Peripheral, midline, central venous included
The Centers for Disease Control and Prevention (CDC) has issued updated guidance to help infection control professionals prevent costly intravascular catheter-related bloodstream infections (BSIs). Some 250,000 cases of central venous catheter (CVC) associated BSIs occur in hospitals annually, with attributable mortality ranging from 12% to 25% for each infection, and a minimum cost to the health care system some $25,000 per case.
The new guidelines are designed for both clinicians who insert catheters and infection control professionals who track and try to prevent them.1 (The complete CDC recommendations are available under guidelines and regulations at www.HIConline.com.)
Although intravascular catheters provide necessary vascular access, their use puts patients at risk for local and systemic infectious complications. One of the ongoing issues in the use of catheters is the frequency of replacement for the devices, dressings, administration sets, and the fluids being administered. In that regard, the CDC has issued a new summary chart, which was published with an error in the recently printed version. (See corrected chart.)
The incidence of catheter-related BSIs varies considerably by type of catheter, frequency of catheter manipulation, and patient-related factors (e.g., underlying disease and acuity of illness), the CDC notes. Peripheral venous catheters are the devices most frequently used for vascular access. Although the incidence of BSIs associated with peripheral venous catheters is usually low, serious infectious complications produce considerable annual morbidity because of the frequency with which such catheters are used. However, the majority of serious catheter-related infections are associated with central venous catheters (CVCs), especially those that are placed in patients in intensive care units (ICU). In the ICU, central venous access might be needed for extended periods of time, and patients can be colonized with hospital-acquired organisms. In addition, the catheter may be manipulated multiple times per day for the administration of fluids, drugs, and blood products.
Moreover, some catheters may be inserted in urgent situations, during which optimal attention to aseptic technique might not be feasible. Certain catheters (e.g., pulmonary artery catheters and peripheral arterial catheters) can be accessed multiple times per day for hemodynamic measurements or to obtain samples for laboratory analysis, augmenting the potential for contamination and subsequent clinical infection.
Measures to minimize the risk for infection associated with intravascular therapy should strike a balance between patient safety and cost effectiveness, the CDC recommends. Reports spanning the past two decades have consistently demonstrated that risk for infection declines following standardization of aseptic care, and that insertion and maintenance of intravascular catheters by inexperienced staff might increase the risk for catheter colonization and infection.
Specialized "IV teams" have shown effectiveness in reducing the incidence of catheter-related infections. Additionally, infection risk increases when nursing staff reductions fall below adequate levels, the CDC adds.
For short peripheral catheters, good hand hygiene before catheter insertion or maintenance, combined with proper aseptic technique during catheter manipulation, provides protection against infection. Good hand hygiene can be achieved through the use of either a waterless, alcohol-based product or an antibacterial soap and water with adequate rinsing.
Appropriate aseptic technique does not necessarily require sterile gloves. A new pair of disposable nonsterile gloves can be used in conjunction with a "no-touch" technique for the insertion of peripheral venous catheters. However, gloves are required by the Occupational Safety and Health Administration as standard precautions for the prevention of bloodborne pathogen exposure. Compared with peripheral venous catheters, CVCs carry a substantially greater risk for infection. Thus, the level of barrier precautions needed to prevent infection during insertion of CVCs should be more stringent. Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape) during the insertion of CVCs substantially reduces the incidence of BSI compared with standard precautions (e.g., sterile gloves and small drapes).
Although the efficacy of such precautions for insertion of PICCs and midline catheters has not been studied, the use of maximal barrier precautions also is probably applicable to PICCs, the CDC advised.
Reference
1. Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002; 51(RR-10):1-32.
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