Influence of insertion site on central venous catheter colonization and bloodstream infection rates

OBJECTIVE: To compare colonization and catheter-related bloodstream infection (CR-BSI) rates among three insertion sites (subclavian, internal jugular, femoral) used for central venous catheter (CVC) placement. DESIGN: Twenty-four-month prospective study, with relative effects analyzed by Cox proportional hazards regression. SETTING: Eight-bed intensive care unit. PATIENTS: Four hundred and ten critically ill patients requiring CVC placement. MEASUREMENTS AND RESULTS: All short-term multi-lumen CVCs, including antimicrobial-coated devices, were studied with management standardized. Six hundred and five CVCs (4,040 catheter days) were analyzed. Colonization and CR-BSI incidence were, respectively, 15.1 (95% CI 13.5-21.0) and 1.8 (95% CI 1.2-4.2) per 1,000 catheter-days. Colonization was higher at the internal jugular (HR 3.64; 95% CI 1.32-10.00; p=0.01) and femoral (HR 5.15; 95% CI 1.82-14.51; p=0.004) sites than at the subclavian site. The femoral site carried a greater risk of being colonized by non-S. epidermidis species than the subclavian and internal jugular sites combined (HR 4.15; 95% CI 1.79-9.61; p=0.001). CVCs inserted in the Department of Emergency Medicine were more colonized than those inserted in the ICU or operating room (HR 2.66; 95% CI 1.27-5.56; p=0.01), and CVCs were less colonized in females than in males (HR 0.49; 95% CI 0.26-0.89; p=0.02). No difference in CR-BSI rates was noted between the three sites. CONCLUSIONS: Colonization was lowest at the subclavian site. Regional differences exist with respect to type of pathogen isolated. Colonization was influenced by insertion location and gender. The incidence of CR-BSI was not different.     

Rifampicin-impregnated central venous catheters: a meta-analysis of randomized controlled trials

BACKGROUND: The use of antimicrobial-impregnated central venous catheters (CVCs) for the prevention of CVC microbial colonization and catheter-related bloodstream infection (CRBSI) remains controversial. METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) evaluating CRBSI and colonization of CVCs impregnated with rifampicin-based antimicrobial combinations. Our main analysis compared the occurrence of CRBSI with rifampicin/minocycline-impregnated CVCs with that of non-rifampicin-impregnated CVCs. The PubMed and Cochrane Central Register of Controlled Trials databases were searched (until October 2006). RESULTS: Eight RCTs were included in the analysis. The main analysis (seven RCTs) demonstrated that rifampicin/minocycline-impregnated CVCs were associated with fewer CRBSIs compared with catheters not impregnated with rifampicin/minocycline (OR 0.23, 95% CI 0.14-0.40). The same was true regarding colonization (OR 0.46, 95% CI 0.31-0.69). Further analysis, comparing rifampicin-based CVCs with non-rifampicin-impregnated CVCs, demonstrated superiority of rifampicin-based CVCs in reducing colonization (OR 0.38, 95% CI 0.24-0.62) and CRBSI (OR 0.24, 95% CI 0.14-0.40). Similar results, suggesting superiority of rifampicin/minocycline-impregnated CVCs, were noted in a subgroup analysis of colonization and CRBSIs in which rifampicin/minocycline-impregnated CVCs were compared with simple, non-tunnelled, non-antimicrobially impregnated CVCs, a subgroup analysis that was performed by excluding low quality RCTs, and a subgroup analysis for colonization comprising studies in which the sonication technique was used. No serious adverse events and no difference in mortality between the two treatment groups were reported. No clear conclusions can be made regarding the impact of the use of rifampicin/minocycline-impregnated CVCs on the development of antimicrobial resistance based on the available data. CONCLUSIONS: The available evidence suggests that rifampicin/minocycline-impregnated CVCs are safe and effective in reducing the rate of catheter colonization and CRBSI. Further research should focus on the possible development of resistance and on pharmacoeconomic issues related to the use of rifampicin/minocycline-impregnated CVCs.     

Brushing has made a sweeping change: use of the endoluminal FAS brush in haemodialysis central venous catheter management.

Common usage of central venous catheter (CVC) access for haemodialysis has presented the haemodialysis nurse with the challenge of maintaining CVCs as a viable form of access. The major complications seen with CVC use are obstruction and infection. A project was undertaken to identify the usefulness of the endoluminal fibrin analysis system (FAS) brush as an intervention in haemodialysis CVC management. The aims of the study were to identify: the reasons for brushing CVCs and the number of occasions brushing is indicated; how successful brushing is in unblocking and improving flow from CVCs, and the length of time the catheter remains patent following successful declotting. Seventeen patients were found suitable for CVC brushing and divided into two groups depending on the indication for brushing. In the group in which the catheter was brushed to restore flow, 73 per cent of brushings were successful, and in 50 per cent of those cases the CVC remained patent for 6 weeks. Sixty per cent of catheter brushings to improve flow were successful, and in 50 per cent of the CVCs flow was sustained over a 6-week period. Overall, the findings support the use of the endoluminal FAS brush for the applications trialled.     

Prevention of catheter-related venous thrombosis with nadroparin in patients receiving chemotherapy for hematologic malignancies: a randomized, placebo-controlled study

BACKGROUND: Hemato-oncology patients treated with intensive chemotherapy usually require the placement of a central venous catheter (CVC). CVCs are frequently complicated by catheter-related central venous thrombosis (CVT), which has been associated with an increased risk of pulmonary embolism and catheter-related infection. OBJECTIVES: To determine the efficacy and safety of thromboprophylaxis with s.c. low-molecular-weight heparin (nadroparin) administered once daily in a randomized placebo-controlled, double-blind trial in patients with hematologic malignancies. PATIENTS AND METHODS: Consecutive patients with hematologic malignancies requiring intensive chemotherapy including autologous stem cell transplantation were eligible. The patients were randomized to receive nadroparin 2850 antifactor Xa units once daily or placebo s.c. for 3 weeks. Venography was performed on day 21 after CVC insertion. Secondary outcomes were bleeding and catheter-related infection. RESULTS: In total, 113 patients were randomized to nadroparin or placebo, and 87 patients (77%) underwent venography. In total, 11 venographically proven catheter-related CVTs were diagnosed. The frequency of catheter-related CVT was not significantly different between study groups, namely four catheter-related CVTs in the placebo group [9%; 95% CI: 0.002-0.16] vs. seven catheter-related CVTs in the nadroparin group (17%; 95% CI: 0.06-0.28). In addition, no difference in the incidence of catheter-related infection or bleeding was observed between the groups. CONCLUSION: This study showed that the actual risk for catheter-related CVT in patients with hematologic malignancies is lower than suggested in earlier studies in cancer patients. Although prophylactic administration of nadroparin appeared to be safe in this group of patients with a high risk of bleeding, it cannot be recommended for the prevention of catheter-related CVT or catheter-related infection in patients with hematologic malignancies.     

The safety of prolonging the use of central venous catheters: a prospective analysis of the effects of using antiseptic-bonded catheters with daily site care

OBJECTIVE: To determine rates of catheter colonization and catheter-related bloodstream infection (CRBSI) when antiseptic-bonded central venous catheters (CVCs) and standardized daily site care are used with no predetermined interval for removal. DESIGN: Prospective observational study. SETTING: Two major trauma centers. PATIENTS: All trauma patients admitted to two major trauma centers that received a CVC from May 1996 through May 1998. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Catheters were semiquantitatively cultured to identify bacterial colonization and CRBSI. Monitored variables included total catheter days, anatomical site of catheter insertion, and area in hospital of catheter insertion. CVC tips and intracutaneous segments were semiquantitatively cultured. A total of 460 (92%) of 501 catheters placed in 324 trauma patients were evaluable, representing 95.5% of all catheter days during the study period. Rates of catheter colonization and CRBSI were 5% (5/1000 catheter days) and 1.5% (1.511000 catheter days), respectively. Subclavian catheters were in place longer than femoral or internal jugular catheters (p < .0001), but the colonization rate was significantly lower (p = .03; relative risk, 0.34; 95% confidence interval, 0.15-0.77). No differences in CRBSI rates among anatomical sites or between catheters used < or =14 days and those used >14 days were identified. CONCLUSION: Femoral and internal jugular antiseptic-bonded CVCs develop bacterial colonization earlier than subclavian CVCs. Subclavian antiseptic-bonded CVCs combined with standardized daily site care may be safely used >14 days in trauma patients.     

Central venous catheter-related bloodstream infections: an analysis of incidence and risk factors in a cohort of 400 patients

Objective: To determine the incidence of central catheter-related bloodstream infection (CR-BSI) and to compare patient and catheter characteristics of those with and without CR-BSI from a clinically suspected subgroup. Secondly, to assess the efficacy of the acridine orange leucocyte cytospin test (AOLC) as a rapid in situ method of detecting central venous catheter (CVC) infection. Design: One-year prospective audit. Setting: Intensive care unit/high dependency unit (ICU/HDU) and general wards of a tertiary referral hospital. Patients and participants: 400 patients with non-tunnelled CVCs. Interventions: Daily surveillance, blood culture from peripheral venepuncture, blood sample from the CVC for assessment of the AOLC test and removal of suspected CVCs were carried out on patients clinically suspected of having CR-BSI. Measurements and results: CR-BSI was diagnosed using well defined criteria. Infection rate was calculated by dividing the number of definitive catheter associated infections by the total number of appropriate catheter in situ days. The AOLC test was performed on all those with suspected CR-BSI. A total of 499 CVCs in 400 patients were assessed, representing 3014 catheter in situ days. Over 80 % of patients were from our ICU/HDU, representing 404 CVCs and 1901 catheter in situ days. A total of 49/499 (9.8 %) CVCs in the same number of patients were suspected of being infected subsequently 12/499 (2.4 %) CVCs [95 % confidence interval (CI) 1.25 to 4.16] in 12 separate patients were demonstrated to be the direct cause of the patient's BSI. Rates of CR-BSI per 1000 catheter days were 3.98 (95 % CI 2.06 to 6.96) for the whole cohort and 4.20 (95 % CI 1.81 to 8.29) for the ICU/HDU subgroup. In the group suspected of having CR-BSI, CVCs were removed unnecessarily in 55 %, and no patient or catheter variables measured were predictive of the development of CR-BSI. The AOLC test was negative in all 12 catheters subsequently shown to be the definitive cause of BSI. Conclusions: We have defined the incidence of CR-BSI in a cohort of patients from a tertiary referral hospital, the rates comparing favourably with those reported for similar populations. We were unable to demonstrate significant differences in any patient or catheter variables between those with and without CR-BSI. The AOLC test used alone was unhelpful as a method to diagnose in situ CVC infection in this patient population. Received: 26 February 1998 Accepted: 30 June 1998     

Central venous catheter use

Central venous catheters (CVCs) are used with increasing frequency in the intensive care unit and in general medical wards. Catheter infection, the most frequent complication of CVC use, is associated with increased morbidity, mortality, and duration of hospital stay. Risk factors in the development of catheter colonisation and bloodstream infection include patient factors (increased risk associated with malignancy, neutropenia, and shock) and treatment-related factors (increased risk associated with total parenteral nutrition, ICU admission for any reason, and endotracheal intubation). Other risk factors are prolonged catheter indwelling time, lack of asepsis during CVC insertion, and frequent manipulation of the catheter. The most important factor is catheter care after placement. Effects of CVC tunnelling on infection rates depend to a large extent on indwelling time and the quality of catheter care. Use of polyurethane dressings can increase the risk of colonisation compared to regular gauze dressing. Thrombus formation around the CVC tip increases the risk of infection; low-dose anticoagulants may decrease this risk. New developments such as CVC impregnation with antibiotics may reduce the risk of infection. Reducing catheter infection rates requires a multiple-strategy approach. Therefore, ICUs and other locations where CVCs are used should implement strict guidelines and protocols for catheter insertion, care, and maintenance.     

Ultrasound detection of guidewire position during central venous catheterization

Introduction

Ultrasound guidance decreases complications of central venous catheter (CVC) placement, but risks of arterial puncture and inadvertent arterial catheter placement exist. Ultrasound-assisted detection of guidewire position in the internal jugular vein could predict correct catheter position before dilation and catheter placement.

Methods

Ultrasound examinations were performed in an attempt to identify the guidewire before dilation and catheter insertion in 20 adult patients requiring CVC placement. Central venous pressures were measured after completion of the procedure.

Results

Guidewires were visible within the lumen of the internal jugular vein in all subjects. Central venous pressures confirmed venous placement of catheters. Ultrasound visualization of the guidewire predicted venous CVC placement with 100% sensitivity (95% confidence interval 80-100%) and 100% specificity (95% confidence interval 80%-100%).

Conclusions

Ultrasound reliably detects the guidewire during CVC placement and visualization of the wire before dilation and catheter insertion may provide an additional measure of safety during ultrasound-guided CVC placement.     

A prospective,longitudinal study of central venous catheter‐related deep venous thrombosis in boys with hemophilia

Summary. Background: Central venous catheters (CVCs) are often inserted into boys with hemophilia to secure venous access for factor prophylaxis and immune tolerance induction therapy. Complications associated with CVCs include catheter‐related infections, local hemorrhage, and mechanical failure. Less frequently reported is CVC‐related deep venous thrombosis (DVT). We conducted a prospective study to determine the frequency and outcome of this complication. Methods: All boys (n = 16) with congenital hemophilia A or B with a CVC in place who were registered in the pediatric comprehensive care program at the Hospital for Sick Children, Toronto, were included in the study. They were prospectively assessed by imaging studies and clinical examinations for CVC‐related DVT at two time‐points, 2 years apart. Each boy was evaluated for inherited hypercoagulability. Results: Eleven (69%) of the 16 boys had radiological evidence of DVT at the first evaluation and 13/16 (81%) at the second evaluation. In two boys there was improvement in the venogram findings at the second evaluation. None of the CVC‐related DVTs completely resolved. Median age at the time of initial insertion of a CVC was 1.0 years (range 0.02–6.7 years). Median duration of CVC placement was 6.4 years (range 3.3–15.5 years). Only 4/13 boys with DVTs had clinical evidence of upper venous system obstruction. Only one boy, who did not develop a DVT, had a low protein C level. Conclusions: CVC‐related DVTs occur in the majority of boys with hemophilia who have CVCs inserted for a prolonged period of time. Annual screening with imaging is recommended for boys with CVCs in place for ≥ 3 years. Consideration should be given to removing CVCs as soon as peripheral venous access is feasible.     

Ultrasound-Guidance Can Reduce Adverse Events During Femoral Central Venous Cannulation

Background

Ultrasound-guidance for internal jugular central venous cannulation (CVC) has become the recommended best practice and has been shown to improve placement success and reduce complications. There is a dearth of studies that evaluate emergency point-of-care ultrasound guidance of femoral CVC.

Objective

Our aim was to determine if point-of-care ultrasound guidance for femoral CVC decreases adverse events and increases the likelihood of successful placement when compared with the landmark technique.

Methods

We conducted an Institutional Review Board–approved, prospective, observational study of consecutive patients who required CVC. Physicians who performed CVC completed a standardized, web-based data sheet for a national CVC registry. We evaluated single-institution data regarding CVC site, ultrasound usage, CVC indication, and mechanical complications (e.g., pneumothorax, arterial puncture, failed access, catheter misdirection, and hematoma). The study period was between January 2006 and June 2010. Analysis using Pearson's χ² and Agresti-Coull binomial confidence intervals was performed; significance was defined as p < 0.05.

Results

We evaluated data for 143 patients who had femoral CVC in our institution. Sixty CVCs (42%) were performed under ultrasound guidance, 83 (58%) via landmark technique (p = 0.0159); 3.3% of femoral central venous lines placed by ultrasound guidance had recorded adverse events compared with 9.6% for the landmark technique (p = 0.145). There was no statistically significant difference in complications between ultrasound-guidance and landmark techniques. Our data showed a trend toward decreased rates of arterial puncture and reduced cannulation attempts resulting in improved placement success.

Conclusions

Our experience shows that ultrasound guidance for femoral CVC might decrease complications and improve placement success, although we cannot recommend this approach without additional data. We recommend a larger study to further evaluate this technique.     

Old and new risk factors for upper extremity deep venous thrombosis

BACKGROUND: Well known risk factors for upper extremity deep venous thrombosis are the presence of a central venous catheter (CVC) and malignancy, but other potential risk factors, such as surgery, injury and hormone replacement therapy (HRT), have not yet been explored. METHODS: We performed a population-based case-control study including 179 consecutive patients, aged 18-70 years with upper extremity deep venous thrombosis and 2399 control subjects. Participants reported on acquired risk factors in a questionnaire and factor V Leiden and prothrombin 20210A mutation were ascertained. Information on CVC was obtained from discharge letters. RESULTS: Forty-two patients (23%) and one control subject (0.04%) had a CVC (ORadj: 1136, 95% CI: 153-8448, adjusted for age and sex). Cancer patients without a CVC had an eightfold increased risk of venous thrombosis of the arm (ORcrude: 7.7, 95% CI: 4.6-13.0). Other evident risk factors were prothrombotic mutations, surgery, immobilization of the arm (plaster cast), oral contraceptive use and family history, with odds ratios varying from 2.0 up to 13.1. The risk in the presence of injury and during puerperium was twofold or more increased, although not significantly. In contrast HRT, unusual exercise, travel and obesity did not increase the risk. Hormone users had an increased risk in the presence of prothrombotic mutations or surgery. Obese persons (BMI > 30 kg m(-2)) undergoing surgery had a 23-fold increased risk of arm thrombosis compared with non-obese persons not undergoing surgery. CONCLUSION: A CVC is a very strong risk factor for arm thrombosis. Most risk factors for thrombosis in the leg are also risk factors for arm thrombosis.     

Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters

Study Objectives

Obtaining intravenous (IV) access in the emergency department (ED) can be especially challenging, and physicians often resort to placement of central venous catheters (CVCs). Use of ultrasound-guided peripheral IV catheters (USGPIVs) can prevent many “unnecessary” CVCs, but the true impact of USGPIVs has never been quantified. This study set out to determine the reduction in CVCs by USGPIV placement.

Methods

This was a prospective, observational study conducted in 2 urban EDs. Patients who were to undergo placement of a CVC due to inability to establish IV access by other methods were enrolled. Ultrasound-trained physicians then attempted USGPIV placement. Patients were followed up for up to 7 days to assess for CVC placement and related complications.

Results

One hundred patients were enrolled and underwent USGPIV placement. Ultrasound-guided peripheral IV catheters were initially successfully placed in all patients but failed in 12 patients (12.0%; 95 confidence interval [CI], 7.0%-19.8%) before ED disposition, resulting in 4 central lines, 7 repeated USGPIVs, and 1 patient requiring no further intervention. Through the inpatient follow-up period, another 11 patients underwent CVC placement, resulting in a total of 15 CVCs (15.0%; 95 CI, 9.3%-23.3%) placed. Of the 15 patients who did receive a CVC, 1 patient developed a catheter-related infection, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate.

Conclusion

Ultrasound prevented the need for CVC placement in 85% of patients with difficult IV access. This suggests that USGPIVs have the potential to reduce morbidity in this patient population.     

Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis

Purpose

Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children.

Methods

We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0–14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention’s National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting.

Results

A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70–3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05–4.61; p = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02–4.64; p = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable.

Conclusions

PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.

     

Use of ultrasound guidance for central venous catheterization: a national survey of intensivists and hospitalists

PurposeThe purpose of the study is to evaluate the frequency and barriers to use of ultrasound guidance for central venous catheter (CVC) insertion by physicians specializing in critical care and hospital medicine.Materials and methodsA national cross-sectional electronic survey of intensivists and hospitalists was administered from November 2014 to January 2015.ResultsThe survey response rate was 5.9% (1013/17 233). Moderate to very frequent use of ultrasound guidance varied by site: internal jugular vein (80%), subclavian vein (31%), and femoral vein (45%). Nearly all physicians (99%) who insert internal jugular CVCs daily use ultrasound guidance, whereas only 46% of physicians who insert subclavian CVCs daily use ultrasound guidance. Use of real-time ultrasound guidance varied by insertion site: internal jugular vein (73%), subclavian vein (28%), and femoral vein (42%). Most physicians (59%) reported not being comfortable with real-time needle tracking at the subclavian site. The most frequently reported barriers to use of ultrasound guidance were (1) limited availability of ultrasound equipment (28%), (2) perception of increased total procedure time (22%), and (3) concern for loss of landmark skills (13%).ConclusionsMost intensivists routinely use ultrasound guidance to insert internal jugular CVCs but not subclavian CVCs. The most commonly reported barrier to ultrasound use was limited access to an ultrasound machine.     

Catheter infection risk related to the distance between insertion site and burned area

A prospective observational study of central venous catheters (CVC) was carried out in order to determine if a CVC inserted near an open burn wound increases catheter infection risk in burned patients. The study was carried out during a 12-month period (1998-1999) at the Benaim Foundation's Burn Unit in Buenos Aires (C.E.P.A.Q.). Eighty-three CVCs were inserted in 20 burned patients during the study period. Twenty-six catheters were inserted near an open wound (NOW) and 57 far from an open wound (FOW). NOW CVCs were considered when 25 cm2 surrounding the catheter's insertion site overlapped the wound. Colonization rates were 84% (22/26 CVCs) in those inserted NOW and 47% (27/57 CVCs) in FOW (P = 0.001). Colonization relative risk of NOW-CVCs was 1.79 (95% confidence interval, 1.3-2.46). Bacteremia rates were 27% (7/26 CVCs) in CVCs inserted NOW and 6% (3/57 CVCs) in FOW (P = 0.004). Bacteremic risk of NOW-CVCs was 5.12 (95% confidence interval, 1.44-18.22). Colonization rates were higher and sooner in NOW-CVCs than in FOW-CVCs. We suggest that insertion of catheters near an open burn wound should be avoided and, if inevitable, should not be left in place for period exceeding 3 days.     

Central venous blood culture: a useful test for catheter colonisation?

OBJECTIVE: To evaluate the widespread practice of using qualitative culture of venous blood taken through central venous catheters (CVCs) as a means of diagnosing catheter colonisation in situ. DESIGN: A prospective clinical study. PATIENTS: Three hundred fifty-one CVCs were inserted into 228 critically ill patients. INTERVENTIONS: Prior to CVC removal, blood was taken for qualitative culture from the CVC and a peripheral site. All catheter tips underwent semi-quantitative analysis of bacterial colony count [1]. MEASUREMENTS AND RESULTS: One hundred eighteen (33.6%) CVCs were found to be colonised on removal. A positive central blood culture had a sensitivity and specificity of 50.8% and 78.9% when compared with the 'gold standard' of catheter tip culture. This gives a positive predictive value of 47.7% and a negative predictive value of 76.5%. The sensitivity and specificity of a positive peripheral blood culture were 41.5% and 77.7% with positive and negative predictive values of 48.8% and 72.9%, respectively. When only those catheters removed because of systemic sepsis (n = 139) were considered, a positive central blood culture had a sensitivity of 58.8% and a specificity of 69.3%. CONCLUSION: Our results indicate that the use of central blood culture confers a small advantage in sensitivity compared with peripheral blood culture. This advantage was further improved by only considering the catheters removed because of systemic sepsis but at the cost of a loss of specificity. Qualitative blood culture is a poor tool for the diagnosis of in-situ CVC colonisation.