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Guidelines for the prevention of intravascular catheter-related infections

      These guidelines have been developed for healthcare personnel who insert intravascular catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home healthcare settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, healthcare infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Diseases Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), American Society for Parenteral and Enteral Nutrition (ASPEN), Society of Interventional Radiology (SIR), American Academy of Pediatrics (AAP), Pediatric Infectious Diseases Society (PIDS), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Catheter-Related Infections published in 2002. These guidelines are intended to provide evidence-based recommendations for preventing intravascular catheter-related infections. Major areas of emphasis include 1) educating and training healthcare personnel who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a > 0.5% chlorhexidine skin preparation with alcohol for antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters and chlorhexidine impregnated sponge dressings if the rate of infection is not decreasing despite adherence to other strategies (i.e, education and training, maximal sterile barrier precautions, and >0.5% chlorhexidine preparations with alcohol for skin antisepsis). These guidelines also emphasize performance improvement by implementing bundled strategies, and documenting and reporting rates of compliance with all components of the bundle as benchmarks for quality assurance and performance improvement.
      As in previous guidelines issued by CDC and HICPAC, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. The system for categorizing recommendations in this guideline is as follows:
      • 1.
        Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
      • 2.
        Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence.
      • 3.
        Category IC. Required by state or federal regulations, rules, or standards.
      • 4.
        Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
      • 5.
        Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.

      Introduction

      In the United States, 15 million central vascular catheter (CVC) days (i.e, the total number of days of exposure to CVCs among all patients in the selected population during the selected time period) occur in intensive care units (ICUs) each year.
      • Mermel L.A.
      Prevention of intravascular catheter-related infections.
      Studies have variously addressed catheter-related bloodstream infections (CRBSI). These infections independently increase hospital costs and length of stay,
      • Dimick J.B.
      • Pelz R.K.
      • Consunji R.
      • Swoboda S.M.
      • Hendrix C.W.
      • Lipsett P.A.
      Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit.
      • Warren D.K.
      • Quadir W.W.
      • Hollenbeak C.S.
      • Elward A.M.
      • Cox M.J.
      • Fraser V.J.
      Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital.
      • Blot S.I.
      • Depuydt P.
      • Annemans L.
      • et al.
      Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections.
      • Renaud B.
      • Brun-Buisson C.
      Outcomes of primary and catheter-related bacteremia. A cohort and case-control study in critically ill patients.
      but have not generally been shown to independently increase mortality. While 80,000 CRBSIs occur in ICUs each year,
      • Mermel L.A.
      Prevention of intravascular catheter-related infections.
      a total of 250,000 cases of BSIs have been estimated to occur annually, if entire hospitals are assessed.
      • Maki D.G.
      • Kluger D.M.
      • Crnich C.J.
      The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies.
      By several analyses, the cost of these infections is substantial, both in terms of morbidity and financial resources expended. To improve patient outcome and to reduce healthcare costs, there is considerable interest by healthcare providers, insurers, regulators, and patient advocates in reducing the incidence of these infections. This effort should be multidisciplinary, involving healthcare professionals who order the insertion and removal of CVCs, those personnel who insert and maintain intravascular catheters, infection control personnel, healthcare managers including the chief executive officer (CEO) and those who allocate resources, and patients who are capable of assisting in the care of their catheters.
      The goal of an effective prevention program should be the elimination of CRBSI from all patient-care areas. Although this is challenging, programs have demonstrated success, but sustained elimination requires continued effort. The goal of the measures discussed in this document is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and the limitations of current strategies and technologies.

      Summary of recommendations

      Education, training and staffing

      • 1.
        Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measuresto prevent intravascular catheter-related infections.
        • Yoo S.
        • Ha M.
        • Choi D.
        • Pai H.
        Effectiveness of surveillance of central catheter-related bloodstream infection in an ICU in Korea.
        • Warren D.K.
        • Zack J.E.
        • Cox M.J.
        • Cohen M.M.
        • Fraser V.J.
        An educational intervention to prevent catheter-associated bloodstream infections in a non-teeaching community medical center.
        • Warren D.K.
        • Zack J.E.
        • Mayfield J.L.
        • et al.
        The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU.
        • Warren D.K.
        • Cosgrove S.E.
        • Diekema D.J.
        • et al.
        A multicenter intervention to prevent catheter-associated bloodstream infections.
        • Higuera F.
        • Rosenthal V.D.
        • Duarte P.
        • Ruiz J.
        • Franco G.
        • Safdar N.
        The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico.
        • Coopersmith C.M.
        • Rebmann T.L.
        • Zack J.E.
        • et al.
        Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit.
        • Coopersmith C.M.
        • Zack J.E.
        • Ward M.R.
        • et al.
        The impact of bedside behavior on catheter-related bacteremia in the intensive care unit.
        • Sherertz R.J.
        • Ely E.W.
        • Westbrook D.M.
        • et al.
        Education of physicians-in-training can decrease the risk for vascular catheter infection.
        • Eggimann P.
        • Harbarth S.
        • Constantin M.N.
        • Touveneau S.
        • Chevrolet J.C.
        • Pittet D.
        Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care.
        Category IA
      • 2.
        Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters.
        • Yoo S.
        • Ha M.
        • Choi D.
        • Pai H.
        Effectiveness of surveillance of central catheter-related bloodstream infection in an ICU in Korea.
        • Warren D.K.
        • Zack J.E.
        • Cox M.J.
        • Cohen M.M.
        • Fraser V.J.
        An educational intervention to prevent catheter-associated bloodstream infections in a non-teeaching community medical center.
        • Warren D.K.
        • Zack J.E.
        • Mayfield J.L.
        • et al.
        The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU.
        • Warren D.K.
        • Cosgrove S.E.
        • Diekema D.J.
        • et al.
        A multicenter intervention to prevent catheter-associated bloodstream infections.
        • Higuera F.
        • Rosenthal V.D.
        • Duarte P.
        • Ruiz J.
        • Franco G.
        • Safdar N.
        The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico.
        • Coopersmith C.M.
        • Rebmann T.L.
        • Zack J.E.
        • et al.
        Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit.
        • Coopersmith C.M.
        • Zack J.E.
        • Ward M.R.
        • et al.
        The impact of bedside behavior on catheter-related bacteremia in the intensive care unit.
        • Sherertz R.J.
        • Ely E.W.
        • Westbrook D.M.
        • et al.
        Education of physicians-in-training can decrease the risk for vascular catheter infection.
        • Eggimann P.
        • Harbarth S.
        • Constantin M.N.
        • Touveneau S.
        • Chevrolet J.C.
        • Pittet D.
        Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care.
        Category IA
      • 3.
        Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters.
        • Sherertz R.J.
        • Ely E.W.
        • Westbrook D.M.
        • et al.
        Education of physicians-in-training can decrease the risk for vascular catheter infection.
        • Eggimann P.
        • Harbarth S.
        • Constantin M.N.
        • Touveneau S.
        • Chevrolet J.C.
        • Pittet D.
        Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care.
        • Nehme A.E.
        Nutritional support of the hospitalized patient. The team concept.
        • Soifer N.E.
        • Borzak S.
        • Edlin B.R.
        • Weinstein R.A.
        Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial.
        • Tomford J.W.
        • Hershey C.O.
        • McLaren C.E.
        • Porter D.K.
        • Cohen D.I.
        Intravenous therapy team and peripheral venous catheter-associated complications. A prospective controlled study.
        • Scalley R.D.
        • Van C.S.
        • Cochran R.S.
        The impact of an i.v. team on the occurrence of intravenous-related phlebitis. A 30-month study.
        • Palefski S.S.
        • Stoddard G.J.
        The infusion nurse and patient complication rates of peripheral-short catheters. A prospective evaluation.
        • Miller J.M.
        • Goetz A.M.
        • Squier C.
        • Muder R.R.
        Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team.
        • Hunter M.R.
        Development of a Vascular Access Team in an acute care setting.
        • Hawes M.L.
        A proactive approach to combating venous depletion in the hospital setting.
        • Brunelle D.
        Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections.
        • Bosma T.L.
        • Jewesson P.J.
        An infusion program resource nurse consult service: our experience in a major Canadian teaching hospital.
        • Pierce C.A.
        • Baker J.J.
        A nursing process model: quantifying infusion therapy resource consumption.
        • Tomford J.W.
        • Hershey C.O.
        The i.v. therapy team: impact on patient care and costs of hospitalization.
        • Davis D.
        • O'Brien M.A.
        • Freemantle N.
        • Wolf F.M.
        • Mazmanian P.
        • Taylor-Vaisey A.
        Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?.
        Category IA
      • 4.
        Ensure appropriate nursing staff levels in ICUs. Observational studies suggest that a higher proportion of “pool nurses” or an elevated patient–to-nurse ratio is associated with CRBSI in ICUs where nurses are managing patients with CVCs.
        • Alonso-Echanove J.
        • Edwards J.R.
        • Richards M.J.
        • et al.
        Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units.
        • Fridkin S.K.
        • Pear S.M.
        • Williamson T.H.
        • Galgiani J.N.
        • Jarvis W.R.
        The role of understaffing in central venous catheter-associated bloodstream infections.
        • Robert J.
        • Fridkin S.K.
        • Blumberg H.M.
        • et al.
        The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit.
        Category IB

      Selection of catheters and sites

      Peripheral catheters and midline catheters
      • 1.
        In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. Category II
      • 2.
        In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site.
        • Maki D.G.
        • Goldman D.A.
        • Rhame F.S.
        Infection control in intravenous therapy.
        • Band J.D.
        • Maki D.G.
        Steel needles used for intravenous therapy. Morbidity in patients with hematologic malignancy.
        Category II
      • 3.
        Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators.
        • Band J.D.
        • Maki D.G.
        Steel needles used for intravenous therapy. Morbidity in patients with hematologic malignancy.
        • Tully J.L.
        • Friedland G.H.
        • Baldini L.M.
        • Goldmann D.A.
        Complications of intravenous therapy with steel needles and Teflon catheters. A comparative study.
        • Ryder M.A.
        Peripheral access options.
        Category IB
      • 4.
        Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs.
        • Band J.D.
        • Maki D.G.
        Steel needles used for intravenous therapy. Morbidity in patients with hematologic malignancy.
        • Tully J.L.
        • Friedland G.H.
        • Baldini L.M.
        • Goldmann D.A.
        Complications of intravenous therapy with steel needles and Teflon catheters. A comparative study.
        Category IA
      • 5.
        Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. Category II
      • 6.
        Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection. If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually. Category II
      • 7.
        Remove peripheral venous catheters if the patients develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter.
        • Maki D.G.
        • Ringer M.
        Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial.
        Category IB
      Central venous catheters
      • 1.
        Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement).
        • Mermel L.A.
        • McCormick R.D.
        • Springman S.R.
        • Maki D.G.
        The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping.
        • Parienti J.J.
        • Thirion M.
        • Megarbane B.
        • et al.
        Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial.
        • Moretti E.W.
        • Ofstead C.L.
        • Kristy R.M.
        • Wetzler H.P.
        Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia.
        • Nagashima G.
        • Kikuchi T.
        • Tsuyuzaki H.
        • et al.
        To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization?.
        • Ruesch S.
        • Walder B.
        • Tramer M.R.
        Complications of central venous catheters: internal jugular versus subclavian access–a systematic review.
        • Sadoyama G.
        • Gontijo Filho P.P.
        Comparison between the jugular and subclavian vein as insertion site for central venous catheters: microbiological aspects and risk factors for colonization and infection.
        • Heard S.O.
        • Wagle M.
        • Vijayakumar E.
        • et al.
        Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia.
        • Richet H.
        • Hubert B.
        • Nitemberg G.
        • et al.
        Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients.
        • Safdar N.
        • Kluger D.M.
        • Maki D.G.
        A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies.
        • Lorente L.
        • Jimenez A.
        • Iribarren J.L.
        • Jimenez J.J.
        • Martin M.M.
        • Mora M.L.
        The micro-organism responsible for central venous catheter related bloodstream infection depends on catheter site.
        • Traore O.
        • Liotier J.
        • Souweine B.
        Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units.
        • Joynt G.M.
        • Kew J.
        • Gomersall C.D.
        • Leung V.Y.
        • Liu E.K.
        Deep venous thrombosis caused by femoral venous catheters in critically ill adult patients.
        • Mian N.Z.
        • Bayly R.
        • Schreck D.M.
        • Besserman E.B.
        • Richmand D.
        Incidence of deep venous thrombosis associated with femoral venous catheterization.
        • Merrer J.
        • De Jonghe B.
        • Golliot F.
        • et al.
        Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.
        • Goetz A.M.
        • Wagener M.M.
        • Miller J.M.
        • Muder R.R.
        Risk of infection due to central venous catheters: effect of site of placement and catheter type.
        • Robinson J.F.
        • Robinson W.A.
        • Cohn A.
        • Garg K.
        • Armstrong J.D.
        2nd. Perforation of the great vessels during central venous line placement.
        • Trottier S.J.
        • Veremakis C.
        • O'Brien J.
        • Auer A.I.
        Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial.
        Category IA
      • 2.
        Avoid using the femoral vein for central venous access in adult patients.
        • Parienti J.J.
        • Thirion M.
        • Megarbane B.
        • et al.
        Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial.
        • Merrer J.
        • De Jonghe B.
        • Golliot F.
        • et al.
        Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.
        • Goetz A.M.
        • Wagener M.M.
        • Miller J.M.
        • Muder R.R.
        Risk of infection due to central venous catheters: effect of site of placement and catheter type.
        • Lorente L.
        • Henry C.
        • Martin M.M.
        • Jimenez A.
        • Mora M.L.
        Central venous catheter-related infection in a prospective and observational study of 2,595 catheters.
        Category 1A
      • 3.
        Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement.
        • Merrer J.
        • De Jonghe B.
        • Golliot F.
        • et al.
        Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.
        • Goetz A.M.
        • Wagener M.M.
        • Miller J.M.
        • Muder R.R.
        Risk of infection due to central venous catheters: effect of site of placement and catheter type.
        • Robinson J.F.
        • Robinson W.A.
        • Cohn A.
        • Garg K.
        • Armstrong J.D.
        2nd. Perforation of the great vessels during central venous line placement.
        Category IB
      • 4.
        No recommendation can be made for a preferred site of insertion to minimize infection risk for a tunneled CVC. Unresolved issue
      • 5.
        Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis.
        • Trottier S.J.
        • Veremakis C.
        • O'Brien J.
        • Auer A.I.
        Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial.
        • Schillinger F.
        • Schillinger D.
        • Montagnac R.
        • Milcent T.
        Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses.
        • Cimochowski G.E.
        • Worley E.
        • Rutherford W.E.
        • Sartain J.
        • Blondin J.
        • Harter H.
        Superiority of the internal jugular over the subclavian access for temporary dialysis.
        • Barrett N.
        • Spencer S.
        • McIvor J.
        • Brown E.A.
        Subclavian stenosis: a major complication of subclavian dialysis catheters.
        • Trerotola S.O.
        • Kuhn-Fulton J.
        • Johnson M.S.
        • Shah H.
        • Ambrosius W.T.
        • Kneebone P.H.
        Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access.
        Category IA
      • 6.
        Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis.
        National Kidney Foundation
        III. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000.
        Category 1A
      • 7.
        Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique.
        • Hind D.
        • Calvert N.
        • McWilliams R.
        • et al.
        Ultrasonic locating devices for central venous cannulation: meta-analysis.
        • Randolph A.G.
        • Cook D.J.
        • Gonzales C.A.
        • Pribble C.G.
        Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature.
        • Froehlich C.D.
        • Rigby M.R.
        • Rosenberg E.S.
        • et al.
        Ultrasound-guided central venous catheter placement decreases complications and decreases placement attempts compared with the landmark technique in patients in a pediatric intensive care unit.
        • Lamperti M.
        • Caldiroli D.
        • Cortellazzi P.
        • et al.
        Safety and efficacy of ultrasound assistance during internal jugular vein cannulation in neurosurgical infants.
        • Schweickert W.D.
        • Herlitz J.
        • Pohlman A.S.
        • Gehlbach B.K.
        • Hall J.B.
        • Kress J.P.
        A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures.
        Category 1B
      • 8.
        Use a CVC with the minimum number of ports or lumens essential for the management of the patient.
        • Clark-Christoff N.
        • Watters V.A.
        • Sparks W.
        • Snyder P.
        • Grant J.P.
        Use of triple-lumen subclavian catheters for administration of total parenteral nutrition.
        • Early T.F.
        • Gregory R.T.
        • Wheeler J.R.
        • Snyder Jr., S.O.
        • Gayle R.G.
        Increased infection rate in double-lumen versus single-lumen Hickman catheters in cancer patients.
        • Hilton E.
        • Haslett T.M.
        • Borenstein M.T.
        • Tucci V.
        • Isenberg H.D.
        • Singer C.
        Central catheter infections: single- versus triple-lumen catheters. Influence of guide wires on infection rates when used for replacement of catheters.
        • Yeung C.
        • May J.
        • Hughes R.
        Infection rate for single lumen v triple lumen subclavian catheters.
        Category IB
      • 9.
        No recommendation can be made regarding the use of a designated lumen for parenteral nutrition. Unresolved issue
      • 10.
        Promptly remove any intravascular catheter that is no longer essential.
        • Pronovost P.
        • Needham D.
        • Berenholtz S.
        • et al.
        An intervention to decrease catheter-related bloodstream infections in the ICU.
        • Berenholtz S.M.
        • Pronovost P.J.
        • Lipsett P.A.
        • et al.
        Eliminating catheter-related bloodstream infections in the intensive care unit.
        • Lederle F.A.
        • Parenti C.M.
        • Berskow L.C.
        • Ellingson K.J.
        The idle intravenous catheter.
        • Parenti C.M.
        • Lederle F.A.
        • Impola C.L.
        • Peterson L.R.
        Reduction of unnecessary intravenous catheter use. Internal medicine house staff participate in a successful quality improvement project.
        Category IA
      • 11.
        When adherence to aseptic technique cannot be ensured (i.e catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e, within 48 hours.
        • Mermel L.A.
        • McCormick R.D.
        • Springman S.R.
        • Maki D.G.
        The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping.
        • Abi-Said D.
        • Raad I.
        • Umphrey J.
        • et al.
        Infusion therapy team and dressing changes of central venous catheters.
        • Capdevila J.A.
        • Segarra A.
        • Pahissa A.
        Catheter-related bacteremia in patients undergoing hemodialysis.
        • Mermel L.A.
        • Maki D.G.
        Infectious complications of Swan-Ganz pulmonary artery catheters. Pathogenesis, epidemiology, prevention, and management.
        • Raad I.I.
        • Hohn D.C.
        • Gilbreath B.J.
        • et al.
        Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion.
        Category IB

      Hand hygiene and aseptic technique

      • 1.
        Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained.
        • Coopersmith C.M.
        • Rebmann T.L.
        • Zack J.E.
        • et al.
        Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit.
        • Boyce J.M.
        • Pittet D.
        Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
        • Bischoff W.E.
        • Reynolds T.M.
        • Sessler C.N.
        • Edmond M.B.
        • Wenzel R.P.
        Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic.
        • Pittet D.
        • Dharan S.
        • Touveneau S.
        • Sauvan V.
        • Perneger T.V.
        Bacterial contamination of the hands of hospital staff during routine patient care.
        Category IB
      • 2.
        Maintain aseptic technique for the insertion and care of intravascular catheters.
        • Mermel L.A.
        • McCormick R.D.
        • Springman S.R.
        • Maki D.G.
        The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping.
        • Abi-Said D.
        • Raad I.
        • Umphrey J.
        • et al.
        Infusion therapy team and dressing changes of central venous catheters.
        • Capdevila J.A.
        • Segarra A.
        • Pahissa A.
        Catheter-related bacteremia in patients undergoing hemodialysis.
        • Raad I.I.
        • Hohn D.C.
        • Gilbreath B.J.
        • et al.
        Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion.
        Category IB
      • 3.
        Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application of skin antiseptics. Category IC
      • 4.
        Sterile gloves should be worn for the insertion of arterial, central, and midline catheters.
        • Mermel L.A.
        • McCormick R.D.
        • Springman S.R.
        • Maki D.G.
        The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping.
        • Abi-Said D.
        • Raad I.
        • Umphrey J.
        • et al.
        Infusion therapy team and dressing changes of central venous catheters.
        • Capdevila J.A.
        • Segarra A.
        • Pahissa A.
        Catheter-related bacteremia in patients undergoing hemodialysis.
        • Raad I.I.
        • Hohn D.C.
        • Gilbreath B.J.
        • et al.
        Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion.
        Category IA
      • 5.
        Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
      • 6.
        Wear either clean or sterile gloves when changing the dressing on intravascular catheters. Category IC

      Maximal sterile barrier precautions

      • 1.
        Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange.
        • Sherertz R.J.
        • Ely E.W.
        • Westbrook D.M.
        • et al.
        Education of physicians-in-training can decrease the risk for vascular catheter infection.
        • Mermel L.A.
        • Maki D.G.
        Infectious complications of Swan-Ganz pulmonary artery catheters. Pathogenesis, epidemiology, prevention, and management.
        • Raad I.I.
        • Hohn D.C.
        • Gilbreath B.J.
        • et al.
        Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion.
        • Carrer S.
        • Bocchi A.
        • Bortolotti M.
        • et al.
        Effect of different sterile barrier precautions and central venous catheter dressing on the skin colonization around the insertion site.
        Category IB
      • 2.
        Use a sterile sleeve to protect pulmonary artery catheters during insertion.
        • Cohen Y.
        • Fosse J.P.
        • Karoubi P.
        • et al.
        The ‘hands-off’ catheter and the prevention of systemic infections associated with pulmonary artery catheter: a prospective study.
        Category IB

      Skin preparation

      • 1.
        Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, an iodophor or chlorhexidine gluconate) before peripheral venous catheter insertion.
        • Maki D.G.
        • Ringer M.
        • Alvarado C.J.
        Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters.
        Category IB
      • 2.
        Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives.
        • Maki D.G.
        • Ringer M.
        • Alvarado C.J.
        Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters.
        • Mimoz O.
        • Pieroni L.
        • Lawrence C.
        • et al.
        Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients.
        Category IA
      • 3.
        No comparison has been made between using chlorhexidine preparations with alcohol and povidone-iodine in alcohol to prepare clean skin. Unresolved issue.
      • 4.
        No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Unresolved issue
      • 5.
        Antiseptics should be allowed to dry according to the manufacturer's recommendation prior to placing the catheter.
        • Maki D.G.
        • Ringer M.
        • Alvarado C.J.
        Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters.
        • Mimoz O.
        • Pieroni L.
        • Lawrence C.
        • et al.
        Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients.
        Category IB

      Catheter site dressing regimens

      • 1.
        Use either sterile gauze or sterile, transparent, semi-permeable dressing to cover the catheter site.
        • Maki D.G.
        • Stolz S.S.
        • Wheeler S.
        • Mermel L.A.
        A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management.
        • Bijma R.
        • Girbes A.R.
        • Kleijer D.J.
        • Zwaveling J.H.
        Preventing central venous catheter-related infection in a surgical intensive-care unit.
        • Madeo M.
        • Martin C.R.
        • Turner C.
        • Kirkby V.
        • Thompson D.R.
        A randomized trial comparing Arglaes (a transparent dressing containing silver ions) to Tegaderm (a transparent polyurethane dressing) for dressing peripheral arterial catheters and central vascular catheters.
        • Rasero L.
        • Degl'Innocenti M.
        • Mocali M.
        • et al.
        Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a randomized, multicenter study. The Italian Nurse Bone Marrow Transplant Group (GITMO).
        Category IA
      • 2.
        If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved.
        • Maki D.G.
        • Stolz S.S.
        • Wheeler S.
        • Mermel L.A.
        A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management.
        • Bijma R.
        • Girbes A.R.
        • Kleijer D.J.
        • Zwaveling J.H.
        Preventing central venous catheter-related infection in a surgical intensive-care unit.
        • Madeo M.
        • Martin C.R.
        • Turner C.
        • Kirkby V.
        • Thompson D.R.
        A randomized trial comparing Arglaes (a transparent dressing containing silver ions) to Tegaderm (a transparent polyurethane dressing) for dressing peripheral arterial catheters and central vascular catheters.
        • Rasero L.
        • Degl'Innocenti M.
        • Mocali M.
        • et al.
        Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a randomized, multicenter study. The Italian Nurse Bone Marrow Transplant Group (GITMO).
        Category II
      • 3.
        Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled.
        • Maki D.G.
        • Stolz S.S.
        • Wheeler S.
        • Mermel L.A.
        A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management.
        • Bijma R.
        • Girbes A.R.
        • Kleijer D.J.
        • Zwaveling J.H.
        Preventing central venous catheter-related infection in a surgical intensive-care unit.
        Category IB
      • 4.
        Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance.
        • Zakrzewska-Bode A.
        • Muytjens H.L.
        • Liem K.D.
        • Hoogkamp-Korstanje J.A.
        Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters.
        • Flowers R.H.
        • Schwenzer K.J.
        • Kopel R.F.
        • Fisch M.J.
        • Tucker S.I.
        • Farr B.M.
        Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. A randomized, controlled trial.
        Category IB
      • 5.
        Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower).
        • Robbins J.
        • Cromwell P.
        • Korones D.N.
        Swimming and central venous catheter-related infections in the child with cancer.
        • Howell P.B.
        • Walters P.E.
        • Donowitz G.R.
        • Farr B.M.
        Risk factors for infection of adult patients with cancer who have tunnelled central venous catheters.
        • Ivy D.D.
        • Calderbank M.
        • Wagner B.D.
        • et al.
        Closed-hub systems with protected connections and the reduction of risk of catheter-related bloodstream infection in pediatric patients receiving intravenous prostanoid therapy for pulmonary hypertension.
        Category IB
      • 6.
        Replace dressings used on short-term CVC sites every 2 days for gauze dressings. Category II
      • 7.
        Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing.
        • Rasero L.
        • Degl'Innocenti M.
        • Mocali M.
        • et al.
        Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a randomized, multicenter study. The Italian Nurse Bone Marrow Transplant Group (GITMO).
        • Timsit J.F.
        • Schwebel C.
        • Bouadma L.
        • et al.
        Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial.
        Category IB
      • 8.
        Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. Category II
      • 9.
        No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. Unresolved issue
      • 10.
        Ensure that catheter site care is compatible with the catheter material.
        • Rao S.P.
        • Oreopoulos D.G.
        Unusual complications of a polyurethane PD catheter.
        • Riu S.
        • Ruiz C.G.
        • Martinez-Vea A.
        • Peralta C.
        • Oliver J.A.
        Spontaneous rupture of polyurethane peritoneal catheter. A possible deleterious effect of mupirocin ointment.
        Category IB
      • 11.
        Use a sterile sleeve for all pulmonary artery catheters.
        • Cohen Y.
        • Fosse J.P.
        • Karoubi P.
        • et al.
        The ‘hands-off’ catheter and the prevention of systemic infections associated with pulmonary artery catheter: a prospective study.
        Category IB
      • 12.
        Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, and MSB.
        • Timsit J.F.
        • Schwebel C.
        • Bouadma L.
        • et al.
        Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial.
        • Garland J.S.
        • Alex C.P.
        • Mueller C.D.
        • et al.
        A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates.
        • Ho K.M.
        • Litton E.
        Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis.
        • Levy I.
        • Katz J.
        • Solter E.
        • et al.
        Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study.
        Category 1B
      • 13.
        No recommendation is made for other types of chlorhexidine dressings. Unresolved issue
      • 14.
        Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site.
        • Lorenzen A.N.
        • Itkin D.J.
        Surveillance of infection in home care.
        • White M.C.
        Infections and infection risks in home care settings.
        • White M.C.
        • Ragland K.E.
        Surveillance of intravenous catheter-related infections among home care clients.
        Category IB
      • 15.
        Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category II

      Patient cleansing

      Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI.
      • Bleasdale S.C.
      • Trick W.E.
      • Gonzalez I.M.
      • Lyles R.D.
      • Hayden M.K.
      • Weinstein R.A.
      Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients.
      • Munoz-Price L.S.
      • Hota B.
      • Stemer A.
      • Weinstein R.A.
      Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute care hospital.
      • Popovich K.J.
      • Hota B.
      • Hayes R.
      • Weinstein R.A.
      • Hayden M.K.
      Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit.
      Category II

      Catheter securement devices

      Use a sutureless securement device to reduce the risk of infection for intravascular catheters.
      • Yamamoto A.J.
      • Solomon J.A.
      • Soulen M.C.
      • et al.
      Sutureless securement device reduces complications of peripherally inserted central venous catheters.
      Category II

      Antimicrobial/Antiseptic impregnated catheters and cuffs

      Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin -impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion.
      • Brun-Buisson C.
      • Doyon F.
      • Sollet J.P.
      • Cochard J.F.
      • Cohen Y.
      • Nitenberg G.
      Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazine-coated catheters: a randomized controlled trial.
      • Ostendorf T.
      • Meinhold A.
      • Harter C.
      • et al.
      Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients–a double-blind, randomised, prospective, controlled trial.
      • Rupp M.E.
      • Lisco S.J.
      • Lipsett P.A.
      • et al.
      Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized, controlled trial.
      • Darouiche R.O.
      • Raad I.I.
      • Heard S.O.
      • et al.
      A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group.
      • Raad I.
      • Darouiche R.
      • Dupuis J.
      • et al.
      Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections. A randomized, double-blind trial. The Texas Medical Center Catheter Study Group.
      • Hanna H.
      • Benjamin R.
      • Chatzinikolaou I.
      • et al.
      Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial.
      • Bhutta A.
      • Gilliam C.
      • Honeycutt M.
      • et al.
      Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach.
      • Chelliah A.
      • Heydon K.H.
      • Zaoutis T.E.
      • et al.
      Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients.
      Category IA

      Systemic antibiotic prophylaxis

      Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI.
      • van de Wetering M.D.
      • van Woensel J.B.M.
      Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in oncology patients.
      Category IB

      Antibiotic/Antiseptic ointments

      Use povidone iodine antiseptic ointment or bacitracin/gramicidin/polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer's recommendation.
      National Kidney Foundation
      III. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000.
      • Maki D.G.
      • Band J.D.
      A comparative study of polyantibiotic and iodophorointments in prevention of vascular catheter-related infection.
      • Fukunaga A.
      • Naritaka H.
      • Fukaya R.
      • Tabuse M.
      • Nakamura T.
      Povidone-iodine ointment and gauze dressings associated with reduced catheter-related infection in seriously ill neurosurgical patients.
      • Johnson D.W.
      • MacGinley R.
      • Kay T.D.
      • et al.
      A randomized controlled trial of topical exit site mupirocin application in patients with tunnelled, cuffed haemodialysis catheters.
      • Fong I.W.
      Prevention of haemodialysis and peritoneal dialysis catheter related infection by topical povidone-iodine.
      • Levin A.
      • Mason A.J.
      • Jindal K.K.
      • Fong I.W.
      • Goldstein M.B.
      Prevention of hemodialysis subclavian vein catheter infections by topical povidone-iodine.
      Category IB

      Antibiotic lock prophylaxis, antimicrobial catheter flush and Catheter lock prophylaxis

      Use prophylactic antimicrobial lock solution in patients with long term catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique.
      • Schwartz C.
      • Henrickson K.J.
      • Roghmann K.
      • Powell K.
      Prevention of bacteremia attributed to luminal colonization of tunneled central venous catheters with vancomycin-susceptible organisms.
      • Rackoff W.R.
      • Weiman M.
      • Jakobowski D.
      • et al.
      A randomized, controlled trial of the efficacy of a heparin and vancomycin solution in preventing central venous catheter infections in children.
      • Carratala J.
      • Niubo J.
      • Fernandez-Sevilla A.
      • et al.
      Randomized, double-blind trial of an antibiotic-lock technique for prevention of gram-positive central venous catheter-related infection in neutropenic patients with cancer.
      • Jurewitsch B.
      • Lee T.
      • Park J.
      • Jeejeebhoy K.
      Taurolidine 2% as an antimicrobial lock solution for prevention of recurrent catheter-related bloodstream infections.
      • Henrickson K.J.
      • Axtell R.A.
      • Hoover S.M.
      • et al.
      Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: a randomized, multicenter, double-blind trial.
      • Garland J.S.
      • Alex C.P.
      • Henrickson K.J.
      • McAuliffe T.L.
      • Maki D.G.
      A vancomycin-heparin lock solution for prevention of nosocomial bloodstream infection in critically ill neonates with peripherally inserted central venous catheters: a prospective, randomized trial.
      • Daghistani D.
      • Horn M.
      • Rodriguez Z.
      • Schoenike S.
      • Toledano S.
      Prevention of indwelling central venous catheter sepsis.
      • Barriga F.J.
      • Varas M.
      • Potin M.
      • et al.
      Efficacy of a vancomycin solution to prevent bacteremia associated with an indwelling central venous catheter in neutropenic and non-neutropenic cancer patients.
      • Dogra G.K.
      • Herson H.
      • Hutchison B.
      • et al.
      Prevention of tunneled hemodialysis catheter-related infections using catheter-restricted filling with gentamicin and citrate: a randomized controlled study.
      • Allon M.
      Prophylaxis against dialysis catheter-related bacteremia with a novel antimicrobial lock solution.
      • Elhassan N.O.
      • Stevens T.P.
      • Gigliotti F.
      • Hardy D.J.
      • Cole C.A.
      • Sinkin R.A.
      Vancomycin usage in central venous catheters in a neonatal intensive care unit.
      • McIntyre C.W.
      • Hulme L.J.
      • Taal M.
      • Fluck R.J.
      Locking of tunneled hemodialysis catheters with gentamicin and heparin.
      • Betjes M.G.
      • van Agteren M.
      Prevention of dialysis catheter-related sepsis with a citrate-taurolidine-containing lock solution.
      • Weijmer M.C.
      • van den Dorpel M.A.
      • Van de Ven P.J.
      • et al.
      Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients.
      • Bleyer A.J.
      • Mason L.
      • Russell G.
      • Raad I.I.
      • Sherertz R.J.
      A randomized, controlled trial of a new vascular catheter flush solution (minocycline-EDTA) in temporary hemodialysis access.
      • Kim S.H.
      • Song K.I.
      • Chang J.W.
      • et al.
      Prevention of uncuffed hemodialysis catheter-related bacteremia using an antibiotic lock technique: a prospective, randomized clinical trial.
      • Al-Hwiesh A.K.
      • Abdul-Rahman I.S.
      Successful prevention of tunneled, central catheter infection by antibiotic lock therapy using vancomycin and gentamycin.
      • Nori U.S.
      • Manoharan A.
      • Yee J.
      • Besarab A.
      Comparison of low-dose gentamicin with minocycline as catheter lock solutions in the prevention of catheter-related bacteremia.
      • Saxena A.K.
      • Panhotra B.R.
      • Sundaram D.S.
      • et al.
      Tunneled catheters' outcome optimization among diabetics on dialysis through antibiotic-lock placement.
      Category II

      Anticoagulants

      Do not routinely use anticoagulant therapy to reduce the risk of catheter-related infection in general patient populations.
      • Randolph A.G.
      • Cook D.J.
      • Gonzales C.A.
      • Andrew M.
      Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials.
      Category II

      Replacement of peripheral and midline catheters

      • 1.
        There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults.
        • Maki D.G.
        • Ringer M.
        Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial.
        • Tager I.B.
        • Ginsberg M.B.
        • Ellis S.E.
        • et al.
        An epidemiologic study of the risks associated with peripheral intravenous catheters.
        • Lai K.K.
        Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours.
        Category 1B
      • 2.
        No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated.
        • Van Donk P.
        • Rickard C.M.
        • McGrail M.R.
        • Doolan G.
        Routine replacement versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: a randomized controlled trial.
        • Webster J.
        • Clarke S.
        • Paterson D.
        • et al.
        Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial.
        • Webster J.
        • Osborne S.
        • Rickard C.
        • Hall J.
        Clinically-indicated replacement versus routine replacement of peripheral venous catheters.
        Unresolved issue
      • 3.
        Replace peripheral catheters in children only when clinically indicated.
        • Maki D.G.
        • Goldman D.A.
        • Rhame F.S.
        Infection control in intravenous therapy.
        • Band J.D.
        • Maki D.G.
        Steel needles used for intravenous therapy. Morbidity in patients with hematologic malignancy.
        Category 1B
      • 4.
        Replace midline catheters only when there is a specific indication. Category II

      Replacement of CVCs, including PICCs and hemodialysis catheters

      • 1.
        Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. Category IB
      • 2.
        Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Category II
      • 3.
        Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection. Category IB
      • 4.
        Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. Category IB
      • 5.
        Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. Category IB
      • 6.
        Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II

      Umbilical catheters

      • 1.
        Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency in the lower extremities, or thrombosis are present.
        • Boo N.Y.
        • Wong N.C.
        • Zulkifli S.S.
        • Lye M.S.
        Risk factors associated with umbilical vascular catheter-associated thrombosis in newborn infants.
        Category II
      • 2.
        Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present.
        • Boo N.Y.
        • Wong N.C.
        • Zulkifli S.S.
        • Lye M.S.
        Risk factors associated with umbilical vascular catheter-associated thrombosis in newborn infants.
        Category II
      • 3.
        No recommendation can be made regarding attempts to salvage an umbilical catheter by administering antibiotic treatment through the catheter. Unresolved issue
      • 4.
        Cleanse the umbilical insertion site with an antiseptic before catheter insertion. Avoid tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine-containing products (e.g., povidone iodine) can be used.
        • Garland J.S.
        • Buck R.K.
        • Maloney P.
        • et al.
        Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial.
        • Krauss A.N.
        • Albert R.F.
        • Kannan M.M.
        Contamination of umbilical catheters in the newborn infant.
        • Landers S.
        • Moise A.A.
        • Fraley J.K.
        • Smith E.O.
        • Baker C.J.
        Factors associated with umbilical catheter-related sepsis in neonates.
        • Cronin W.A.
        • Germanson T.P.
        • Donowitz L.G.
        Intravascular catheter colonization and related bloodstream infection in critically ill neonates.
        • Miller K.L.
        • Coen P.E.
        • White W.J.
        • Hurst W.J.
        • Achey B.E.
        • Lang C.M.
        Effectiveness of skin absorption of tincture of I in blocking radioiodine from the human thyroid gland.
        Category IB
      • 5.
        Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance.
        • Zakrzewska-Bode A.
        • Muytjens H.L.
        • Liem K.D.
        • Hoogkamp-Korstanje J.A.
        Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters.
        • Flowers R.H.
        • Schwenzer K.J.
        • Kopel R.F.
        • Fisch M.J.
        • Tucker S.I.
        • Farr B.M.
        Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. A randomized, controlled trial.
        Category IA
      • 6.
        Add low-doses of heparin (0.25–1.0 U/ml) to the fluid infused through umbilical arterial catheters.
        • Ankola P.A.
        • Atakent Y.S.
        Effect of adding heparin in very low concentration to the infusate to prolong the patency of umbilical artery catheters.
        • David R.J.
        • Merten D.F.
        • Anderson J.C.
        • Gross S.
        Prevention of umbilical artery catheter clots with heparinized infusates.
        • Horgan M.J.
        • Bartoletti A.
        • Polansky S.
        • Peters J.C.
        • Manning T.J.
        • Lamont B.M.
        Effect of heparin infusates in umbilical arterial catheters on frequency of thrombotic complications.
        Category IB
      • 7.
        Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Optimally, umbilical artery catheters should not be left in place >5 days.
        • Boo N.Y.
        • Wong N.C.
        • Zulkifli S.S.
        • Lye M.S.
        Risk factors associated with umbilical vascular catheter-associated thrombosis in newborn infants.
        • Fletcher M.A.
        • Brown D.R.
        • Landers S.
        • Seguin J.
        Umbilical arterial catheter use: report of an audit conducted by the Study Group for Complications of Perinatal Care.
        Category II
      • 8.
        Umbilical venous catheters should be removed as soon as possible when no longer needed, but can be used up to 14 days if managed aseptically.
        • Seguin J.
        • Fletcher M.A.
        • Landers S.
        • Brown D.
        • Macpherson T.
        Umbilical venous catheterizations: audit by the Study Group for Complications of Perinatal Care.
        • Loisel D.B.
        • Smith M.M.
        • MacDonald M.G.
        • Martin G.R.
        Intravenous access in newborn infants: impact of extended umbilical venous catheter use on requirement for peripheral venous lines.
        Category II
      • 9.
        An umbilical catheter may be replaced if it is malfunctioning, and there is no other indication for catheter removal, and the total duration of catheterization has not exceeded 5 days for an umbilical artery catheter or 14 days for an umbilical vein catheter. Category II

      Peripheral arterial catheters and pressure monitoring devices for adult and pediatric patients

      • 1.
        In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of insertion to reduce the risk of infection.
        • Lorente L.
        • Jimenez A.
        • Iribarren J.L.
        • Jimenez J.J.
        • Martin M.M.
        • Mora M.L.
        The micro-organism responsible for central venous catheter related bloodstream infection depends on catheter site.
        • Traore O.
        • Liotier J.
        • Souweine B.
        Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units.
        • Martin C.
        • Saux P.
        • Papazian L.
        • Gouin F.
        Long-term arterial cannulation in ICU patients using the radial artery or dorsalis pedis artery.
        • Koh D.B.
        • Gowardman J.R.
        • Rickard C.M.
        • Robertson I.K.
        • Brown A.
        Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters.
        Category IB
      • 2.
        In children, the brachial site should not be used. The radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion.
        • Lorente L.
        • Jimenez A.
        • Iribarren J.L.
        • Jimenez J.J.
        • Martin M.M.
        • Mora M.L.
        The micro-organism responsible for central venous catheter related bloodstream infection depends on catheter site.
        Category II
      • 3.
        A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion.
        • Traore O.
        • Liotier J.
        • Souweine B.
        Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units.
        • Koh D.B.
        • Gowardman J.R.
        • Rickard C.M.
        • Robertson I.K.
        • Brown A.
        Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters.
        • Rijnders B.J.
        • Van Wijngaerden E.
        • Wilmer A.
        • Peetermans W.E.
        Use of full sterile barrier precautions during insertion of arterial catheters: a randomized trial.
        Category IB
      • 4.
        During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. Category II
      • 5.
        Replace arterial catheters only when there is a clinical indication. Category II
      • 6.
        Remove the arterial catheter as soon as it is no longer needed. Category II
      • 7.
        Use disposable, rather than reusable, transducer assemblies when possible.
        • Donowitz L.G.
        • Marsik F.J.
        • Hoyt J.W.
        • Wenzel R.P.
        Serratia marcescens bacteremia from contaminated pressure transducers.
        • Luskin R.L.
        • Weinstein R.A.
        • Nathan C.
        • Chamberlin W.H.
        • Kabins S.A.
        Extended use of disposable pressure transducers. A bacteriologic evaluation.
        • Maki D.G.
        • Hassemer C.A.
        Endemic rate of fluid contamination and related septicemia in arterial pressure monitoring.
        • Mermel L.A.
        • Maki D.G.
        Epidemic bloodstream infections from hemodynamic pressure monitoring: signs of the times.
        • Tenold R.
        • Priano L.
        • Kim K.
        • Rourke B.
        • Marrone T.
        Infection potential of nondisposable pressure transducers prepared prior to use.
        Category IB
      • 8.
        Do not routinely replace arterial catheters to prevent catheter-related infections.
        • Eyer S.
        • Brummitt C.
        • Crossley K.
        • Siegel R.
        • Cerra F.
        Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance.
        • Raad I.
        • Umphrey J.
        • Khan A.
        • Truett L.J.
        • Bodey G.P.
        The duration of placement as a predictor of peripheral and pulmonary arterial catheter infections.
        • Thomas F.
        • Burke J.P.
        • Parker J.
        • et al.
        The risk of infection related to radial vs femoral sites for arterial catheterization.
        • Leroy O.
        • Billiau V.
        • Beuscart C.
        • et al.
        Nosocomial infections associated with long-term radial artery cannulation.
        Category II
      • 9.
        Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced.
        • Mermel L.A.
        • McCormick R.D.
        • Springman S.R.
        • Maki D.G.
        The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping.
        • Luskin R.L.
        • Weinstein R.A.
        • Nathan C.
        • Chamberlin W.H.
        • Kabins S.A.
        Extended use of disposable pressure transducers. A bacteriologic evaluation.
        Category IB
      • 10.
        Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile.
        • Donowitz L.G.
        • Marsik F.J.
        • Hoyt J.W.
        • Wenzel R.P.
        Serratia marcescens bacteremia from contaminated pressure transducers.
        • Fisher M.C.
        • Long S.S.
        • Roberts E.M.
        • Dunn J.M.
        • Balsara R.K.
        Pseudomonas maltophilia bacteremia in children undergoing open heart surgery.
        • Stamm W.E.
        • Colella J.J.
        • Anderson R.L.
        • Dixon R.E.
        Indwelling arterial catheters as a source of nosocomial bacteremia. An outbreak caused by Flavobacterium Species.
        • Weinstein R.A.
        • Emori T.G.
        • Anderson R.L.
        • Stamm W.E.
        Pressure transducers as a source of bacteremia after open heart surgery. Report of an outbreak and guidelines for prevention.
        Category IA
      • 11.
        4Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed flush system (i.e, continuous flush), rather than an open system (i.e, one that requires a syringe and stopcock), to maintain the patency of the pressure monitoring catheters.
        • Mermel L.A.
        • Maki D.G.
        Epidemic bloodstream infections from hemodynamic pressure monitoring: signs of the times.
        • Shinozaki T.
        • Deane R.S.
        • Mazuzan Jr., J.E.
        • Hamel A.J.
        • Hazelton D.
        Bacterial contamination of arterial lines. A prospective study.
        Category II
      • 12.
        When the pressure monitoring system is accessed through a diaphragm, rather than a stopcock, scrub the diaphragm with an appropriate antiseptic before accessing the system.
        • Mermel L.A.
        • Maki D.G.
        Epidemic bloodstream infections from hemodynamic pressure monitoring: signs of the times.
        Category IA
      • 13.
        Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit.
        • Mermel L.A.
        • Maki D.G.
        Epidemic bloodstream infections from hemodynamic pressure monitoring: signs of the times.
        • Solomon S.L.
        • Alexander H.
        • Eley J.W.
        • et al.
        Nosocomial fungemia in neonates associated with intravascular pressure-monitoring devices.
        • Weems Jr., J.J.
        • Chamberland M.E.
        • Ward J.
        • Willy M.
        • Padhye A.A.
        • Solomon S.L.
        Candida parapsilosis fungemia associated with parenteral nutrition and contaminated blood pressure transducers.
        Category IA
      • 14.
        Sterilize reusable transducers according to the manufacturers' instructions if the use of disposable transducers is not feasible.
        • Mermel L.A.
        • Maki D.G.
        Epidemic bloodstream infections from hemodynamic pressure monitoring: signs of the times.
        • Solomon S.L.
        • Alexander H.
        • Eley J.W.
        • et al.
        Nosocomial fungemia in neonates associated with intravascular pressure-monitoring devices.
        • Weems Jr., J.J.
        • Chamberland M.E.
        • Ward J.
        • Willy M.
        • Padhye A.A.
        • Solomon S.L.
        Candida parapsilosis fungemia associated with parenteral nutrition and contaminated blood pressure transducers.
        • Villarino M.E.
        • Jarvis W.R.
        • O'Hara C.
        • Bresnahan J.
        • Clark N.
        Epidemic of Serratia marcescens bacteremia in a cardiac intensive care unit.
        • Beck-Sague C.M.
        • Jarvis W.R.
        • Brook J.H.
        • et al.
        Epidemic bacteremia due to Acinetobacter baumannii in five intensive care units.
        Category IA

      Replacement of administration sets

      • 1.
        In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals,
        • Gillies D.
        • Wallen M.M.
        • Morrison A.L.
        • Rankin K.
        • Nagy S.A.
        • O’Riordan E.
        Optimal timing for intravenous administration set replacement.
        but at least every 7 days.
        • Sitges-Serra A.
        • Linares J.
        • Perez J.L.
        • Jaurrieta E.
        • Lorente L.
        A randomized trial on the effect of tubing changes on hub contamination and catheter sepsis during parenteral nutrition.
        • Snydman D.R.
        • Donnelly-Reidy M.
        • Perry L.K.
        • Martin W.J.
        Intravenous tubing containing burettes can be safely changed at 72 hour intervals.
        • Maki D.G.
        • Botticelli J.T.
        • LeRoy M.L.
        • Thielke T.S.
        Prospective study of replacing administration sets for intravenous therapy at 48- vs 72-hour intervals. 72 hours is safe and cost-effective.
        • Josephson A.
        • Gombert M.E.
        • Sierra M.F.
        • Karanfil L.V.
        • Tansino G.F.
        The relationship between intravenous fluid contamination and the frequency of tubing replacement.
        Category IA
      • 2.
        No recommendation can be made regarding the frequency for replacing intermittently used administration sets.Unresolved issue
      • 3.
        No recommendation can be made regarding the frequency for replacing needles to access implantable ports. Unresolved issue
      • 4.
        Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion.
        • Melly M.A.
        • Meng H.C.
        • Schaffner W.
        Microbiol growth in lipid emulsions used in parenteral nutrition.
        • Mershon J.
        • Nogami W.
        • Williams J.M.
        • Yoder C.
        • Eitzen H.E.
        • Lemons J.A.
        Bacterial/fungal growth in a combined parenteral nutrition solution.
        • Gilbert M.
        • Gallagher S.C.
        • Eads M.
        • Elmore M.F.
        Microbial growth patterns in a total parenteral nutrition formulation containing lipid emulsion.
        • Maki D.G.
        • Martin W.T.
        Nationwide epidemic of septicemia caused by contaminated infusion products. IV. Growth of microbial pathogens in fluids for intravenous infusions.
        Category IB
      • 5.
        Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed, per the manufacturer's recommendation (FDA website Medwatch).
        • Bennett S.N.
        • McNeil M.M.
        • Bland L.A.
        • et al.
        Postoperative infections traced to contamination of an intravenous anesthetic, propofol.
        Category IA
      • 6.
        No recommendation can be made regarding the length of time a needle used to access implanted ports can remain in place. Unresolved issue

      Needleless intravascular catheter systems

      • 1.
        Change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently than every 72 hours.
        • Moretti E.W.
        • Ofstead C.L.
        • Kristy R.M.
        • Wetzler H.P.
        Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia.
        • Arduino M.J.
        • Bland L.A.
        • Danzig L.E.
        • McAllister S.K.
        • Aguero S.M.
        Microbiologic evaluation of needleless and needle-access devices.
        • Brown J.D.
        • Moss H.A.
        • Elliott T.S.
        The potential for catheter microbial contamination from a needleless connector.
        • Cookson S.T.
        • Ihrig M.
        • O'Mara E.M.
        • et al.
        Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device.
        • Seymour V.M.
        • Dhallu T.S.
        • Moss H.A.
        • Tebbs S.E.
        • Elliot T.S.
        A prospective clinical study to investigate the microbial contamination of a needleless connector.
        • Luebke M.A.
        • Arduino M.J.
        • Duda D.L.
        • et al.
        Comparison of the microbial barrier properties of a needleless and a conventional needle-based intravenous access system.
        • McDonald L.C.
        • Banerjee S.N.
        • Jarvis W.R.
        Line-associated bloodstream infections in pediatric intensive-care-unit patients associated with a needleless device and intermittent intravenous therapy.
        • Mendelson M.H.
        • Short L.J.
        • Schechter C.B.
        • et al.
        Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of staff, patient, and institutional outcomes.
        Category II
      • 2.
        Change needleless connectors no more frequently than every 72 hours or according to manufacturers' recommendations for the purpose of reducing infection rates.
        • Arduino M.J.
        • Bland L.A.
        • Danzig L.E.
        • McAllister S.K.
        • Aguero S.M.
        Microbiologic evaluation of needleless and needle-access devices.
        • Cookson S.T.
        • Ihrig M.
        • O'Mara E.M.
        • et al.
        Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device.
        • McDonald L.C.
        • Banerjee S.N.
        • Jarvis W.R.
        Line-associated bloodstream infections in pediatric intensive-care-unit patients associated with a needleless device and intermittent intravenous therapy.
        • Mendelson M.H.
        • Short L.J.
        • Schechter C.B.
        • et al.
        Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of staff, patient, and institutional outcomes.
        Category II
      • 3.
        Ensure that all components of the system are compatible to minimize leaks and breaks in the system.
        • Do A.N.
        • Ray B.J.
        • Banerjee S.N.
        • et al.
        Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting.
        Category II
      • 4.
        Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices.
        • Cookson S.T.
        • Ihrig M.
        • O'Mara E.M.
        • et al.
        Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device.
        • McDonald L.C.
        • Banerjee S.N.
        • Jarvis W.R.
        Line-associated bloodstream infections in pediatric intensive-care-unit patients associated with a needleless device and intermittent intravenous therapy.
        • Do A.N.
        • Ray B.J.
        • Banerjee S.N.
        • et al.
        Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting.
        • Soothill J.S.
        • Bravery K.
        • Ho A.
        • Macqueen S.
        • Collins J.
        • Lock P.
        A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hemopoietic stem cell transplant ward.
        • Casey A.L.
        • Burnell S.
        • Whinn H.
        • Worthington T.
        • Faroqui M.H.
        • Elliott T.S.
        A prospective clinical trial to evaluate the microbial barrier of a needleless connector.
        Category IA
      • 5.
        Use a needleless system to access IV tubing. Category IC
      • 6.
        When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves.
        • Rupp M.E.
        • Sholtz L.A.
        • Jourdan D.R.
        • et al.
        Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve.
        • Salgado C.D.
        • Chinnes L.
        • Paczesny T.H.
        • Cantey J.R.
        Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital.
        • Maragakis L.L.
        • Bradley K.L.
        • Song X.
        • et al.
        Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.
        • Field K.
        • McFarlane C.
        • Cheng A.C.
        • et al.
        Incidence of catheter-related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian hematology-oncology unit.
        Category II

      Performance improvement

      Use hospital-specific or collaborative-based performance improvement initiatives in which multifaceted strategies are “bundled” together to improve compliance with evidence-based recommended practices.
      • Eggimann P.
      • Harbarth S.
      • Constantin M.N.
      • Touveneau S.
      • Chevrolet J.C.
      • Pittet D.
      Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care.
      • Pronovost P.
      • Needham D.
      • Berenholtz S.
      • et al.
      An intervention to decrease catheter-related bloodstream infections in the ICU.
      • Berenholtz S.M.
      • Pronovost P.J.
      • Lipsett P.A.
      • et al.
      Eliminating catheter-related bloodstream infections in the intensive care unit.
      • Costello J.M.
      • Morrow D.F.
      • Graham D.A.
      • Potter-Bynoe G.
      • Sandora T.J.
      • Laussen P.C.
      Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit.
      • Frankel H.L.
      • Crede W.B.
      • Topal J.E.
      • Roumanis S.A.
      • Devlin M.W.
      • Foley A.B.
      Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU.
      • Galpern D.
      • Guerrero A.
      • Tu A.
      • Fahoum B.
      • Wise L.
      Effectiveness of a central line bundle campaign on line-associated infections in the intensive care unit.
      • McKee C.
      • Berkowitz I.
      • Cosgrove S.E.
      • et al.
      Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality.
      • Pronovost P.J.
      • Berenholtz S.M.
      • Goeschel C.A.
      Improving the quality of measurement and evaluation in quality improvement efforts.
      Category IB

      Background information

      Terminology and estimates of risk

      The terminology used to identify different types of catheters is confusing, because many clinicians and researchers use different aspects of the catheter for informal reference. A catheter can be designated by the type of vessel it occupies (e.g., peripheral venous, central venous, or arterial); its intended life span (e.g., temporary or short-term versus permanent or long-term); its site of insertion (e.g., subclavian, femoral, internal jugular, peripheral, and peripherally inserted central catheter [PICC]); its pathway from skin to vessel (e.g., tunneled versus nontunneled); its physical length (e.g., long versus short); or some special characteristic of the catheter (e.g., presence or absence of a cuff, impregnation with heparin, antibiotics or antiseptics, and the number of lumens). To accurately define a specific type of catheter, all of these aspects should be described (Table 1).
      Table 1Catheters Used for Venous and Arterial Access
      Catheter typeEntry siteLengthComments
      Peripheral venous cathetersUsually inserted in veins of forearm or hand<3 inchesPhlebitis with prolonged use; rarely associated with bloodstream infection
      Peripheral arterial cathetersUsually inserted in radial artery; can be placed in femoral, axillary, brachial, posterior tibial arteries<3 inchesLow infection risk; rarely associated with bloodstream infection
      Midline cathetersInserted via the antecubital fossa into the proximal basilic or cephalic veins; does not enter central veins, peripheral catheters3 to 8 inchesAnaphylactoid reactions have been reported with catheters made of elastomeric hydrogel; lower rates of phlebitis than short peripheral catheters
      Nontunneled central venous cathetersPercutaneously inserted into central veins (subclavian, internal jugular, or femoral)≥8 cm depending on patient sizeAccount for majority of CRBSI
      Pulmonary artery cathetersInserted through a Teflon® introducer in a central vein (subclavian, internal jugular, or femoral)≥30 cm depending on patient sizeUsually heparin bonded; similar rates of bloodstream infection as CVCs; subclavian site preferred to reduce infection risk
      Peripherally inserted central venous catheters (PICC)Inserted into basilic, cephalic, or brachial veins and enter the superior vena cava≥20 cm depending on patient sizeLower rate of infection than nontunneled CVCs
      Tunneled central venous cathetersImplanted into subclavian, internal jugular, or femoral veins≥8 cm depending on patient sizeCuff inhibits migration of organisms into catheter tract; lower rate of infection than nontunneled CVC
      Totally implantableTunneled beneath skin and have subcutaneous port accessed with a needle; implanted in subclavian or internal jugular vein≥8 cm depending on patient sizeLowest risk for CRBSI; improved patient self-image; no need for local catheter-site care; surgery required for catheter removal
      Umbilical cathetersInserted into either umbilical vein or umbilical artery≤6 cm depending on patient sizeRisk for CRBSI similar with catheters placed in umbilical vein versus artery
      Likewise the terms used to describe intravascular catheter-related infections can also be confusing because catheter-related bloodstream infection (CRBSI) and central line–associated bloodstream infection (CLABSI) are often used interchangeably even though the meanings differ.
      CRBSI is a clinical definition, used when diagnosing and treating patients, that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI. It is not typically used for surveillance purposes. It is often problematic to precisely establish if a BSI is a CRBSI due to the clinical needs of the patient (the catheter is not always pulled), limited availability of microbiologic methods (many labs do not use quantitative blood cultures or differential time to positivity), and procedural compliance by direct care personnel (labeling must be accurate). Simpler definitions are often used for surveillance purposes. For example, CLABSI is a term used by CDC's National Healthcare Safety Network (NHSN) (NHSN CLABSI information: http://www.cdc.gov/nhsn/psc_da.html).
      • Horan T.C.
      • Andrus M.
      • Dudeck M.A.
      CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.
      A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site. However, since some BSIs are secondary to other sources other than the central line (e.g., pancreatitis, mucositis) that may not be easily recognized, the CLABSI surveillance definition may overestimate the true incidence of CRBSI.

      Epidemiology and microbiology in adult and pediatric patients

      National estimates of CLABSI rates are available through CDC's NHSN, a surveillance system for healthcare-associated infections, and are available on CDC's website: http://www.cdc.gov/nhsn/dataStat.html. A recent report highlights data from 1545 hospitals in 48 States and the District of Columbia that monitor infections in one or more ICUs and/or non-ICUs (e.g., patient care areas, wards).
      • Edwards J.R.
      • Peterson K.D.
      • Mu Y.
      • et al.
      National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009.
      Because BSI rates are influenced by patient-related factors, such as severity of illness and type of illness (e.g., third-degree burns versus post-cardiac surgery), by catheter-related factors, (such as the condition under which the catheter was placed and catheter type), and by institutional factors (e.g., bed-size, academic affiliation), these aggregate, risk-adjusted rates can be used as benchmarks against which hospitals can make intra- and inter-facility comparisons.
      The most commonly reported causative pathogens remain coagulase-negative staphylococci, Staphylococcus aureus, enterococci, and Candida spp.
      • Wisplinghoff H.
      • Bischoff T.
      • Tallent S.M.
      • Seifert H.
      • Wenzel R.P.
      • Edmond M.B.
      Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study.
      Gram negative bacilli accounted for 19% and 21% of CLABSIs reported to CDC
      • Gaynes R.
      • Edwards J.R.
      Overview of nosocomial infections caused by gram-negative bacilli.
      and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database, respectively.
      • Wisplinghoff H.
      • Bischoff T.
      • Tallent S.M.
      • Seifert H.
      • Wenzel R.P.
      • Edmond M.B.
      Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study.
      For all common pathogens causing CLABSIs, antimicrobial resistance is a problem, particularly in ICUs. Although methicillin-resistant Staphylococcus aureus (MRSA) now account for more than 50% of all Staphylococcus aureus isolates obtained in ICUs, the incidence of MRSA CLABSIs has decreased in recent years, perhaps as a result of prevention efforts.
      • Burton D.C.
      • Edwards J.R.
      • Horan T.C.
      • Jernigan J.A.
      • Fridkin S.K.
      Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in US intensive care units, 1997–2007.
      For gram negative rods, antimicrobial resistance to third generation cephalosporins among Klebsiella pneumoniae and E. coli has increased significantly as has imipenem and ceftazidine resistance among Pseudomonas aeruginosa.
      • Gaynes R.
      • Edwards J.R.
      Overview of nosocomial infections caused by gram-negative bacilli.
      Candida spp. are increasingly noted to be fluconazole resistant.

      Pathogenesis

      There are four recognized routes for contamination of catheters: 1) migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter with colonization of the catheter tip; this is the most common route of infection for short-term catheters;
      • Mermel L.A.
      • McCormick R.D.
      • Springman S.R.
      • Maki D.G.
      The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping.
      • Safdar N.
      • Maki D.G.
      The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters.
      • Maki D.G.
      • Weise C.E.
      • Sarafin H.W.
      A semiquantitative culture method for identifying intravenous-catheter-related infection.
      2) direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices;
      • Raad I.
      • Costerton W.
      • Sabharwal U.
      • Sacilowski M.
      • Anaissie E.
      • Bodey G.P.
      Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization and duration of placement.
      • Dobbins B.M.
      • Kite P.
      • Kindon A.
      • McMahon M.J.
      • Wilcox M.H.
      DNA fingerprinting analysis of coagulase negative staphylococci implicated in catheter related bloodstream infections.
      3) less commonly, catheters might become hematogenously seeded from another focus of infection;
      • Anaissie E.
      • Samonis G.
      • Kontoyiannis D.
      • et al.
      Role of catheter colonization and infrequent hematogenous seeding in catheter-related infections.
      and 4) rarely, infusate contamination might lead to CRBSI.
      • Raad I.
      • Hanna H.A.
      • Awad A.
      • et al.
      Optimal frequency of changing intravenous administration sets: is it safe to prolong use beyond 72 hours?.
      Important pathogenic determinants of CRBSI are 1) the material of which the device is made; 2) the host factors consisting of protein adhesions, such as fibrin and fibronectin, that form a sheath around the catheter;
      • Mehall J.R.
      • Saltzman D.A.
      • Jackson R.J.
      • Smith S.D.
      Fibrin sheath enhances central venous catheter infection.
      and 3) the intrinsic virulence factors of the infecting organism, including the extracellular polymeric substance (EPS) produced by the adherent organisms.
      • Donlan R.M.
      • Costerton J.W.
      Biofilms: survival mechanisms of clinically relevant microorganisms.
      Some catheter materials also have surface irregularities that enhance the microbial adherence of certain species (e.g., S. epidermidis and C. albicans).
      • Hawser S.P.
      • Douglas L.J.
      Biofilm formation by Candida species on the surface of catheter materials in vitro.
      • Stillman R.M.
      • Soliman F.
      • Garcia L.
      • Sawyer P.N.
      Etiology of catheter-associated sepsis. Correlation with thrombogenicity.
      Catheters made of these materials are especially vulnerable to microbial colonization and subsequent infection. Due to the formation of the fibrin sheath, silastic catheters are associated with higher risk of catheter infections than polyurethane catheters.
      • Mehall J.R.
      • Saltzman D.A.
      • Jackson R.J.
      • Smith S.D.
      Fibrin sheath enhances central venous catheter infection.
      On the other hand, biofilm formation by C. albicans occurs more readily on silicone elastomer catheter surfaces than polyurethane catheters.
      • Hawser S.P.
      • Douglas L.J.
      Biofilm formation by Candida species on the surface of catheter materials in vitro.
      Modification of the biomaterial surface properties has been shown to influence the ability of C. albicans to form biofilm.
      • Stillman R.M.
      • Soliman F.
      • Garcia L.
      • Sawyer P.N.
      Etiology of catheter-associated sepsis. Correlation with thrombogenicity.
      Additionally, certain catheter materials are more thrombogenic than others, a characteristic that also might predispose to catheter colonization and infection.
      • Raad I.I.
      • Luna M.
      • Khalil S.A.
      • Costerton J.W.
      • Lam C.
      • Bodey G.P.
      The relationship between the thrombotic and infectious complications of central venous catheters.
      • Herrmann M.
      • Suchard S.J.
      • Boxer L.A.
      • Waldvogel F.A.
      • Lew P.D.
      Thrombospondin binds to Staphylococcus aureus and promotes staphylococcal adherence to surfaces.
      This association has led to emphasis on preventing catheter-related thrombus as an additional mechanism for reducing CRBSI.
      • Shanks R.M.
      • Sargent J.L.
      • Martinez R.M.
      • Graber M.L.
      • O'Toole G.A.
      Catheter lock solutions influence staphylococcal biofilm formation on abiotic surfaces.
      • Chatzinikolaou I.
      • Zipf T.F.
      • Hanna H.
      • et al.
      Minocycline-ethylenediaminetetraacetate lock solution for the prevention of implantable port infections in children with cancer.
      The adherence properties of a given microorganism in relationship to host factors are also important in the pathogenesis of CRBSI. For example, S. aureus can adhere to host proteins (e.g., fibrinogen, fibronectin) commonly present on catheters by expressing clumping factors (ClfA and ClfB) that bind to the protein adhesins.
      • Mehall J.R.
      • Saltzman D.A.
      • Jackson R.J.
      • Smith S.D.
      Fibrin sheath enhances central venous catheter infection.
      • Herrmann M.
      • Suchard S.J.
      • Boxer L.A.
      • Waldvogel F.A.
      • Lew P.D.
      Thrombospondin binds to Staphylococcus aureus and promotes staphylococcal adherence to surfaces.
      • McDevitt D.
      • Francois P.
      • Vaudaux P.
      • Foster T.J.
      Identification of the ligand-binding domain of the surface-located fibrinogen receptor (clumping factor) of Staphylococcus aureus.
      • Ni Eidhin D.
      • Perkins S.
      • Francois P.
      • Vaudaux P.
      • Hook M.
      • Foster T.J.
      Clumping factor B (ClfB), a new surface-located fibrinogen-binding adhesin of Staphylococcus aureus.
      Furthermore, adherence is enhanced through the production by microbial organisms, such as coagulase negative staphylococci,
      • Mack D.
      • Davies A.P.
      • Harris L.G.
      • Rohde H.
      • Horstkotte M.A.
      • Knobloch J.K.
      Microbial interactions in Staphylococcus epidermidis biofilms.
      • von Eiff C.
      • Peters G.
      • Heilmann C.
      Pathogenesis of infections due to coagulase-negative staphylococci.
      S. aureus,
      • Zhu Y.
      • Weiss E.C.
      • Otto M.
      • Fey P.D.
      • Smeltzer M.S.
      • Somerville G.A.
      Staphylococcus aureus metabolism in a biofilm: the influence of arginine on polysaccharide intercellular adhesin synthesis, biofilm formation, and pathogenesis.
      Pseudomonas aeruginosa,
      • Murga R.
      • Miller J.M.
      • Donlan R.M.
      Biofilm formation by gram-negative bacteria on central venous catheter connectors: effect of conditioning films in a laboratory model.
      and Candida species
      • Douglas L.J.
      Candida biofilms and their role in infection.