infection Control32, 291295.
P. Ramritu et al.
20 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
-
8/3/2019 Catheter Related Infxts JAN
19/20
Appendix 1
Details of data extracted.
Clinical data: experimental and observational studies
Study aim/objective
Definitions of study outcomes
Study design: type, appropriateness to aim
Study setting/characteristics of sample/inclusion criteria/sample size; study dates
Details of intervention type, regimen, co-interventions
Outcomes baseline measures, details of measurement, summary results
Duration of follow-up
Investigators conclusions, reviewer agreements and any reservations
Hand search of reference list
Data analysis
Preintervention comparability table
Similarity of subjects at start of study
Quality: experimental studies
Method of allocation, randomization; blinding
Sample size power calculation
Equal treatment of groups other than intervention
Bias due to drop out, characteristics and reasons for withdrawalsAppropriateness of statistical analysis, intention to treat or as treated
Dealing with confounding variables
Quality
Observational studies
Method of sample selection
Comparability of groups at baseline
Drop-out rate
Details of withdrawal
Appropriateness of statistical analysis
Summary of reviewers judgement for experimental and observational studies
Soundness of methodology design
Generalizability of findings
Clinical importance of outcomes
Harm/benefit analysisRisk of bias
Need for author contact for further information/ statistical assessment required
Acceptance of paper into review
Study grading for experimental studies
Category 1: study well designed experimental study; findings generalizable
Category 2: acceptable design, in absence of category 1, accept study into review
Category 3: methodologically fatally flawed, reject study.
Study grading for observational studies
Category 1: well designed observational study, findings generalizable
Category 2: acceptable design, in absence of category 1, accept study into review
Category 3: methodologically fatally flawed, reject study.
Sources: (Scottish Intercollegiate Guidelines Network 2001) & (Pratt et al. 2001).
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