CERTIFICATE IN INFECTION CONTROL PART 2

ASPECTS OF INFECTION CONTROL RELATED TO CENTRAL VENOUS CATHETERS

A REVIEW OF THE LITERATURE

by JOSEF TRAPANI INTENSIVE THERAPY UNIT JULY, 2003

INTRODUCTION

Central venous catheterisation refers to the placement of an indwelling catheter within the superior or inferior vena cava or right atrium, or a large vein leading to these vessels (Mallet and Bailey, 1996). The possible uses of a central venous catheter (CVC) include:

Monitoring central venous pressure (CVP) in seriously ill patients Administration of large amounts of intravenous fluids or blood, e.g. in cases of shock or major surgery Providing long term access for:
Hydration Repeated Repeated Repeated

or electrolyte maintenance

administration of drugs, such as cytotoxic and antibiotic therapy transfusion of blood or blood products specimen collection

Administration of total parenteral nutrition (ibid.).

Despite their undisputed value in the treatment and care of both critically ill and chronically ill individuals, the use of central venous catheters faces various potential complications including infection, thrombosis, occlusion, dislodgement, extravasation, infiltration and catheter damage (Dougherty, 2000).

The aim of this essay is to review the medical and nursing literature about the prevention of CVCrelated infections. This is based on a literature search conducted on the MEDLINE and CINAHL databases.

CATHETER-RELATED INFECTIONS AND THEIR CAUSES

Catheter-related blood stream infection is estimated to occur in 6,000 patients each year in the UK alone (Pratt et al., 2001). Data compiled by van Vliet et al. (2001, as cited by Woodrow (2002)) suggests that some local or systemic infection occurs in between 1 and 14% of patients with a central venous catheter. According to Simcock (2001c), infection is the most frequent complication related to central venous catheters and usually occurs when microorganisms on the patients skin or health carers hands migrate down the catheter tract or through its hubs and subsequently colonise the catheter. Infections are usually caused by bacterial (most notably Staphylococcal) species, but fungal infections are also common, especially in immunosuppressed patients (Simcock 2001c). The effects of such infections include increased morbidity and mortality, discontinuation of central venous therapy (Field, 2002), and extra costs in antibiotic delivery and prolonged hospitalisation (Pittet et al., 1994; Parker, 1999).

CVC-infections are most likely to occur during the insertion of the central venous catheter, dressing changes, changing infusion bags or bottles and adding substances to infusion bags (Field, 2002). Risk of infection is influenced by the adequacy of asepsis maintained, the solution and technique used to disinfect the skin prior to insertion, the type of infusate, the type of dressing and the catheter material (Dougherty, 2000). Infection may also occur because of to-and-fro movements of the catheter, inadequate training of nurses and poor documentation, clot formation (Simcock 2001c) as well as circumstances particular to each patient such as his/her underlying condition and psychological well being (Rickard, 2001; 2003). Moreover, an increased length of time

in situ (Cornock, 1996b) and a larger number of catheter ports and lumens (Simcock, 2001a) also increase the risk of infection because they increase the chances of manipulation and provide more ports of entry for infective microogranisms (Harrison, 1997).

HAND HYGIENE, ASEPSIS AND STAFF TRAINING

During insertion of the catheter the operator should use maximal barrier precautions including sterile gloves, a sterile gown and large sterile drapes (OGrady et al., 2003; Pratt et al., 2001). Strict hand washing by all personnel coming in contact with a central venous catheter is a crucial factor in preventing infections (Harrison, 1997) because skin flora and cross-infection by staff are the commonest factors for the transfer of staphylococci (Drewett, 2000). The aseptic non-touch technique (Rowley, 2001) should be used during dressing changes and catheter handling (Cornock, 1996), during drug administration and catheter flushing (Drewett, 2000) and whenever the insertion site is exposed or the closed system broken (Nicol et al., 2000; Mallet and Bailey, 1996; Dougherty, 2000). Besides not touching the skin, some authors also recommend the use of (non-sterile) gloves in order to prevent descaling (shedding) of bacteria onto key points of infection (Hatchett, 2000; Simcock, 2001b).

Various researchers have studied the impact of interventions aimed at training health professionals in preventing catheter-related infections. In one study, intensive training in hand hygiene led to a reduction of infection rates from 40 to 8% (Puntis et al., 1990 as cited by Harrison, 1997). Similarly a study by Faubion et al. (1986, as cited by Rickard,

2003) showed that a training programme for members of a catheter insertion and maintenance team could reduce catheter-related blood stream infection by up to eight times. Eggimann et al. (2000) carried out an education campaign among critical care unit staff on various aspects of infection control related to the insertion and care of central venous catheters. The overall rate of infections among patients with a CVC decreased from 12.7% in the control period prior to the intervention to 8.1% in the period following the intervention. The study, which included 13,200 catheter days, also suggested a reduction in exit site infections and in blood stream infections of 64% and 67% respectively (Eggimann et al., 2000). The intervention consisted of slideshows, practical demonstrations and issuing of strict guidelines (ibid.). In a similar pre- and post-

intervention observational study by Coppersmith et al. (2002), primary blood stream infections dropped from 10.8 per 1000 catheter days to 3.7 per 1000 catheter days, a decrease of 60% (P < 0.0001). This meant an estimated cost saving of between $185,000 and $2.8 million for the 18 months after the intervention. This particular intervention consisted of a 10-page self study module on risk factors and practice modifications involved in catheter-related infections, verbal in-service at staff meetings and fact sheets and posters reinforcing the information in the study module (Coppersmith et al., 2002). These encouraging research findings suggest that similar education and training programmes should be carried out locally.

While these and other studies have shown the effectiveness of proper training, research shows that many health care professionals are not adequately trained to care for central venous catheters. In one study for example, only 23% of the Intensive Care Unit

nurses under study complied with the protocols for CVC care they were supposed to use (Roach et al., 1996). In view of this, Rickard (2003) stresses the need for training and a systematic updating of protocols so as to ensure that all nurses carry out procedures in the same way and to promote easier monitoring and development. Besides lack of training, understaffing is also a factor which might hinder nurses from applying good aseptic measures in caring for patients with a CVC, especially in the critical care setting. Fridkin et al. (1996) report a case-control study which demonstrated that the patient-to-nurse ratio was an independent risk factor for CVC related bloodstream infection, even after controlling for TPN use, mechanical ventilation and the period of hospitalisation.

MINIMISING HANDLING AND MAINTAINING A CLOSED SYSTEM

Infusion systems attached to central venous catheters should be maintained closed at all times (Mallett and Bailey, 1996). Bungs are to be left on catheter hubs when these are not in use (Drewett, 2000). Needle-free port systems help ensure that a closed system is maintained at all times (Cheeseman, 2001). Catheter manipulation and the number of staff handling a CVC should be minimum (Cornock, 1996) because handling increases the chances of entry of microogranisms (Drewett, 2000). Patients should also be

educated on this point and advised to carefully wash their hands if they participate in catheter care (ibid.). In this way patient participation has an active role in the prevention of infections.

SKIN DISINFECTION PRIOR TO INSERTION Debate surrounds choosing what antiseptic should be used to prepare the site prior to insertion of a CVC. In a classic prospective controlled clinical trial comparing the efficacy of three different antiseptics, Maki et al. (1991) randomly allocated each of 668 catheters inserted in a 20-bedded surgical ITU into one of three groups according to whether the skin area was disinfected with 2% aqueous chlorhexidine gluconate, 10% povidone iodine and 70% isopropyl-alcohol. Ratios of local catheter related infections and of catheter-related bacteraemia were very similar in the povidone-iodine and the alcohol groups but were 3 to 5 fold higher than those in the chlorhexidine group (Odds Ratio = 0.32; 95% Confidence Interval: 0.1 0.86; P = 0.02) (Maki et al., 1991). In particular, chlorhexidine (a cationic biguanide and broad spectrum germicide effective against nearly all nosocomial bacteria and yeasts) was significantly superior to the other two agents for preventing infections due to coagulase negative staphylococci (P = 0.03) (ibid.).

The superiority of chlorhexidine gluconate was confirmed by a meta-analysis of 8 clinical randomised controlled trials (identified from a detailed search of various databases, reference lists and libraries) involving a total of 4143 catheters (Chaiyakunapruk et al., 2002). When they combined the results of all these studies, the researchers established that in catheters inserted in skin sites disinfected with chlorhexidine gluconate were significantly lower than those in sites prepared with povidone-iodine (risk ratio = 0.49; 95% confidence interval: 0.31 0.71). Catheter related blood stream infection was also significantly less common in sites prepared with

chlorhexidine gluconate (risk ratio = 0.49; 95% confidence interval: 0.28 0.88) (Chaiyakunapruk et al., 2002). Hence the absolute risk reduction when using

chlorhexidine gluconate was 7.1% for colonisation and 1.1% for catheter-related blood stream infection. The researchers estimate that the for every 1000 central venous catheter sites disinfected with chlorhexidine gluconate rather than povidone-iodine, 71 episodes of catheter colonisation and 11 episodes of catheter-related blood stream infections would be prevented (ibid.). Based on these and similar findings, various guidelines for nursing procedures recommend the use of chlorhexidine gluconate for skin disinfection prior to the insertion of central venous catheters (Mallet and Bailey, 1996; Parker, 1999; Nicol et al., 2000; OGrady et al., 2003). Pratt et al. (2001) also recommend the routine use of chlorhexidine gluconate and the use of povidone-iodine in patients with a hypersensitivity to chlorhexidine gluconate. Despite such clear evidence favouring the use of

chlorhexidine, locally povidone-iodine is practically the only disinfectant used to prepare the skin for CVC insertion.

CARE AND DRESSING OF THE CATHETER EXIT SITE Drewett (2000) recommends disinfecting catheter hubs with 0.5% chlorhexidine gluconate in 70% alcohol while Harrison (1997) recommends the use of the same disinfectant for cleansing catheter exit sites. On the other hand Oliver (1997) questions the indiscriminate use of antiseptics in the management of wounds (such as CVC entry sites) because they may impair wound healing and may encourage the propagation of resistant organisms. In view of this, Simcock (2001b) advises routine cleaning of

catheter exit sites with sterile normal saline and sterile gauze with the aim of removing

blood, exudates or other debris which might provide a focus of infection. The site should be dried with a sterile dry swab or allowed to air dry before a new dressing is applied so as to promote dressing adherence (Simcock, 2001b).

Controversy also surrounds the frequency of dressing changes. Most texts however advice regular inspection of the insertion site and changing dressings only when there is haemoserous discharge, soreness, unexpected pyrexia, and a wet, damaged or soiled dressing (Cornock, 1996; Mallett and Bailey, 1996; Dougherty, 2000). When changing a dressing, the catheter site should be checked for any signs of inflammation or discharge (ibid.). While indiscriminately changing dressings everyday is no longer recommended, dressings should neither be indiscriminately left unchanged for a week. During a 12month intervention in a 20-bed medical-surgical ICU, prolonging the interval between the changes of catheter-site dressings from 3 times weekly to once weekly was associated with a significant increase in blood stream infections (P = 0.003) (Curchoe et al., 2003).

The catheter exit site should be covered with a sterile dressing so as to reduce the probability of contamination, for example by accidentally touching the site (Rickard, 2003). The ideal dressing should provide an effective barrier to bacteria, securely fix the catheter, be easy to apply and remove and be comfortable for the patient (Mallett and Bailey, 1996). Transparent film dressings have the advantage of being waterproof,

securely fixing the catheter and allowing easy inspection of the site for signs of infection like redness, swelling and discharge without having to change the dressing (Mallett and Bailey, 1996; Hatchett, 2000; Nicol et al., 2000). Certain transparent dressings are

however difficult to keep in place, especially when the catheter is in the internal jugular vein (Harrison, 1997) and tend to be more costly and less available than using sterile dry dressings and tape (Simcock, 2001b).

Dressings may provide a warm moist environment which promotes growth and colonisation of skin organisms such as Staphylococcus aureus (Rickard, 2003). Hence if a transparent dressing is used, it must be waterproof from the outside but permeable to water vapour on the side touching the catheter site so as to prevent accumulation of moisture around the exit site (Pratt et al., 2001). Studies by Keenleyside (1993) and Treston-Auraund et al., 1997) (both cited by Dougherty (2000) as well as that by Little and Palmer (1998) showed that there was no significant difference in rates of infection between such semi-permeable transparent polyurethane dressings and sterile gauze and tape dressings. Other studies have however suggested that dry gauze and tape dressings produce less contamination than various vapour permeable dressings (Maki et al., 1994 as cited by Drewett (2000); Petrosino et al. (1988 as cited by Harrison (1997)). Reynolds et al. (1997) compared the incidence of catheter-related sepsis with Tegaderm and Opsite IV3000 dressings. No statistically significant difference between the two

dressings was found in accumulation of fluid, skin microbial colonisation, local infection or systemic infection, suggesting that there was no apparent advantage of using the more permeable Opsite IV3000 dressing (Reynolds et al., 1997). Which dressing should be used therefore remains a subject of debate because the research findings on this topic remain inconclusive.

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CATHETERS IMPREGNATED WITH ANTIMICROBIALS Various researchers have studied the effectiveness of coating central venous catheters with antibiotics or an antiseptic material in reducing catheter associated colonisation and septicaemia. Maki et al. (1997) randomly allocated 158 adults into receiving a standard triple-lumen polyurethane CVC (control group) or an indistinguishable one impregnated with chlorhexidine and silver sulfadiazine. On removal, antiseptic-coated catheters were significantly less likely to be colonised than control catheters (13.5% vs. 24.1%; P = 0.005) and nearly fivefold less likely to produce a blood stream infection (1.0% vs. 4.7%; P = 0.03) (Maki et al., 1997). This implies preventing 3 infections for every 1000 catheter-days (ibid.). In a similar study, among 281 hospital patients in 5 universitybased hospitals, coating catheters with minocycline and rifampicin was an independent protective factor against catheter-related colonisation (P < 0.05) (Raad et al., 2002). In both studies no adverse effects or signs of resistance were observed. Similar results were obtained in a study by Collin (1999) and a meta-analysis by Main et al. (2000) (both cited by Pickard (2003).

On the other hand, studies by Sheng et al. (2000) and Loo et al. (1998) showed that catheters impregnated with antiseptics were associated with a significant decrease in catheter colonisation but with no significant decrease in bloodstream infections while in the study of 232 central venous catheters inserted into 181 patients by Theaker et al. (2002) there was no significant difference between antiseptic-impregnated catheters and standard catheters, even in terms of colonisation alone. A literature review and economic assessment by Oinonen et al. (2000) concluded that antimirobial-coated CVCs are an

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effective approach to reducing the incidence of catheter colonisation but the evidence that such devices can also reduce the incidence of CVC-associated bacteraemia is not as strong. In view of such inconclusive evidence, the UK Department of Health

recommends using CVCs impregnated with antiseptic or antimicrobial coating only for patients requiring a CVC for a short period and for patients who are at a particular risk of acquiring infections (Simcock, 2001a).

A study by Pierce et al. (2000) suggested that heparin-bonded central venous catheters are associated with a significant reduction in infections (Risk Ratio = 0.11; P < 0.00005) and similarly Pratt et al. (2001) recommended routinely flushing CVCs with an anticoagulant unless this is contraindicated by the manufacturer. Lean et al. (2003)

tested a new model in which the catheter hub incorporates an antiseptic chamber filled with 3% iodinated alcohol. The prevalence of both hub colonisation (14.4% vs. 4.3%; P < 0.001) and catheter-related blood stream infections (7% vs. 1.7%; P < 0.049) was significantly lower in the new model compared to catheters with standard hubs (Lean et al., 2003).

Vassilomanolakis et al. (1995) (as cited by Harrison (1997)) argue that giving patients a short course of antibiotics before the placement of a CVC was associated with a reduction in episodes of catheter-related infections. Guidelines issued by the UK

Department of Health however do not recommend this practice (Pratt et al., 2001).

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SITE OF INSERTION, NUMBER OF LUMENS AND TUNNELLING Central venous catheters inserted in the subclavian vein carry a lower risk of infection than those inserted in the jugular or femoral vein (Parker, 1999) because they are easier to immobilise with a dressing and because of the close proximity of jugular lines to oropharyngeal secretions (Pratt et al., 2001). On the other hand insertion in the

subclavian vein is often considered to be more difficult as it tends to be associated with a higher frequency of mechanical complications such as pneumothorax and arterial puncture (Reusch et al., 2002).

Although according to Woodrow (2002) the evidence on whether multi-lumen catheters increase the risk of colonisation and infection is inconclusive, it is often recommended to use single lumen catheters, unless a multi-lumen catheter is absolutely necessary for patient management (Drewett, 2000; Pratt et al., 2001). Total parenteral nutrition should always be administered exclusively on a lumen or catheter (Pratt et al., 2001) because the high calorific content of TPN solutions is an excellent medium for microbial proliferation and hence it is even more important not to interrupt the closed system (Nicol et al., 2000). Also TPN solutions are incompatible with a large number of drugs and solutions (ibid.).

In some cases, a central venous catheter is tunnelled under the skin in an attempt to reduce the risk for infections. This is because in a tunnelled catheter the exit site is some distance away from the point of insertion into the vein thereby reducing the likelihood of bloodstream contamination from bacteria in the skin (Simcock, 2001a; Nicol, 2000).

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Also, tunnelled catheters usually include a fibrous cuff which provides a mechanical barrier to bacteria (ibid.). Tunnelled catheters were shown to reduce the risk of infections in patients with long-term catheterisation (Vost and Longstaff, 1997) but routine tunnelling of short-term catheters is not recommended (Pratt et al., 2001; Woodrow, 2002). In a 3-year controlled trial among in-patients receiving TPN, tunnelling did lower the rate of catheter-associated sepsis but to a much smaller degree than good aseptic nursing by a clinical nutrition nurse (Keohane et al., 1983).

CATHETER AND ADMINISTRATION SET REPLACEMENT

Parker (1999) cites three well-controlled clinical trials (Josephson et al., 1985; Maki et al., 1987; Syndman et al., 1987) which showed that replacing intravenous fluid administration sets every 72 hours (rather than every 24 or 48 hours) does not increase the likelihood of catheter-related infections. In view of this many authors advocate changing administration lines and hubs every 72 hours, changing lines used for TPN every 24 hours (due to their high lipid and carbohydrate content being a potential medium for bacterial growth), changing blood-product giving sets at the end of transfusion and changing all lines and extensions if the catheter itself is replaced (Mallett and Bailey, 1996; Drewett, 2000; Nicol et al., 2000; Pratt et al., 2001). Field (2002) argues that if a TPN solution is prepared in a sterile room at the pharmacy and no additions are made at ward level the giving set can be changed once a week. An in-vitro prospective study by Rickard et al. (2002) showed that intravascular administration sets are accurate and in appropriate condition after seven days of continuous use although potential increases in

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infection rates were not studied. Various guidelines agree on the recommendation that central venous catheters should not be changed routinely in an effort to prevent infection (Parker, 1999; Pratt et al., 2001; OGrady et al., 2003) but that they should be removed as soon as they are no longer required (Woodrow, 2002). If a CVC is to be changed, a different site is to be used because replacement over a guidewire is likely to infect the new one as sepsis frequently results from skin bacteria that gain access to the circulation through cannulation (Woodrow, 2002).

CONCLUSION Infections related to central venous catheters can have deleterious effects, not only for patients but also to the financial status of health care systems. This essay has discussed the various ways in which nurses can actively attempt to reduce the occurrence of such infections. It is finally recommended that local health authorities issue research-based guidelines or protocols related to the care of central venous catheters are issued as soon as possible as this should promote better and more standardised catheter care.

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Reynolds M.G., Tebbs S.E., Elliott T.S.J. (1997) Do dressings with increased permeability reduce the incidence of central venous catheter related sepsis? Intensive and Critical Care Nursing. 13(1): 26-9. February. Rickard C.M., Wallis S.C., Courtney M., Lipman J., Daley P.J.P. (2002) Intravascular administration sets are accurate and in appropriate condition after 7 days of continuous use: an in vitro study. Journal of Advanced Nursing. 37(4): 330-337. April. Rowley S. (2001) Aseptic non-touch technique. Nursing Times. 97(7) (Suppl.): VI-VIII. February 15. Ruesch S., Walder B., Tramar M.R. (2002) Complications of central venous catheters: internal jugular versus subclavian access--a systematic review. Critical Care Medicine. 30(2): 454-60. Safdar N., Maki D.G. (2002) Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Critical Care Medicine. 30(12): 2632-5. Sheng WH, Ko WJ, Wang JT, Chang SC, Hsueh PR, Luh KT. (2000) Evaluation of antiseptic-impregnated central venous catheters for prevention of catheter-related infection in intensive care unit patients. Diagnostic Microbiology and Infectious Diseases. 38(1): 1-5. Simcock L. (2001a) Central venous catheters: Some common clinical questions. Nursing Times. 97(19): 34-36. May 10. Simcock L. (2001b) Complications of CVCs and their nursing management. Nursing Times. 97(20): 36-38. May 17. Simcock L. (2001c) The use of central venous catheters for IV therapy. Nursing Times. 97(18): 34-35. May 3. Syndman D., Pober B., Murray S., Gordea H., Maika J., Perry L. (1982) Predictive value of surveillance skin culture in total parenteral nutrition related infection. Lancet. ii: 1385-88. Theaker C., Juste R., Lucas N., Tallboys C., Azadian B., Soni N. (2002) Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill. Journal of Hospital Infection. 52(4): 310-2. Vost J., Longstaff V. (1997) Infection control and related issues in intravascular therapy. British Journal of Nursing. 6(15): 846-857. August 14. Woodrow P. (2002) Central venous catheters and central venous pressure. Nursing Standard. 16(26): 45-51. March 13.

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