Central Venous Catheters, Including Peripherally Inserted Central Catheters (PICCs), Hemodialysis, and Pulmonary Artery Catheters, in Adult and Pediatric Patients

I. Surveillance
A. Conduct surveillance in intensive care units (ICUs) and other patient populations to determine catheter-related bloodstream infection (CRBSI) rates, monitor trends in those rates, and assist in identifying lapses in infection-control practices. Category IA
B. Express ICU data as the number of catheter-associated bloodstream infections (BSIs) per 1,000 catheter-days for both adults and children and stratify by birth weight categories for neonatal ICUs to facilitate comparisons with national data in comparable patient populations and health-care settings. Category IB
C. Investigate events leading to unexpected life-threatening or fatal outcomes. This includes any process variation for which a recurrence would likely present an adverse outcome. Category IC

II. General Principles

A. Use a central venous catheter (CVC) with the minimum number of ports or lumens essential for the management of the patient. Category IB
B. Use an antimicrobial or antiseptic-impregnated CVC in adults whose catheter is expected to remain in place >5 days if, after implementing a comprehensive strategy to reduce rates of CRBSI, the CRBSI rate remains above the goal set by the individual institution based on benchmark rates (see Table 2 in the original guideline document) and local factors. The comprehensive strategy should include the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a 2% chlorhexidine preparation for skin antisepsis during CVC insertion. Category IB
C. No recommendation can be made for the use of impregnated catheters in children. Unresolved issue
D. Designate personnel who have been trained and exhibit competency in the insertion of catheters to supervise trainees who perform catheter insertion. Category IA
E. Use totally implantable access devices for patients who require long-term, intermittent vascular access. For patients requiring frequent or continuous access, a peripherally inserted central catheter (PICC) or tunneled CVC is preferable. Category II
F. Use a cuffed CVC for dialysis if the period of temporary access is anticipated to be prolonged (e.g., >3 weeks) (Foundation, 2001; Moss et al., 1990). Category IB
G. Use a fistula or graft instead of a CVC for permanent access for dialysis .Category IB
H. Do not use hemodialysis catheters for blood drawing or applications other than hemodialysis except during dialysis or under emergency circumstances. Category II
I. Use povidone-iodine antiseptic 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. Category II

III. Selection of Catheter Insertion Site
A. Weigh the risk and benefits of placing a 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). Category IA
B. Use a subclavian site (rather than a jugular or a femoral site) in adult patients to minimize infection risk for nontunneled CVC placement. Category IA
C. No recommendation can be made for a preferred site of insertion to minimize infection risk for a nontunneled CVC. Unresolved issue
D. Place catheters used for hemodialysis and pheresis in a jugular or femoral vein rather than a subclavian vein to avoid venous stenosis if catheter access is needed. Category IA

IV. Maximal Sterile Barrier Precautions During Catheter Insertion
A. Use aseptic technique including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, for the insertion of CVCs (including PICCs) or guidewire exchange. Category IA
B. Use a sterile sleeve to protect pulmonary artery catheters during insertion. Category IB

V. Replacement of Catheter
A. Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. Category IB
B. 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 I
C. Guidewire exchange
1. Do not use guidewire exchanges routinely for nontunneled catheters to prevent infection. Category IB
2. Use a guidewire exchange to replace a malfunctioning nontunneled catheter if no evidence of infection is present. Category IB
3. Use a new set of sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
VI. Catheter and Catheter-site Care

A. General measures
Designate one port exclusively for hyperalimentation if a multilumen catheter is used to administer parenteral nutrition. Category II

B. Antibiotic lock solutions
Do not routinely use antibiotic lock solutions to prevent CRBSI. Use prophylactic antibiotic lock solution only in special circumstances (e.g., in treating a patient with a long-term cuffed or tunneled catheter or port who has a history of multiple CRBSIs despite optimal maximal adherence to aseptic technique. Category II

C. Catheter-site dressing regimens
1. Replace the catheter-site dressing when it becomes damp, loosened, or soiled or when inspection of the site is necessary. Category IA
2. Replace dressings used on short-term CVC sites every 2 days for gauze dressings and at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter outweighs the benefit of changing the dressing. Category IB
3. Replace dressings used on tunneled or implanted CVC sites no more than once per week, until the insertion site has healed. Category IB
4. 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
D. No recommendation can be made for the use of chlorhexidine sponge dressings to reduce the incidence of infection. Unresolved issue
E. Do not use chlorhexidine sponge dressings in neonates aged <7 days or of gestational age <26 weeks. Category II
F. No recommendation can be made for the use of sutureless securement devices. Unresolved issue
G. Ensure that catheter-site care is compatible with the catheter material. Category IB
H. Use a sterile sleeve for all pulmonary artery catheters. Category IB
Peripheral Venous Catheters, Including Midline Catheters, in Adult and Pediatric Patients


Additional Recommendations for Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric Patients

I. Selection of Pressure Monitoring System
Use disposable, rather than reusable, transducer assemblies when possible. Category IB

II. Replacement of Catheter and Pressure Monitoring System
A. Do not routinely replace peripheral arterial catheters to prevent catheter-related infections. Category II
B. 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. Category IB

III. Care of Pressure Monitoring Systems
A. General measures
1. Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile. Category IA
2. Minimize 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. Category II
3. When the pressure monitoring system is accessed through a diaphragm rather than a stopcock, wipe the diaphragm with an appropriate antiseptic before accessing the system. Category IA
4. Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit. Category IA
B. Sterilization or disinfection of pressure monitoring systems
1. Use disposable transducers. Category IB
2. Sterilize reusable transducers according to the manufacturer's instructions if the use of disposable transducers is not feasible. Category IA
Recommendations for Umbilical Catheters
I. Replacement of Catheters
A. Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency, or thrombosis are present. Category II
B. Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present. Category II
C. No recommendation can be made for treating through an umbilical venous catheter suspected of being infected. Unresolved issue
D. Replace umbilical venous catheters only if the catheter malfunctions. Category II

II. Catheter-site Care
A. 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. Category IB
B. Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance. Category IA
C. Add low doses of heparin (0.25-1.0 F/ml) to the fluid infused through umbilical arterial catheters. Category IB
D. 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 . Category II
E. 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. Category II