Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections

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GUIDELINES Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections Naomi P. O'Grady, 1 Mary Alexander, 2 Lillian A. Burns, 3 E. Patchen Dellinger, 4 Jeffrey
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GUIDELINES Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections Naomi P. O'Grady, 1 Mary Alexander, 2 Lillian A. Burns, 3 E. Patchen Dellinger, 4 Jeffrey Garland, 5 Stephen O. Heard, 6 Pamela A. Lipsett, 7 Henry Masur, 1 Leonard A. Mermel, 8 Michele L. Pearson, 9 Issam I. Raad, 10 Adrienne G. Randolph, 11 Mark E. Rupp, 12 Sanjay Saint, 13 and the Healthcare Infection Control Practices Advisory Committee (HICPAC) (Appendix 1) 1 Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland; 2 Infusion Nurses Society, Norwood, Massachusetts; 3 Staten Island University Hospital, Staten Island, New York; 4 Department of Surgery, University of Washington, Seattle, Washington; 5 Department of Pediatrics, Wheaton Franciscan Healthcare-St. Joseph, Milwaukee, Wisconsin; 6 Department of Anesthesiology, University of Massachusetts Medical School, Worcester, Massachusetts; 7 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; 8 Division of Infectious Diseases, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island; 9 Office of Infectious Diseases, CDC, Atlanta, Georgia; 10 Department of Infectious Diseases, MD Anderson Cancer Center, Houston, Texas; 11 Department of Anesthesiology, The Children's Hospital, Boston, Massachusetts; 12 Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska; and 13 Department of Internal Medicine, Ann Arbor VA Medical Center and University of Michigan, Ann Arbor, Michigan 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 Received 31 January 2011; accepted 4 February Correspondence: Naomi P. O'Grady, MD, Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, Center Drive MSC 1662 Bethesda, MD Clinical Infectious Diseases 2011;52(9): Published by Oxford University Press on behalf of the Infectious Diseases Society of America /2011/ $37.00 DOI: /cid/cir138 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 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 HIC- PAC, each recommendation is categorized on the basis Preventing Intravascular Catheter Related Infections d CID 2011:52 (1 May) d 1087 of existing scientific data, theoretical rationale, applicability, and economic impact. The system for categorizing recommendations in this guideline is as follows: d Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. d 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. d Category IC. Required by state or federal regulations, rules, or standards. d Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. d Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. INTRODUCTION 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 measures to prevent intravascular catheter-related infections [7 15]. Category IA 2. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters [7 15]. Category IA 3. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. [14 28]. 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 [29 31]. Category IB In the United States, 15 million central vascular catheter (CVC) days (i.e, the total number of daysofexposuretocvcsamongall patients in the selected population during the selected time period) occur in intensive care units (ICUs) each year [1]. Studies have variously addressed catheter-related bloodstream infections (CRBSI). These infections independently increase hospital costs and length of stay [2 5], but have not generally been shown to independently increase mortality. While 80,000 CRBSIs occur in ICUs each year [1], a total of 250,000 cases of BSIs have been estimated to occur annually, if entire hospitals are assessed [6]. 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. 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 [32, 33]. 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 [33 35]. Category IB 4. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs [33, 34]. 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 [36]. Category IB 1088 d CID 2011:52 (1 May) d O Grady et al 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) [37 53]. Category IA 2. Avoid using the femoral vein for central venous access in adult patients [38, 50, 51, 54]. 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 [50 52]. 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 [53,55 58]. Category IA 6. Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis [59]. 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. [60 64]. Category 1B 8. Use a CVC with the minimum number of ports or lumens essential for the management of the patient [65 68]. 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 [69 72]. 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 [37,73 76]. 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 [12,77 79]. Category IB 2. Maintain aseptic technique for the insertion and care of intravascular catheters [37, 73, 74, 76]. 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 [37, 73, 74, 76]. 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 [14, 75, 76, 80]. Category IB 2. Use a sterile sleeve to protect pulmonary artery catheters during insertion [81]. 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 [83]. 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 [83, 84]. 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 [83, 84]. Category IB Catheter Site Dressing Regimens 1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site [85 88]. Category IA 2. If the patient is diaphoretic or if the site is bleeding or oozing, use gauze dressing until this is resolved [85 88]. Category II 3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled [84, 85]. 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 [89, 90]. 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 Preventing Intravascular Catheter Related Infections d CID 2011:52 (1 May) d 1089 protected with an impermeable cover during the shower) [91 93]. 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 [88, 94]. 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 longterm cuffed and tunneled CVCs. Unresolved issue 10. Ensure that catheter site care is compatible with the catheter material [95, 96]. Category IB 11. Use a sterile sleeve for all pulmonary artery catheters [81]. 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 [94, 97 99]. 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 [ ]. 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 [ ]. Category II Catheter Securement Devices Use a sutureless securement device to reduce the risk of infection for intravascular catheters [106]. 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 [ ]. 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 [115]. 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 [59, ]. 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 [ ]. Category II Anticoagulants Do not routinely use anticoagulant therapy to reduce the risk of catheter-related infection in general patient populations [139]. Category II Replacement of Peripheral and Midline Catheters 1. There is no need to replace peripheral catheters more frequently than every hours to reduce risk of infection and phlebitis in adults [36, 140, 141]. Category 1B 2. No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated [ ]. Unresolved issue 3. Replace peripheral catheters in children only when clinically indicated [32, 33]. 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 catheterrelated infections. Category IB 2. Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding
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