Guidelines for the Prevention of Intravascular Catheter-Related Infections

Guidelines for the Prevention of Intravascular Catheter-Related Infections
Strategies for Prevention of Catheter-related Infections
1. Selection of site for catheter insertion
2. Type of catheter material used (e.g., Teflon, polyurethane, polyvinyl chloride, polyethylene, steel)
3. Hand hygiene and aseptic technique during catheter insertion (e.g., use of antibacterial soap and water, alcohol-based products, gloves, etc.)
4. Skin antisepsis with povidone-iodine or chlorhexidine
5. Catheter site dressing regimens (e.g., use of transparent, semipermeable polyurethane dressings, gauze, or chlorhexidine-impregnated sponge [Biopatch])
6. Use of catheter securement devices (sutures versus sutureless)
7. Use of in-line filters
8. Use of antimicrobial/antiseptic impregnated catheters and cuffs (e.g., chlorhexidine/silver sulfadiazine, minocycline/rifampin, platinum/silver impregnated catheters; silver cuffs)
9. Systemic antibiotic prophylaxis (e.g., vancomycin) (considered but not recommended because of risk-benefit ratio)
10. Application of antibiotic/antiseptic ointment (e.g., povidone-iodine, mupirocin) to catheter site
11. Antibiotic lock prophylaxis
12. Anticoagulant flush solutions (e.g., heparin, warfarin)
13. Scheduled replacement of catheters
14. Replacement of administration sets, needleless systems, and parenteral fluids
15. Use of needleless infusion systems
16. Use of multidose parenteral medication vials
17. Special considerations for prevention of catheter-related infections in pediatric patients and in patients on hemodialysis or those receiving parenteral nutrition.
18. Health-care worker education and training
MAJOR OUTCOMES CONSIDERED
· Incidence of and risk for intravascular catheter-related infection and phlebitis
· Morbidity and mortality due to intravascular catheter-related infections
· Healthcare costs associated with intravascular catheter-related infections
Recommendations Grading Scheme
Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC. Required for implementation, as mandated by federal or state regulation or standard.
Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
No recommendation. Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exist.
RECOMMENDATIONS:
Recommendations for Placement of Intravascular Catheters in Adults and Children
I. Health-care Worker Education and Training
A. Educate health-care workers regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection-control measures to prevent intravascular catheter-related infections. Category IA
B. Assess knowledge of and adherence to guidelines periodically for all persons who insert and manage intravascular catheters .Category IA
C. Ensure appropriate nursing staff levels in intensive care units (ICUs) to minimize the incidence of catheter-related bloodstream infections (CRBSIs). Category IB
II. Surveillance
A. Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis, depending on the clinical situation of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection (BSI), the dressing should be removed to allow thorough examination of the site). Category IB
B. Encourage patients to report to their health-care provider any changes in their catheter site or any new discomfort. Category II
C. Record the operator, date, and time of catheter insertion and removal, and dressing changes on a standardized form. Category II
D. Do not routinely culture catheter tips. Category IA
III. Hand Hygiene
A. Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams. Observe hand hygiene 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. Category IA
B. Use of gloves does not obviate the need for hand hygiene . Category IA
IV. Aseptic Technique During Catheter Insertion and Care
A. Maintain aseptic technique for the insertion and care of intravascular catheters. Category IA
B. Wear clean or sterile gloves when inserting an intravascular catheter as required by the Occupational Safety and Health Administration Bloodborne Pathogens Standard. Category IC. Wearing clean gloves rather than sterile gloves is acceptable for the insertion of peripheral intravascular catheters if the access site is not touched after the application of skin antiseptics. Sterile gloves should be worn for the insertion of arterial and central catheters. Category IA
C. Wear clean or sterile gloves when changing the dressing on intravascular catheters. Category IC
V. Catheter Insertion
Do not routinely use arterial or venous cutdown procedures as a method to insert catheters. Category IA
VI. Catheter Site Care
A. Cutaneous antisepsis
1. Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing changes. Although a 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor, or 70% alcohol can be used. Category IA
2. No recommendation can be made for the use of chlorhexidine in infants aged <2 months. Unresolved issue
3. Allow the antiseptic to remain on the insertion site and to air dry before catheter insertion. Allow povidone iodine to remain on the skin for at least 2 minutes, or longer if it is not yet dry before insertion. Category IB
4. Do not apply organic solvents (e.g., acetone and ether) to the skin before insertion of catheters or during dressing changes. Category IA
VII. Catheter-site Dressing Regimens
A. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. Category IA
B. Tunneled central venous catheter (CVC) sites that are well healed might not require dressings. Category II
C. If the patient is diaphoretic, or if the site is bleeding or oozing, gauze dressing is preferable to a transparent, semi-permeable dressing. Category II
D. Replace catheter-site dressing if the dressing becomes damp, loosened, or visibly soiled. Category IB
E. Change dressings at least weekly for adult and adolescent patients depending on the circumstances of the individual patient. Category II
F. Do not use topical antibiotic ointment or creams on insertion sites (except when using dialysis catheters) because of their potential to promote fungal infections and antimicrobial resistance. Category IA (See Central Venous Catheters, Including Peripherally Inserted Central Venous Catheters [PICCs], Hemodialysis, and Pulmonary Artery Catheters, in Adult and Pediatric Patients, Section II.I).
G. Do not submerge the catheter under 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). Category II
VIII. Selection and Replacement of Intravascular Catheters
A. Select the catheter, insertion technique, and insertion site with the lowest risk for complications (infectious and noninfectious) for the anticipated type and duration of IV therapy. Category IA
B. Promptly remove any intravascular catheter that is no longer essential. Category IA
C. Do not routinely replace central venous or arterial catheters solely for the purposes of reducing the incidence of infection. Category IB
D. Replace peripheral venous catheters at least every 72-96 hours in adults to prevent phlebitis (Lai, 1998). Leave peripheral venous catheters in place in children until IV therapy is completed, unless complications (e.g., phlebitis and infiltration) occur.Category IB
E. When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and after no longer than 48 hours. Category II
F. Use clinical judgment to determine when to replace a catheter that could be a source of infection (e.g., do not routinely replace catheters in patients whose only indication of infection is fever). Do not routinely replace venous catheters in patients who are bacteremic or fungemic if the source of infection is unlikely to be the catheter . Category II
G. Replace any short-term CVC if purulence is observed at the insertion site, which indicates infection. Category IB
H. Replace all CVCs if the patient is hemodynamically unstable and CRBSI is suspected. Category II
I. Do not use guidewire techniques to replace catheters in patients suspected of having catheter-related infection. Category IB
IX. Replacement of Administration Sets*, Needleless Systems, and Parenteral Fluids
A. Administration sets
1. Replace administration sets, including secondary sets and add-on devices, no more frequently than at 72-hour intervals, unless catheter-related infection is suspected or documented. Category IA
2. Replace tubing used to administer blood, blood products, or lipid emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion. Category IB. If the solution contains only dextrose and amino acids, the administration set does not need to be replaced more frequently than every 72 hours. Category II
3. Replace tubing used to administer propofol infusions every 6 or 12 hours, depending on its use, per the manufacturer's recommendation. Category IA
*(Note: Administration sets include the area from the spike of tubing entering the fluid container to the hub of the vascular access device. However, a short extension tube might be connected to the catheter and might be considered a portion of the catheter to facilitate aseptic technique when changing administration sets.)
B. Needleless intravascular devices
1. Change the needleless components at least as frequently as the administration set. Category II
2. Change caps no more frequently than every 72 hours or according to manufacturers. Category II
3. Ensure that all components of the system are compatible to minimize leaks and breaks in the system. Category II
4. Minimize contamination risk by wiping the access port with an appropriate antiseptic and accessing the port only with sterile devices .Category IB
C. Parenteral fluids
1. Complete the infusion of lipid-containing solutions (e.g., 3-in-1 solutions) within 24 hours of hanging the. Category IB
2. Complete the infusion of lipid emulsions alone within 12 hours of hanging the emulsion. If volume considerations require more time, the infusion should be completed within 24 hours. Category IB
3. Complete infusions of blood or other blood products within 4 hours of hanging the blood. Category II
4. No recommendation can be made for the hang time of other parenteral fluids. Unresolved issue
X. IV-injection Ports
A. Clean injection ports with 70% alcohol or an iodophor before accessing the system. Category IA
B. Cap all stopcocks when not in use . Category IB
XI. Preparation and Quality Control of IV Admixtures
A. Admix all routine parenteral fluids in the pharmacy in a laminar-flow hood using aseptic technique. Category IB
B. Do not use any container of parenteral fluid that has visible turbidity, leaks, cracks, or particulate matter or if the manufacturer's expiration date has passed. Category IB
C. Use single-dose vials for parenteral additives or medications when possible. Category II
D. Do not combine the leftover content of single-use vials for later use. Category IA
E. If multidose vials are used
1. Refrigerate multidose vials after they are opened if recommended by the manufacturer. Category II
2. Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial. Category IA
3. Use a sterile device to access a multidose vial and avoid touch contamination of the device before penetrating the access diaphragm. Category IA
4. Discard multidose vial if sterility is compromised. Category IA
XII. In-line Filters
Do not use filters routinely for infection-control purposes. Category IA
XIII. IV-therapy Personnel
Designate trained personnel for the insertion and maintenance of intravascular catheters. Category IA
XIV. Prophylactic Antimicrobials
Do not administer intranasal or systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or bloodstream infection (BSI). Category IA
I. Selection of peripheral catheter
A. Select catheters on the basis of the intended purpose and duration of use, known complications (e.g., phlebitis and infiltration), and experience of individual catheter operators. Category IB
B. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs. Category IA
C. Use a midline catheter or peripherally inserted central catheter (PICC) when the duration of IV therapy will likely exceed 6 days. Category IB
II. Selection of Peripheral-catheter Insertion Site
A. In adults, use an upper- instead of a lower-extremity site for catheter insertion. Replace a catheter inserted in a lower-extremity site to an upper-extremity site as soon as possible. Category IA
B. In pediatric patients, the hand, the dorsum of the foot, or the scalp can be used as the catheter insertion site. Category II
C. Replacement of catheter
1. 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 catheter-related bloodstream infection (CRBSI), an opaque dressing should be removed and the site inspected visually. Category II
2. Remove peripheral venous catheters if the patient develops signs of phlebitis (e.g., warmth, tenderness, erythema, and palpable venous cord), infection, or a malfunctioning catheter. Category IB
3. In adults, replace short, peripheral venous catheters at least 72-96 hours to reduce the risk for phlebitis. If sites for venous access are limited and no evidence of phlebitis or infection is present, peripheral venous catheters can be left in place for longer periods, although the patient and the insertion sites should be closely monitored. Category IB
4. Do not routinely replace midline catheters to reduce the risk for infection. Category IB
5. In pediatric patients, leave peripheral venous catheters in place until IV therapy is completed, unless a complication (e.g., phlebitis and infiltration) occurs. Category IB
III. Catheter and Catheter-site Care
Do not routinely apply prophylactic topical antimicrobial or antiseptic ointment or cream to the insertion site of peripheral venous catheters. Category IA