Prevalence of the use of central venous access devices within and outside of the intensive care unit: results of a survey among hospitals in the prevention epicenter program of the Centers for Disease Control and Prevention.

OBJECTIVE: To determine the prevalence of central venous catheter (CVC) use among patients both within and outside the ICU setting. DESIGN: A 1-day prevalence survey of CVC use among adult inpatients at six medical centers participating in the Prevention Epicenter Program of the CDC. Using a standardized form, observers at each Epicenter performed a hospital-wide survey, collecting data on CVC use. SETTING: Inpatient wards and ICUs of six large urban teaching hospitals. RESULTS: At the six medical centers, 2,459 patients were surveyed; 29% had CVCs. Among the hospitals, from 43% to 80% (mean, 59.3%) of ICU patients and from 7% to 39% (mean, 23.7%) of non-ICU patients had CVCs. Despite the lower rate of CVC use on non-ICU wards, the actual number of CVCs outside the ICUs exceeded that of the ICUs. Most catheters were inserted in the subclavian (55%) or jugular (22%) site, with femoral (6%) and peripheral (15%) sites less commonly used. The jugular (33.0% vs 16.6%; P < .001) and femoral (13.8% vs 2.7%; P < .001) sites were more frequently used in ICU patients, whereas peripherally inserted (19.9% vs 5.9%; P < .001) and subclavian (60.7% vs 47.3%; P < .001) catheters were more commonly used in non-ICU patients. CONCLUSIONS: Current surveillance and infection control efforts to reduce morbidity and mortality associated with bloodstream infections concentrate on the high-risk ICU patients with CVCs. Our survey demonstrated that two-thirds of identified CVCs were not in ICU patients and suggests that more efforts should be directed to patients with CVCs who are outside the ICU.     

Device-associated infection rates for non-intensive care unit patients.

BACKGROUND: Reference data from intensive care units (ICUs) are not applicable to non-ICU patients because of the differences in device use rates, length of stay, and severity of underlying diseases among the patient populations. In contrast to the huge amount of data available for ICU patients, appropriate surveillance data for non-ICU patients have been missing in Germany. OBJECTIVE: To establish a new module ("DEVICE-KISS") of the German Nosocomial Infection Surveillance System for generating stratified reference data for non-ICU wards. SETTING: Non-ICU patients from 42 German hospitals. METHODS: Monthly patient-days, device-days and nosocomial infections (NIs) (using Centers for Disease Control and Prevention definitions) were counted. Device use rates were calculated, and NI rates were stratified by different medical specialities. RESULTS: From July 2002 through June 2004, among the 77 wards, there were a total of 536,955 patient-days and 74,188 device-days (for CVC-associated primary bloodstream infections, there were 181,401 patient-days and 8,317 central vascular catheter [CVC]-days in 29 wards; for urinary catheter-associated urinary tract infections, there were 445,536 patient-days and 65,871 urinary catheter-days in 65 wards) and 483 NIs (36 bloodstream infections and 447 urinary tract infections). The mean device use rates were 4.6 device-days per 100 patient-days for CVCs (29 wards) and 14.8 device-days per 100 patient-days for urinary catheters (65 wards), respectively. Mean device-associated NI rates were 4.3 infections per 1,000 CVC-days for CVC-associated bloodstream infections and 6.8 infections per 1,000 urinary catheter-days for catheter-associated urinary tract infections. CONCLUSIONS: DEVICE-KISS allows non-ICUs to recognize an outlier position with regard to NIs by providing well-founded reference data for non-ICU patients.     

Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected

Catheter-related bloodstream infections (CRBSIs) are among the most frequent healthcare-associated infections and cause considerable morbidity, mortality, and resource use. CRBSI surveillance serves quality improvement, but is often restricted to intensive care units (ICUs). We conducted a four-month prospective cohort study of all non-cuffed central venous catheters (CVCs) to design an efficient CRBSI surveillance and prevention programme. CVCs were assessed on a daily basis for ward exposure time, care parameters, and the occurrence of laboratory-confirmed CRBSI. Overall, 248 patients with 426 CVCs accounted for 3567 CVC-days (median: 5) and 15 CRBSI episodes. CVCs were inserted by anaesthetists, ICU physicians and internists in 45%, 47%, and 8% of cases, respectively. CVC utilisation rates for intensive care, internal medicine, non-abdominal surgery and abdominal surgery were 29.8, 3.8, 1.7 and 4.9 per 100 patient-days, respectively. Fourteen percent of patients changed wards while having a CVC in place, so spending CVC-days at risk within multiple departments. CRBSI incidence densities for ICU, internal medicine, surgery and abdominal surgery were 5.6, 1.9, 2.4 and 7.7 per 1000 CVC-days at risk, respectively. In a univariate Cox proportional hazards model, the high CRBSI rate in abdominal surgery was associated with longer CVC duration, frequent use of parenteral nutrition and CVC insertion by anaesthetists. CRBSI numbers were insufficient to perform a multivariate analysis. Our surveillance revealed similar CRBSI rates in both ICU and non-ICU departments, and when frequent ward transfers occurred. Hospital-wide CRBSI surveillance is advisable when a large proportion of CVC-days occur outside the ICU.     

Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units.

BACKGROUND: Defining risk factors for central venous catheter (CVC)-associated bloodstream infections (BSIs) is critical to establishing prevention measures, especially for factors such as nurse staffing and antimicrobial-impregnated CVCs. METHODS: We prospectively monitored CVCs, nurse staffing, and patient-related variables for CVC-associated BSIs among adults admitted to eight ICUs during 2 years. RESULTS: A total of 240 CVC-associated BSIs (2.8%) were identified among 4,535 patients, representing 8,593 CVCs. Antimicrobial-impregnated CVCs reduced the risk for CVC-associated BSI only among patients whose CVC was used to administer total parenteral nutrition (TPN, 2.6 CVC-associated BSIs per 1,000 CVC-days vs no TPN, 7.5 CVC-associated BSIs per 1,000 CVC-days; P = .006). Among patients not receiving TPN, there was an increase in the risk of CVC-associated BSI in patients cared for by "float" nurses for more than 60% of the duration of the CVC. In multivariable analysis, risk factors for CVC-associated BSIs were the use of TPN in non-antimicrobial-impregnated CVCs (P = .0001), patient cared for by a float nurse for more than 60% of CVC-days (P = .0019), no antibiotics administered to the patient within 48 hours of insertion (P = .0001), and patient unarousable for 70% or more of the duration of the CVC (P = .0001). Peripherally inserted central catheters (PICCs) were associated with a lower risk for CVC-associated BSI (P = .0001). CONCLUSIONS: Antimicrobial-impregnated CVCs reduced the risk of CVC-associated BSI by 66% in patients receiving TPN. Limiting the use of float nurses for ICU patients with CVCs and the use of PICCs may also reduce the risk of CVC-associated BSI.     

A prospective, randomized study in critically ill patients using the Oligon Vantex catheter

Microbial colonization and the incidence of catheter-related bloodstream infections (CR-BSI) associated with Oligon Vantex silver central venous catheters (CVC) in critically ill patients were determined. A prospective, randomized, controlled 17-month trial was carried out in an intensive care unit (ICU). All patients requiring a triple-lumen CVC for four days or longer were enrolled. Patients were randomized to receive a standard polyurethane CVC or an Oligon Vantex silver CVC. Before removal of the catheter either due to discharge from the ICU or suspected infection, blood for cultures was taken via the CVC and a peripheral site. Skin and hub swabs and catheter-tips were also cultured. Two hundred and six catheters, 103 in both groups, were evaluated. In the control group (CG) 45/103 (44%) and in the silver group (SG) 30/103 (29%) were colonized or had a CR-BSI (P=0.04). The SG was less likely to be colonized than the CG when the catheter remained in situ for eight days or less (P=0.03) or over 15 days (P=0.01); a second or subsequent catheter was present in the same patient (P=0.002), or if the CVC was placed in the internal jugular vein (P=0.05). Multivariate logistic-regression showed predisposing factors for catheter colonization were jugular and femoral sites, second or subsequent catheter, and being a member of the CG. CR-BSI occurred in five cases (four in CG). Rates of CR-BSI per 1000 catheter-days in the CG were 2.8 and in the SG, 0.8 (P<0.001). The Oligon Vantex silver catheter reduced the incidence of catheter-colonization and may decrease the risk of CR-BSI.     

Risk Factors for the Development of Catheter‐Related Bloodstream Infections in Patients Receiving Home Parenteral Nutrition

Background: Risk factors for development of catheter‐related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN). Methods: Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006‐December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN. Results: In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non‐PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone‐iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine‐containing regimens. Conclusion: Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.     

重症监护病房中心静脉导管相关性血流感染病原菌及相关因素分析

目的探讨医院重症监护病房(ICU)中心静脉导管导管相关性血流感染(CRBSI)的病原菌分布特点及其耐药情况,并分析CRBSI的相关因素。方法对医院各科ICU 2008年1~12月所有放置中心静脉导管进行回顾性分析。结果109例患者总置管日2456 d,共送检165份中心导管尖端和283份血培养标本,导管53例阳性,阳性率为32.1%,与导管尖端培养出同一种细菌的血培养14例,导管尖端细菌定植率为21.6‰,感染率为5.7‰;引起CRBSI病原菌主要是凝固酶阴性葡萄球菌(28.6%)、金黄色葡萄球菌(21.4%)和白色假丝酵母菌(21.4%)。结论研究显示,引起CRBSI的菌株耐药率非常高,应加强导管管理的全程监控。     

Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the prevention epicenter program.

OBJECTIVE: To determine the extent to which evidence-based practices for the prevention of central venous catheter (CVC)-associated bloodstream infections are incorporated into the policies and practices of academic intensive care units (ICUs) in the United States and to determine variations in the policies on CVC insertion, use, and care. DESIGN: A 9-page written survey of practices and policies for nontunneled CVC insertion and care. SETTING: ICUs in 10 academic tertiary-care hospitals. PARTICIPANTS: ICU medical directors and nurse managers. RESULTS: Twenty-five ICUs were surveyed (1-6 ICUs per hospital). In 80% of the units, 5 separate groups of clinicians inserted 24%-50% of all nontunneled CVCs. In 56% of the units, placement of more than two-thirds of nontunneled CVCs was performed in a single location in the hospital. Twenty units (80%) had written policies for CVC insertion. Twenty-eight percent of units had a policy requiring maximal sterile-barrier precautions when CVCs were placed, and 52% of the units had formal educational programs with regard to CVC insertion. Eighty percent of the units had a policy requiring staff to perform hand hygiene before inserting CVCs, but only 36% and 60% of the units required hand hygiene before accessing a CVC and treating the exit site, respectively. CONCLUSION: ICU policy regarding the insertion and care of CVCs varies considerably from hospital to hospital. ICUs may be able to improve patient outcome if evidence-based guidelines for CVC insertion and care are implemented.     

Catheter-associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study.

OBJECTIVE: To determine the incidence of central venous catheter (CVC)-associated bloodstream infection (CA-BSI) among patients admitted to general medical wards outside the intensive care unit (ICU). DESIGN: Prospective cohort study performed over a 13-month period, from April 1, 2002, through April 30, 2003. SETTING: Four selected general medical wards at Barnes-Jewish Hospital, a 1,250-bed teaching hospital in Saint Louis, Missouri. PATIENTS; All patients admitted to 4 general medical wards. RESULTS: A total of 7,337 catheter-days were observed during 33,174 patient-days. The device utilization ratio (defined as the number of catheter-days divided by the number of patient-days) was 0.22 overall and was similar among the 4 wards (0.21, 0.25, 0.19, and 0.24). Forty-two episodes of CA-BSI were identified (rate, 5.7 infections per 1,000 catheter-days). Twenty-four (57%) of the 42 cases of CA-BSI were caused by gram-positive bacteria: 10 isolates (24%) were coagulase-negative staphylococci, 10 (24%) were Enterococcus species, and 3 (7%) were Staphylococcus aureus. Gram-negative bacteria caused 7 infections (17%). Five CA-BSIs (12%) were caused by Candida albicans, and 5 infections (12%) had a polymicrobial etiology. Thirty-five patients (83%) with CA-BSI had nontunneled CVCs in place. CONCLUSIONS: Non-ICU medical wards in the study hospital had device utilization rates that were considerably lower than those of medical ICUs, but CA-BSI rates were similar to CA-BSI rates in medical ICUs in the United States. Studies of catheter utilization and on CVC insertion and care should be performed on medical wards. CA-BSI prevention strategies that have been used in ICUs should be studied on medical wards.     

Prevention of central venous catheter-related bloodstream infections using non-technologic strategies.

OBJECTIVE: To evaluate the incidence of nosocomial bacteremias related to the use of non-impregnated central venous catheters (CVCs) when only non-technologic strategies were used to prevent them. DESIGN: This was a prospective study of infectious complications of CVCs placed in intensive care unit (ICU) patients from April 1997 to December 2001. SETTING: The medical-surgical ICU of a tertiary-care, university-affiliated hospital in Argentina. METHODS: We studied all patients admitted to the ICU using non-impregnated CVCs. Maximal sterile barrier precautions (ie, use of cap, mask, sterile gown, sterile gloves, and large sterile drape), strict handwashing, preparation of the patients' skin with antiseptic solutions, insertion and management of catheters by trained personnel, and continuing quality improvement programs aimed at appropriate insertion and maintenance of catheters were employed. RESULTS: During the study period, 2,525 patients were admitted to the ICU. Eight hundred sixty-eight patients had 1,037 CVCs inserted. The number of CVC-related bloodstream infections (BSIs), acquired in the ICU, was 2.7 per 1,000 CVC-days (13 nosocomial CVC-related BSIs during 4,770 days of CVC use). Microorganisms isolated included methicillin-susceptible Staphylococcus aureus (n = 6), methicillin-resistant S. aureus (n = 2), coagulase-negative methicillin-resistant Staphylococcus (n = 2), Escherichia coli (n = 1), Klebsiella pneumoniae (n = 1), and Enterobacter cloacae (n = 1). CONCLUSIONS: A low rate of catheter-related BSI was achieved without antimicrobial-impregnated catheters. The incidence of CVC-associated bacteremias corresponded to the 10th to 20th percentile range of the National Nosocomial Infections Surveillance System hospitals for the same type of ICU.     

Bloodstream infections among patients using central venous catheters in intensive care units

Central Venous Catheters (CVC), widely used in Intensive Care Units (ICU) are important sources of bloodstream infections (BSI). This prospective cohort epidemiological analytical study, aimed to infer the incidence of BSI, the risk factors associated and evaluate the care actions related to the use of these catheters in seven ICU in the Federal District--Brasília, Brazil. From the 630 patients using CVC, 6.4% developed BSI (1.5% directly related to the catheter and 4.9% clinic BSI). The hospitalization term was 3.5 times greater among these patients. Different modalities of catheter insertion and antiseptic substances use were observed. Time of CVC permanence was significantly associated to infection incidence (p<1x10(-8)) as well as the right subclavian access and double-lumen catheters. Patients with neurological disorders and those submitted to tracheotomy were the most affected. We suggest the organization of a "catheter group" aiming to standardize procedures related to the use of catheters in order to reduce the hospitalization term and hospital costs.     

Survey of knowledge, beliefs, and practices of neonatal intensive care unit healthcare workers regarding nosocomial infections, central venous catheter care, and hand hygiene.

OBJECTIVE: To assess the knowledge, beliefs, and practices of neonatal intensive care unit (NICU) healthcare workers (HCWs). DESIGN: Self-administered survey. SETTING: A 55-bed NICU. PARTICIPANTS: NICU HCWs (N = 215). RESULTS: The response rate was 68%. Ninety-two percent knew central venous catheters (CVCs) should be capped, clamped, or connected to running fluids at all times. Ninety-five percent knew when to change gloves. Thirty-one percent knew the recommended duration for handwashing. Most HCWs believed sterile technique in CVC care (96%), gloves (91%), and handwashing (99%) prevent nosocomial infection (NI). Sixty-seven percent used sterile barriers to insert CVCs, 76% reported wearing gloves, 81% reported routine handwashing, 35% knew that bacterial hand counts are higher with rings, 30% knew that long fingernails are associated with higher gram-negative bacterial hand contamination, and 35% knew that artificial fingernails are associated with higher gram-negative bacterial hand contamination. Most (93%) believed HCWs can affect outcomes of patients with NIs. Fewer believed rings (40%), artificial fingernails (61%), and long fingernails (48%) play a role in NIs, or that policies concerning number of rings (50%), cutting fingernails (35%), or prohibiting artificial fingernails (47%) would prevent NIs. Sixty-one percent of HCWs regularly wore at least one ring to work, 56% wore their fingernails shorter than the fingertip, and 8% wore artificial fingernails. CONCLUSIONS: A disconnect existed between CVC knowledge and beliefs and practice. HCWs did not know the relationship between bacterial hand counts and rings and fingernails, and did not believe rings or long or artificial fingernails increased the risk of NIs.     

Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit

This study was conducted to evaluate the impact of central venous catheters impregnated with chlorhexidine and silver sulphadiazine on the incidence of colonization and catheter-related bloodstream infection in critically ill patients. One hundred and thirty-three patients requiring central venous catheterization were chosen at random to receive either an antiseptic-impregnated triple-lumen catheter (N=64) or a standard triple-lumen catheter (N=69). The mean (SD) durations of catheterization for the antiseptic and standard catheters were 11.7 (5.8) days (median 10; range 3-29) and 8.9 (4.6) days (median 8.0; range 3-20), respectively (P=0.006). Fourteen (21.9%) of the antiseptic catheters and 14 (20.3%) of the standard catheters had been colonized at the time of removal (P=0.834). Four cases (6.3%) of catheter-related bloodstream infection were associated with antiseptic catheters and one case (1.4%) was associated with a standard catheter (P=0.195). The catheter colonization rates were 18.7/1000 catheter-days for the antiseptic catheter group and 22.6/1000 catheter-days for the standard catheter group (P=0.640). The catheter-related bloodstream infection rates were 5.3/1000 catheter-days for the antiseptic catheter group and 1.6/1000 catheter-days for the standard catheter group (P=0.452). In conclusion, our results indicate that the use of antiseptic-impregnated central venous catheters has no effect on the incidence of either catheter colonization or catheter-related bloodstream infection in critically ill patients.     

Scheduled replacement of central venous catheters is not necessary.

Although half of intensivists routinely replace their central venous catheters (CVCs), this practice is not supported by data from randomized control studies or by pathophysiology of CVC infection. The daily risk of CVC infection is considered to be a constant; the risk of catheter infection is directly related to the duration of catheter insertion. Consequently, the routine change of the catheter is able to decrease the number of infections per catheter but not to modify the number of infections per day of catheter insertion. This assertion is supported by evidence-based medicine: scheduled replacement every 3 or 7 days has not been shown to alter the infectious risks of CVCs in randomized studies or a meta-analysis. Moreover, routine replacement at a new site exposes the patient to an increased risk of mechanical complications. The overall rate of mechanical complications per catheter inserted is approximately 3%. Guidewire exchange of the catheters may reduce the risk of mechanical complications, but unfortunately is associated with a higher rate of catheter colonization and catheter-related bacteremia. Routine replacement of CVCs is not necessary.     

Total parenteral nutrition catheter sepsis: impact of the team approach

For a period of 32 months from the inception of the Parenteral and Enteral Nutrition (PEN) Team at the University of Michigan, the infection rate (IR) related to central venous catheters (CVCs) for total parenteral nutrition (TPN) was prospectively evaluated. Six hundred twenty-two catheters were placed in 377 patients for a total of 9,200 patient days. The length of CVC stay ranged from 2 to 108 days with a mean of 14.5. CVC longevity was longer on units where certification of nurses by the PEN team was mandatory (mean 20.4 days, IR 3.5%) vs comparable units which utilized informal instruction (mean 14.4 days, IR 3.5%). Twenty-two catheters led to patient sepsis for a rate of 3.5%, or 2.39 CVC-related infections per 1000 patient days. The preteam infection rate was 24.0%, as determined by a 6-month prospective study. Infection rates for CVCs used for TPN only and those used for parenteral nutrition (PN) plus blood products, antibiotics, and CVP measurements were identical, 3.5%. The team approach can effectively increase PN catheter longevity and reduce infection rates. Conservative cost accounting of best and worst case scenarios determined a range of $3,700 to $8,900 per episode of catheter sepsis.     

Octenidine hydrochloride for the care of central venous catheter insertion sites in severely immunocompromised patients.

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.     

Infectious complications of implantable ports and Hickman catheters in paediatric haematology-oncology patients

The aim of this study was to define and compare the infectious and non-infectious complications associated with Hickman catheters and implantable ports in children. The study was conducted over a three-year period in the Department of Haematology-Oncology at the Schneider Children's Medical Center of Israel. All patients who required a central venous catheter (CVC) were included in the study. For each episode of catheter-associated bloodstream infection, demographic, clinical and microbiology data were recorded. During the study period, 419 tunnelled CVCs (246 implantable ports and 173 Hickman) were inserted in 281 patients. Compared with implantable ports, Hickman catheters were associated with a significantly higher rate of bloodstream infections (4.656 vs 1.451 episodes per 1000 catheter-days), shorter time to first infection (52.31 vs 108.82 days, P < 0.001), shorter duration of catheterization (140.75 vs 277.28 days, P < 0.001), and higher rate of removal because of mechanical complications (P < 0.005). Gram-positive bacterial infections were more prevalent in the implantable port group (63.6% vs 41.6%), whereas Gram-negative rods, polymicrobial infections and mycobacterial infections were more prevalent in the Hickman group (31.4% vs 50.9%, 17% vs 36% and 0% vs 4.4%, respectively; P < 0.05 for all). Haematopoietic stem cell transplantation was identified as an independent risk factor for infection [odds ratio (OR) -1.68, P = 0.005] and for catheter removal due to complications (OR -2.0, P < 0.001). Implantable ports may be considered the preferred device for most paediatric oncology and stem cell transplantation patients.     

Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia

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.     

Bloodstream infection related to catheter connections: a prospective trial of two connection systems

Bloodstream infections (BSIs) related to central venous catheters (CVCs) and arterial catheters (ACs) are an increasing problem in the management of critically ill patients. Our objective was to assess the efficacy of a needle-free valve connection system (SmartSite), Alaris Medical Systems, San Diego, CA, USA) in the prevention of catheter-related bloodstream infection (CR-BSI). Patients admitted to an intensive care unit were prospectively assigned to have a CVC and AC connected with either a needle-free valve connection system (NFVCS) or a three-way stopcock connection (3WSC). The characteristics of the patients were similar in the two groups. Before manipulation, the NFVCS was disinfected with chlorhexidine digluconate 0.5% alcoholic solution. The 3WSC was not disinfected between use but it was covered with a protection cap. A total of 799 patients requiring the insertion of a multilumen CVC or AC for >48h from 1 April 2002 to 31 December 2003 were included. CR-BSI rates were 4.61 per 1000 days of catheter use in the disinfected NFVCS group and 4.11 per 1000 days of catheter use in the 3WSC group (P=0.59). When CVC-BSIs and AC-BSIs were analysed separately, the rate of CVC-BSI was 4.26 per 1000 days of catheter use in the NFVCS group, compared with 5.27 in the 3WSC group (P=0.4). The incidence rate of AC-BSI was 5.00 per 1000 days of catheter use in the NFVCS group, compared with 2.83 in the 3WSC group (P=0.08). The use of NFVCS does not reduce the incidence of catheter-related bacteraemia. The arterial catheter (AC) is a significant source of infection in critically ill patients.     

Association of parenteral nutrition catheter sepsis with urinary tract infections

The infection rate (IR) of central venous catheters (CVCs) used for parenteral nutrition (PN) was prospectively evaluated over a 12-month period, with emphasis on the relationship between CVC sepsis and preexisting sites of infection. Sepsis was presumed if the CVC tip or blood culture was positive, or if defervescence followed CVC removal. Four hundred seventy-three CVCs were placed for PN for a total of 5,422 patient days, with a mean length of stay of 11.5 days. Twenty two CVCs led to sepsis for an IR of 4.65% or 4.06 infections per 1000 patient days. Twenty of the 22 septic CVCs were in patients with other sites of infection. The IR was 12.0% (20/166) when other sites of infection were present and 0.65% (2/307) in the absence of a second site. The mean length of stay was 13.2 days for CVCs with other sites of infection and 10.3 days for CVCs with no other site of infection. Fifty nine percent of septic CVCs had secondary sites of infection that included urinary tract infections (UTI). Of all septic CVCs, 22.7% had no site of infection other than UTI. The presence of UTI appears to present a high risk of CVC sepsis. Appropriate identification and treatment of UTI prior to CVC insertion is recommended.