Leonard A. Mermel

Guidelines for the Prevention of Intravascular Catheter–Related Infections

Naomi P. O’Grady, Mary Alexander, E. Patchen Dellinger, Julie L. Gerberding, Stephen O. Heard, Dennis G. Maki, Henry Masur, Rita D. McCormick, Leonard A. Mermel, Michele L. Pearson, Issam I. Raad, Adrienne Randolph, and Robert A. Weinstein National Institutes of Health, Bethesda, Maryland; Infusion Nurses Society, Cambridge, and University of Massachusetts Medical School, Worcester, and The Children’s Hospital, Boston, Massachusetts; University of Washington, Seattle; Office of the Director, Centers for Disease Control and Prevention (CDC), and Division of Healthcare Quality Promotion, National Center for Infectious Diseases, CDC, Atlanta, Georgia; University of Wisconsin Medical School and Hospital and Clinics, Madison; Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode Island; MD Anderson Cancer Center, Houston, Texas; and Cook County Hospital and Rush Medical College, Chicago, Illinois

Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Guidelines for the Management of Intravascular Catheter-Related Infections

These guidelines from the Infectious Diseases Society of America (IDSA), the American College of Critical Care Medicine (for the Society of Critical Care Medicine), and the Society for Healthcare Epidemiology of America contain recommendations for the management of adults and children with, and diagnosis of infections related to, peripheral and nontunneled central venous catheters (CVCs), pulmonary artery catheters, tunneled central catheters, and implantable devices. The guidelines, written for clinicians, contain IDSA evidence-based recommendations for assessment of the quality and strength of the data. Recommendations are presented according to the type of catheter, the infecting organism, and the associated complications. Intravascular catheter-related infections are a major cause of morbidity and mortality in the United States. Coagulase-negative staphylococci, Staphylococcus aureus, aerobic gram-negative bacilli, and Candida albicans most commonly cause catheter-related bloodstream infection. Management of catheter-related infection varies according to the type of catheter involved. After appropriate cultures of blood and catheter samples are done, empirical i.v. antimicrobial therapy should be initiated on the basis of clinical clues, the severity of the patients acute illness, underlying disease, and the potential pathogen(s) involved. In most cases of nontunneled CVC-related bacteremia and fungemia, the CVC should be removed. For management of bacteremia and fungemia from a tunneled catheter or implantable device, such as a port, the decision to remove the catheter or device should be based on the severity of the patients illness, documentation that the vascular-access device is infected, assessment of the specific pathogen involved, and presence of complications, such as endocarditis, septic thrombosis, tunnel infection, or metastatic seeding. When a catheter-related infection is documented and a specific pathogen is identified, systemic antimicrobial therapy should be narrowed and consideration given for antibiotic lock therapy, if the CVC or implantable device is not removed. These guidelines address the issues related to the management of catheter-related bacteremia and associated complications. Separate guidelines will address specific issues related to the prevention of catheter-related infections. Performance indicators for the management of catheter-related infection are included at the end of the document. Because the pathogenesis of catheter-related infections is complicated, the virulence of the pathogens is variable, and the host factors have not been well defined, there is a notable absence of compelling clinical data to make firm recommendations for an individual patient. Therefore, the recommendations in these guidelines are intended to support, and not replace, good clinical judgment. Also, a section on selected, unresolved clinical issues that require further study and research has been included. There is an urgent need for large, well-designed clinical studies to delineate management strategies more effectively, which will improve clinical outcomes and save precious health care resources.

Prevention of Intravascular Catheter–Related Infections

Several million intravascular catheters are purchased each year by U.S. hospitals and clinics. Use of these devices place large numbers of patients at risk for catheter-related bloodstream infection. Most serious infections are associated with central venous catheters rather than small peripheral catheters (1); this is particularly evident in intensive care units (ICUs). According to a computer model of utilization of ICU beds based on American Hospital Association data (Halpern N. Personal communication), there were approximately 31 million patient-days annually in ICUs in the United States over the past 6 years. On the basis of data from the Centers for Disease Control and Prevention (2), the risk for exposure to these devices per ICU day was 48%, leading to approximately 15 million central line-days per year in ICUs. With an average of 5.3 central line-associated bloodstream infections per 1000 catheter-days in ICUs (2), approximately 16 000 central line-associated bloodstream infections occurred in ICUs in the United States each year. The attributable mortality has ranged from 12% to 25% in prospective studies (1, 3) but was an average of 3% in a meta-analysis (4). The attributable cost per infection is

Strategies to prevent surgical site infections in acute care hospitals.

3700 to

The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: A prospective study utilizing molecular subtyping

29 000 (3, 5). Therefore, in U.S. ICUs, approximately 500 to 4000 patients die annually of central venous catheter-related bloodstream infections. The annual cost of caring for patients with central line-associated bloodstream infections is

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals

60 million to

Guidelines for the prevention of intravascular catheter-related infections.

460 million. A significant proportion of non-ICU patients have central venous catheters (for example, patients on hematology-oncology wards), and many patients are discharged with central venous catheters in place. These patients are also at risk for serious catheter-related infections. The microbes that colonize catheter hubs and the skin surrounding the insertion site are the source of most catheter-related bloodstream infections (6-8). Therefore, successful preventive strategies must reduce colonization of the insertion site and hubs or minimize microbial spread extraluminally from the skin or intraluminally from the hubs toward the catheter tip lying in the bloodstream (Figure). Inhibiting the adherence and growth of pathogens that reach the intravascular segment of the catheter would also be ideal. Figure. Source of intravascular catheter-related infections. Attention to simple and practical interventions reduces the risk for intravascular catheter-related bloodstream infections (9-11). This review updates the expanding body of literature on the prevention of these infections. Methods Clinical studies of intravascular catheters were identified by searching the MEDLINE database for articles published from January 1966 to February 1999. The proceedings of the Infectious Diseases Society of America from 1994 through 1999, the Interscience Conference on Antimicrobial Agents and Chemotherapy from 1984 through 1999, and the proceedings of the Society for Healthcare Epidemiology of America Annual Meetings from 1989 through 1998 were reviewed, as were bibliographies of review articles and book chapters. Unless otherwise stated, the randomized studies included in this article meet the following criteria: Catheters were inserted into new sites, not old sites over a guidewire; catheter cultures were done by using semi-quantitative or quantitative methods; and catheter-related bloodstream infections were confirmed by microbial growth from percutaneously drawn blood cultures that matched microbial growth from the involved catheter. Authors were contacted directly if these criteria were not stated in published studies. Randomized studies that met these criteria but involved catheter exchange over guidewires into old insertion sites were included only if overwhelming evidence refuted the findings of a single randomized trial involving catheter insertion into new sites only. Any reference to these studies is specifically noted as such in this review. Case-control and cohort studies were included if they investigated issues not addressed in randomized trials regardless of whether they disclosed the site from which blood was drawn for culture or whether catheters were inserted into old sites over guidewires. Case-control or cohort studies are specifically noted as such in this review. The significance of differences in prevention strategies was determined by using the Mantel-Haenszel test or the Fisher exact test if the value of a test variable was less than 5. Relative risks, odds ratios, and 95% CIs were calculated by using EpiInfo, version 6 (Centers for Disease Control and Prevention, Atlanta, Georgia). Recommendations for preventive strategies are modified from previously published criteria (12), and the strength of the evidence is graded as follows: I, evidence from a well-designed meta-analysis of randomized, controlled trials; IIa, evidence from at least one randomized, controlled trial meeting the preceding criteria; IIb, evidence from at least one randomized, controlled trial that allowed catheter exchange over guidewires into old sites; III, evidence from at least one well-designed clinical trial without randomization; and IV, evidence from opinions of authorities in the field based on clinical experience, descriptive studies, or expert committee reports. If more than one type of evidence was available to support a specific recommendation (such as a meta-analysis [I] and an expert committee report [IV]), only the highest applicable evidence for the recommendation is listed. Recommendations for which results are conflicting reflect the prevailing view, and the highest rated trial based on the preceding criteria is cited. Preventive strategies are reviewed in the order in which one would approach a patient undergoing intravascular catheterization. Prophylaxis is discussed, followed by procedures surrounding catheter insertion, such as the site of insertion, tunneling of catheters, and antisepsis. Recommendations for maintenance of catheters follows, such as nursing care of catheters and types of available catheter hubs. Antimicrobial-coated or antimicrobial-impregnated catheters are then reviewed. Preventive Strategies Intravenous Antimicrobial Prophylaxis Prophylaxis with vancomycin or teicoplanin during central venous catheter insertion has not been demonstrated to reduce the incidence of catheter-related bloodstream infection (13-15 [Table 1]). Two studies (13, 14) failed to show a difference in early catheter-related bloodstream infection in the antibiotic prophylaxis groups, and in another study (15), the incidence of bloodstream infection was higher in the prophylaxis group (Table 1). Because these studies had small samples, they cannot rule out the possibility of a beneficial effect. Prophylaxis with vancomycin or teicoplanin at insertion of a central venous catheter is not recommended on the basis of the available data [IIa]. Table 1. Efficacy of Systemic Antimicrobial Prophylaxis during Central Venous Catheter Insertion in the Prevention of Catheter-Related Infection Addition of vancomycin to flush solutions or total parenteral nutrition solutions reduced the risk for catheter-related bloodstream infection with coagulase-negative staphylococci in one study of neonates (odds ratio, 0 [95% CI, 0.0 to 0.7]) (16). However, Centers for Disease Control and Prevention guidelines recommend against prophylactic use of vancomycin because it is an independent risk factor for acquisition of vancomycin-resistant enterococci (17). Prolonged administration of vancomycin-containing dialysate through peritoneal dialysis catheters is associated with peritonitis due to Staphylococcus epidermidis, with markedly reduced susceptibility to vancomycin and exit-site colonization with vancomycin-resistant enterococci (18). Prolonged use of systemic vancomycin to treat S. aureus infection is associated with development of intermediate resistance to vancomycin (19-22) and subpopulations of S. aureus with reduced vancomycin susceptibility (22, 23). Therefore, prevention of intravascular catheter-related infections should not involve vancomycin or other therapeutic agents [IV]. Efforts should be focused on interventions that are not likely to encourage the emergence of antimicrobial resistance, such as maximal barrier precautions. Warfarin and Heparin Prophylaxis Several of the different protein components of a thrombus increase adherence of S. aureus, S. epidermidis, and Candida species to catheters (24-27). Thrombus formation on indwelling intravascular catheters is associated with catheter-related bloodstream infection (28, 29). Very-low-dose warfarin reduces venographically documented thrombosis with long-term use of central venous catheters (relative risk, 0.25 [CI, 0.09 to 0.7]) (30) and reduced thrombosis in an observational study (31). Prophylaxis with very-low-dose warfarin should be strongly considered for patients with long-term, indwelling intravascular catheters [IIa]. In a meta-analysis, prophylactic heparin reduced the risk for catheter-related central venous thrombosis (relative risk, 0.4 [CI, 0.2 to 0.8]) (32); however, the analysis failed to show a significant difference in the risk for central venous catheter-related bloodstream infection when it was given in a bolus infusion or added to intravenous solutions (relative risk, 0.26 [CI, 0.07 to 1.03]) (32). Most heparin solutions contain preservatives with antimicrobial activity (33). Thus, the fewer catheter-related infections associated with heparin use may be due to the preservative, reduced thrombus formation, or both. Prophylactic heparin should be administered to patients with short-term central venous catheters [I]. Three U of heparin per mL in total parenteral nutrition solution, 5000 U every 6 or 12 hours in a flush solution, or 2500 U of subcutaneous low-molecular-weight heparin daily all reduce the risk for catheter-related central venous thrombosis (32). Heparin treatment should be disconti

Strategies to Prevent Catheter‐Associated Urinary Tract Infections in Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals to implement and prioritize their surgical site infection (SSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Burden of SSIs as complications in acute care facilities.a. SSIs occur in 2%-5% of patients undergoing inpatient surgery in the United States.b. Approximately 500,000 SSIs occur each year.2. Outcomes associated with SSIa. Each SSI is associated with approximately 7-10 additional postoperative hospital days.b. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI.i. Seventy-seven percent of deaths among patients with SSI are direcdy attributable to SSI.c. Attributable costs of SSI vary, depending on the type of operative procedure and the type of infecting pathogen; published estimates range from

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals

3,000 to