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1.  Clinical review: New technologies for prevention of intravascular catheter-related infections 
Critical Care  2003;8(3):157-162.
Intravascular catheters have become essential devices for the management of critically and chronically ill patients. However, their use is often associated with serious infectious complications, mostly catheter-related bloodstream infection (CRBSI), resulting in significant morbidity, increased duration of hospitalization, and additional medical costs. The majority of CRBSIs are associated with central venous catheters (CVCs), and the relative risk for CRBSI is significantly greater with CVCs than with peripheral venous catheters. However, most CVC-related infections are preventable, and different measures have been implemented to reduce the risk for CRBSI, including maximal barrier precautions during catheter insertion, catheter site maintenance, and hub handling. The focus of the present review is on new technologies for preventing infections that are directed at CVCs. New preventive strategies that have been shown to be effective in reducing risk for CRBSI, including the use of catheters and dressings impregnated with antiseptics or antibiotics, the use of new hub models, and the use of antibiotic lock solutions, are briefly described.
doi:10.1186/cc2380
PMCID: PMC468883  PMID: 15153233
catheter-related bloodstream infections; central venous catheters; new technologies; prevention
2.  Central venous catheter-related infection in a prospective and observational study of 2,595 catheters 
Critical Care  2005;9(6):R631-R635.
Introduction
Central venous catheterization is commonly used in critically ill patients and may cause different complications, including infection. Although there are many studies about CVC-related infection, very few have analyzed it in detail. The objective of this study was to analyze the incidence of catheter-related local infection (CRLI) and catheter-related bloodstream infection (CRBSI) with central venous catheters (CVCs) according to different access sites.
Methods
This is a prospective and observational study, conducted in a 24-bed medical surgical intensive care unit of a 650-bed university hospital. All consecutive patients admitted to the ICU during 3 years (1 May 2000 and 30 April 2003) were included.
Results
The study included 2,018 patients. The number of CVCs and days of catheterization duration were: global, 2,595 and 18,999; subclavian, 917 and 8,239; jugular, 1,390 and 8,361; femoral, 288 and 2,399. CRLI incidence density was statistically higher for femoral than for jugular (15.83 versus 7.65, p < 0.001) and subclavian (15.83 versus 1.57, p < 0.001) accesses, and higher for jugular than for subclavian access (7.65 versus 1.57, p < 0.001). CRBSI incidence density was statistically higher for femoral than for jugular (8.34 versus 2.99, p = 0.002) and subclavian (8.34 versus 0.97, p < 0.001) accesses, and higher for jugular than for subclavian access (2.99 versus 0.97, p = 0.005).
Conclusion
Our results suggest that the order for punction, to minimize the CVC-related infection risk, should be subclavian (first order), jugular (second order) and femoral vein (third order).
doi:10.1186/cc3824
PMCID: PMC1414031  PMID: 16280064
3.  Culture Positivity of CVCs Used for TPN: Investigation of an Association with Catheter-Related Infection and Comparison of Causative Organisms between ICU and Non-ICU CVCs 
A relationship between central venous catheter (CVC) tip colonisation and catheter-related blood-stream infection (CRBSI) has been suggested. We examined culture positivity of CVC tips (colonised and infected CVCs) in a total parenteral nutrition (TPN) population. Our aims were to define the relationship between culture positivity and CRBSI, and to compare causative organisms between culture positive and CRBSI CVCS, and between ward and ICU CVCs. All patients receiving TPN via non-tunnelled CVCs during the study (1997–2009) were included. All CVC tips were analysed. Data were collated contemporaneously. A TPN audit committee determined whether CVC tip culture positivity reflected colonisation/CRBSI using CDC criteria. 1,392 patients received TPN via 2,565 CVCs over 15,397 CVC days. 25.4% of CVCs tips were culture positive, of these 32% developed CRBSI. There was a nonsignificant trend of higher Gram negative Bacilli isolation in ICU CVCs (P = 0.1), ward CVCs were associated with higher rates of staphylococcal isolation (P = 0.01). A similar pattern of organisms were cultured from CRBSI and culture positive CVCs. The consistent relationship between CRBSI and culture positive CVCs, and similar pattern of causative organisms further supports an aetiological relationship between culture positive CVC tips and CRBSI, supporting the contention that CVC culture-positivity may be a useful surrogate marker for CRBSI rates.
doi:10.1155/2012/257959
PMCID: PMC3345241  PMID: 22577526
4.  Prevention of catheter related bloodstream infection by silver iontophoretic central venous catheters: a randomised controlled trial 
Journal of Clinical Pathology  2003;56(10):731-735.
Aim: To evaluate the efficacy of silver iontophoretic central venous catheters in preventing catheter related colonisation and bloodstream infection among high risk patients in a tertiary hospital.
Methods: Patients requiring central venous access for a period greater than seven days were stratified into two groups according to systemic inflammatory response syndrome criteria before being randomly assigned to receive either silver iontophoretic or control catheters. The incidence of catheter colonisation and catheter related bloodstream infection (CRBSI) was recorded.
Results: Three hundred and four single lumen study catheters were inserted into 268 patients. Total duration of catheterisation was 5449 days (median, 12 days/catheter). Complete data could be evaluated in 270 catheters: 128 silver iontophoretic catheters and 140 untreated catheters. Forty seven silver iontophoretic catheters (36.7%) were colonised compared with 48 control catheters (33.8%). Seven cases (5.5%) of CRBSI occurred in patients who received silver iontophoretic catheters, compared with 11 cases (7.7%) in patients receiving control catheters. There was no significant difference in the incidence of catheter colonisation or CRBSI between silver iontophoretic and control catheters. When the duration of catheter placement was taken into consideration, Kaplan-Meier analysis showed no significant difference in the risk of CRBSI between the silver iontophoretic catheters and the untreated catheters (p = 0.77).
Conclusion: There was no significant difference in the incidence of catheter colonisation or CRBSI among high risk patients between silver iontophoretic catheters and control catheters. Future prospective, randomised studies with a larger number of catheters are encouraged to confirm or refute these results.
PMCID: PMC1770068  PMID: 14514774
antiseptics; catheter related bloodstream infection; central venous catheter; iontophoresis; silver ions
5.  Catheter Related Bloodstream Infection (CR-BSI) in ICU Patients: Making the Decision to Remove or Not to Remove the Central Venous Catheter 
PLoS ONE  2012;7(3):e32687.
Background
Approximately 150 million central venous catheters (CVC) are used each year in the United States. Catheter-related bloodstream infections (CR-BSI) are one of the most important complications of the central venous catheters (CVCs). Our objective was to compare the in-hospital mortality when the catheter is removed or not removed in patients with CR-BSI.
Methods
We reviewed all episodes of CR-BSI that occurred in our intensive care unit (ICU) from January 2000 to December 2008. The standard method was defined as a patient with a CVC and at least one positive blood culture obtained from a peripheral vein and a positive semi quantitative (>15 CFU) culture of a catheter segment from where the same organism was isolated. The conservative method was defined as a patient with a CVC and at least one positive blood culture obtained from a peripheral vein and one of the following: (1) differential time period of CVC culture versus peripheral culture positivity of more than 2 hours, or (2) simultaneous quantitative blood culture with 5∶1 ratio (CVC versus peripheral).
Results
53 CR-BSI (37 diagnosed by the standard method and 16 by the conservative method) were diagnosed during the study period. There was a no statistically significant difference in the in-hospital mortality for the standard versus the conservative method (57% vs. 75%, p = 0.208) in ICU patients.
Conclusion
In our study there was a no statistically significant difference between the standard and conservative methods in-hospital mortality.
doi:10.1371/journal.pone.0032687
PMCID: PMC3293859  PMID: 22403696
6.  Time to Blood Culture Positivity as a Marker for Catheter-Related Candidemia▿  
Journal of Clinical Microbiology  2008;46(7):2222-2226.
Candida spp. are important causes of nosocomial bloodstream infections. Around 80% of patients with candidemia have an indwelling central venous catheter (CVC). Determining whether the CVC is the source of candidemia has implications for patient management. We assessed whether the time to detection of Candida species in peripheral blood (time to positivity [TTP]) can serve as a marker for catheter-related candidemia. Prospective surveillance of Candida bloodstream infection was conducted in two medical centers. TTP was recorded by the BacT/Alert automated system. Sixty-four candidemia episodes were included. Fifty patients (78%) had an indwelling CVC. Thirteen patients (20.3%) had definite catheter-related candidemia. TTP was shorter for definite catheter-related candidemia (17.3 ± 2 h) than that for candidemia from other sources (38.2 ± 3 h; P < 0.001). A TTP cutoff of 30 h was 100% sensitive and 51.4% specific for catheter-related candidemia (area under the receiver-operator characteristic curve of 0.76). We conclude that TTP in peripheral blood is a sensitive but nonspecific marker for catheter-related candidemia and that a TTP of more than 30 h can help exclude an intravascular catheter as the possible source of candidemia.
doi:10.1128/JCM.00214-08
PMCID: PMC2446879  PMID: 18480222
7.  Bloodstream Infection in Neutropenic Cancer Patients Related to Short-Term Nontunnelled Catheters Determined by Quantitative Blood Cultures, Differential Time to Positivity, and Molecular Epidemiological Typing with Pulsed-Field Gel Electrophoresis 
Journal of Clinical Microbiology  2003;41(1):118-123.
To determine the rate of catheter-related bloodstream infection (CRBSI) among cases of primary bloodstream infection (BSI) in febrile neutropenic cancer patients with short-term nontunnelled catheters, quantitative paired blood cultures (Isolator) from the central venous catheter (CVC) and peripheral vein were obtained between November 1999 and January 2001. Bactec blood culture bottles were obtained to determine the differential time to positivity (DTP). CRBSI was defined as a quantitative blood culture ratio of >5:1 (CVC versus peripheral) with proven identity of isolates from positive peripheral and CVC blood cultures as confirmed by pulsed-field gel electrophoresis. Forty-nine episodes of primary BSI were detected among 235 cancer patients with febrile neutropenia. Of these, 18 episodes (37%) were CRBSI and 31 (63%) were BSI with an unknown portal of entry. Coagulase-negative staphylococci were present in nine cases of CRBSI (50%). The identity of isolates from peripheral and CVC blood cultures was confirmed in all cases. Earlier positivity (>2 h) of CVC-drawn versus peripheral blood cultures was observed in 18 of 22 CRBSI-associated blood cultures (sensitivity, 82%; specificity, 88%; positive predictive value, 75%; negative predictive value, 92%). In summary, CRBSI accounted for 37% of cases of primary BSI in this population of neutropenic cancer patients. DTP compares favourably with quantitative blood cultures for the diagnosis of CRBSI and may be particularly useful for patients in whom catheter salvage is highly desirable.
doi:10.1128/JCM.41.1.118-123.2003
PMCID: PMC149641  PMID: 12517836
8.  Systematic review of emergency department central venous and arterial catheter infection 
Background
There is an extensive critical care literature for central venous catheter and arterial line infection, duration of catheterization, and compliance with infection control procedures. The emergency medicine literature, however, contains very little data on central venous catheters and arterial lines. As emergency medicine practice continues to incorporate greater numbers of critical care procedures such as central venous catheter placement, infection control is becoming a greater issue.
Aims
We performed a systematic review of studies reporting baseline data of ED-placed central venous catheters and arterial lines using multiple search methods.
Methods
Two reviewers independently assessed included studies using explicit criteria, including the use of ED-placed invasive lines, the presence of central line-associated bloodstream infection, and excluded case reports and review articles. Finding significant heterogeneity among studies, we performed a qualitative assessment.
Results
Our search produced 504 abstracts, of which 15 studies were evaluated, and 4 studies were excluded because of quality issues leaving 11 cohort studies. Four studies calculated infection rates, ranging 0–24.1/1,000 catheter-days for central line-associated and 0–32.8/1,000 catheter-days for central line-related bloodstream infection. Average duration of catheterization was 4.9 days (range 1.6–14.1 days), and compliance with infection control procedures was 33–96.5%. The data were too poor to compare emergency department to in-hospital catheter infection rates.
Conclusions
The existing data for emergency department-placed invasive lines are poor, but suggest they are a source of infection, remain in place for a significant period of time, and that adherence to maximum barrier precautions is poor. Obtaining accurate rates of infection and comparison between emergency department and inpatient lines requires prospective study.
doi:10.1007/s12245-010-0225-5
PMCID: PMC3047889  PMID: 21373313
Central venous catheter; Central line; Systematic review; Infectious disease; Central line-associated bloodstream infection; Central line-related bloodstream infection; Catheter-associated bloodstream infection; Catheter-related bloodstream infection
9.  Alcaligenes xylosoxidans Bloodstream Infections in Outpatient Oncology Office 
Emerging Infectious Diseases  2008;14(7):1046-1052.
Gaps in infection control led to biofilm production in central venous catheters and resultant bloodstream infection.
In 2002, we investigated a cluster of patients with Alcaligenes xylosoxidans bloodstream infections by conducting a matched case–control study and a prospective study. Pulsed-field gel electrophoresis (PFGE) was performed on blood culture isolates, and 1 explanted central venous catheter (CVC) was tested for biofilm. We identified 12 cases of A. xylosoxidans bloodstream infection. Case-patients were more likely than controls to have had a CVC (7/7 [100%] vs 4/47 [8.7%], respectively; p<0.0001). Ten case isolates were indistinguishable by PFGE analysis, and A. xylosoxidans biofilm from the CVC matched the outbreak strain. We observed multiple breaches in infection control, which may have caused contamination of multidose vials used to flush the CVCs. Our study links A. xylosoxidans with CVC biofilm and highlights areas for regulation and oversight in outpatient settings.
doi:10.3201/eid1407.070894
PMCID: PMC2600348
Alcaligenes xylosoxidans; outbreak; outpatient; central venous catheter; bacteremia; research
10.  Central venous catheter-related bloodstream infections in the intensive care unit 
Context:
Central venous catheter-related bloodstream infection (CRBSI) is associated with high rates of morbidity and mortality in critically ill patients.
Aims:
This study was conducted to determine the incidence of central venous catheter-related infections (CRIs) and to identify the factors influencing it. So far, there are very few studies that have been conducted on CRBSI in the intensive care unit in India.
Settings and Design:
This was a prospective, observational study carried out in the medical intensive care unit (MICU) over a period of 1 year from January to December 2004.
Materials and Methods:
A total of 54 patients with indwelling central venous catheters of age group between 20 and 75 years were included. The catheters were cultured using the standard semiquantitative culture (SQC) method. Statistical analysis used SPSS-10 version statistical software.
Results:
A total of 54 CVC catheters with 319 catheter days were included in this study. Of 54 patients with CVCs studied for bacteriology, 39 (72.22%) catheters showed negative SQCs and also negative blood cultures. A total of 15 (27.77%) catheters were positive on SQC, of which 10 (18.52%) were with catheter-associated infection and four (7.41%) were with catheter-associated bacteremia; the remaining one was a probable catheter-associated bacteremia. CRIs were high among catheters that were kept in situ for more than 3 days and emergency procedures where two or more attempts were required for catheterization (P < 0.05). In multivariate analysis of covariance duration of catheter in situ for >3 days, inexperienced venupucturist, more number of attempts and emergency CVC were associated with more incidence of CVCBSIs, with P <0.02. The duration of catheter in situ was negatively correlated (-0.53) and number of attempts required to put CVC was positively correlated (+0.39) with incidence of CVCBSIs. Sixty-five percent of the isolates belonged to the CONS group (13/20). Staphylococcus epidermidis showed maximum susceptibility to amikacin, doxycycline and amoxycillin with clavulanic acid and was susceptible to vancomycin (100%). Klebsiella pneumoniae was 100% susceptible to amikacin and ciprofloxacin. Escherichia coli was susceptible to amikacin and cefotaxime.
Conclusions:
The overall incidence of CRI was 27.77% (15/54). Catheter-associated BSIs were 47.31 per 1000 catheter-days. CRI was low in the catheters inserted by the experienced venipuncturists, elective procedure and CVC kept in situ for ≤3 days. S. epidermidis was the most common isolate.
doi:10.4103/0972-5229.92074
PMCID: PMC3271557  PMID: 22346032
Catheter-related infection; catheter-associated infection; semiquantitative culture
11.  How Should Long-Term Tunneled Central Venous Catheters Be Managed in Microbiology Laboratories in Order To Provide an Accurate Diagnosis of Colonization? 
Journal of Clinical Microbiology  2012;50(3):1003-1007.
Guidelines recommend the roll-plate technique for short-term central venous catheter (CVC) tip cultures. However, the issue of whether the roll-plate technique is better than the sonication method for long-term CVCs remains unresolved. In addition, no data are available for predicting the value of direct Gram staining in anticipating catheter colonization or catheter-related bloodstream infection (CRBSI) in these long-term CVCs. Our objectives were to compare the roll-plate technique and the sonication method and to define the validity values of Gram staining for the prediction of colonization and CRBSI in patients with long-term tunneled CVCs. During the study period, all tunneled CVCs removed at our institution were prospectively and routinely sent to the microbiology laboratory for Gram staining (first) and tip culture (the Maki technique and sonication, in a random order). We received 149 tunneled CVCs, 39 (26.2%) of which were colonized and 11 (7.4%) of which were associated with CRBSI. Overall, the roll-plate method detected 94.9% of the colonized catheters, whereas sonication detected only 43.6% (P < 0.001). The validity values of Gram staining for the detection of colonization and CRBSI were as follows: a sensitivity of 35.9% to 60.0%, a specificity of 100% to 94.2%, a positive predictive value of 100% to 42.9%, and a negative predictive value of 81.5% to 97.0%. The roll-plate technique proved to be better than sonication for the detection of bacteria in long-term tunneled CVCs. Gram staining of the tips of tunneled CVCs can anticipate a positive culture and rule out CRBSI. In our opinion, direct Gram staining should be incorporated into routine microbiological assessments of long-term catheter tips.
doi:10.1128/JCM.05758-11
PMCID: PMC3295088  PMID: 22170928
12.  Management of occlusion and thrombosis associated with long-term indwelling central venous catheters 
Lancet  2009;374(9684):159.
Long-term central venous catheters (CVC) facilitate care for patients with chronic illnesses, but catheter occlusions and catheter-related thrombosis (CRT) are common complications. This review summarizes management of CVC and CRT.
Mechanical CVC occlusions require cause-specific therapy; whereas, thrombotic occlusions usually resolve with thrombolytic therapy, such as alteplase. Prophylaxis with thrombolytic flushes may decrease CVC infections and CRT, but confirmatory studies and cost-effectiveness analysis are needed.
Risk factors for CRT include previous catheter infections, malposition of the catheter tip, and prothrombotic states. CRT can lead to catheter infection, pulmonary embolism, and post-thrombotic syndrome. CRT is diagnosed primarily using Doppler ultrasound or venography and treated with anticoagulation for 6 weeks to a year, depending on the extent of the thrombus, response to initial therapy, and whether thrombophilic factors persist. Prevention of CRT includes proper positioning of the CVC and prevention of infections; anticoagulation prophylaxis is not recommended at present.
doi:10.1016/S0140-6736(09)60220-8
PMCID: PMC2814365  PMID: 19595350
13.  Catheter-related bloodstream infections in neonatal intensive care units 
Korean Journal of Pediatrics  2011;54(9):363-367.
Central venous catheters (CVCs) are regularly used in intensive care units, and catheter-related bloodstream infection (CRBSI) remains a leading cause of healthcare-associated infections, particularly in preterm infants. Increased survival rate of extremely-low-birth-weight infants can be partly attributed to routine practice of CVC placement. The most common types of CVCs used in neonatal intensive care units (NICUs) include umbilical venous catheters, peripherally inserted central catheters, and tunneled catheters. CRBSI is defined as a laboratory-confirmed bloodstream infection (BSI) with either a positive catheter tip culture or a positive blood culture drawn from the CVC. BSIs most frequently result from pathogens such as gram-positive cocci, coagulase-negative staphylococci, and sometimes gram-negative organisms. CRBSIs are usually associated with several risk factors, including prolonged catheter placement, femoral access, low birth weight, and young gestational age. Most NICUs have a strategy for catheter insertion and maintenance designed to decrease CRBSIs. Specific interventions slightly differ between NICUs, particularly with regard to the types of disinfectants used for hand hygiene and appropriate skin care for the infant. In conclusion, infection rates can be reduced by the application of strict protocols for the placement and maintenance of CVCs and the education of NICU physicians and nurses.
doi:10.3345/kjp.2011.54.9.363
PMCID: PMC3250601  PMID: 22232628
Catheter; Bacteremia; Intensive care units; Newborn
14.  Evaluation of a novel endoluminal brush method for in situ diagnosis of catheter related sepsis. 
Journal of Clinical Pathology  1997;50(4):278-282.
AIMS: To determine the accuracy of a novel endoluminal brush method for the diagnosis of catheter related sepsis (CRS), which is performed in situ and hence does not require line sacrifice. METHODS: 230 central venous catheters in 216 patients were examined prospectively for evidence of CRS or colonisation using an endoluminal brush method in conjunction with peripheral blood cultures. The results were compared with those obtained using methods that require line sacrifice: extraluminal sampling (Maki roll) or endoluminal sampling (modified Cleri flush) of microorganisms. RESULTS: Only 16% of 128 patients suspected clinically of having line associated infection were confirmed as having CRS. In addition, 2 of 102 patients not suspected of having line associated infection had CRS. Line colonisation was apparent in approximately twice as many catheters using the Maki roll criteria (92%) compared with either the endoluminal brush (43%) or Cleri flush (43%). Furthermore, colonised catheters sampled using the Maki roll technique yielded mixed growth twice as often as when examined by endoluminal methods (17 and 8 cases, respectively). It was rare to detect either only endoluminal (4 of 22 episodes) or extraluminal (1 of 22 episodes) microorganisms in cases of CRS. In contrast, catheters defined as being colonised most frequently (59% of episodes) yielded only significant extraluminal growth. Only one case of CRS (5%) would have been "missed" if lines yielding a negative result from endoluminal brush sampling had been left in situ. Conversely, four episodes of CRS (18%) would not have been diagnosed by relying on extraluminal sampling alone. CONCLUSIONS: Diagnosis of CRS by the endoluminal brush method can be achieved without line sacrifice and is more sensitive (95%) and specific (84%) than extraluminal sampling of the catheter tip by the Maki roll technique (82% and 66%, respectively).
PMCID: PMC499875  PMID: 9215141
15.  Can a New Antiseptic Agent Reduce the Bacterial Colonization Rate of Central Venous Lines in Post-Cardiac Surgery Patients? 
Background:
Central venous (CV) catheters play an essential role in the management of critically ill patients in the Intensive Care Unit (ICU). CV lines are, however, allied to catheter-associated blood stream infections. Bacterial colonization of CV lines is deemed the main cause of catheter-associated infection. The purpose of our study was to compare bacterial colony counts in the catheter site before CV line insertion in two groups of post-cardiac surgery patients: a group receiving Sanosil (an antiseptic agent composed of H2O2 and silver) and a control group.
Methods:
This interventional prospective double-blinded clinical trial recruited the patients in three post-cardiac surgery ICUs of a heart center. The participants were divided into interventional (113 patients) and control (136 patients) groups. Sanosil was added to the routine preparation procedure (Chlorhexidine bath one day before and scrub with Povidone-Iodine just before the CV line insertion). After the removal of the CV lines, the catheters tips were sent for culture and evaluation of colony counts.
Results:
Catheter colonization occurred in 55 (22.1%) patients: 26 (23%) patients in the Sanosil group and 29 (21.3%) in the control group; there was no significant statistical difference between the two groups (p value = 0.75, RR = 1.05, 95% CI: 0.76–1.45). The most common organism having colonized in the cultures of the catheter tips was staphylococcus epidermis: 20 cases in the control group and 16 cases in the intervention group.
Conclusion:
Catheter colonization frequently occurs in post-cardiac surgery patients. However, our results did not indicate the effectiveness of adding Sanosil to the routine preparation procedure with respect to reducing catheter bacterial colonization.
PMCID: PMC3740112  PMID: 23967028
Central venous catheters; Infection; Anti-infective agents, local
16.  Reduction of central venous catheter associated blood stream infections following implementation of a resident oversight and credentialing policy 
Background
This study assesses the impact that a resident oversight and credentialing policy for central venous catheter (CVC) placement had on institution-wide central line associated bloodstream infections (CLABSI). We therefore investigated the rate of CLABSI per 1,000 line days during the 12 months before and after implementation of the policy.
Methods
This is a retrospective analysis of prospectively collected data at an academic medical center with four adult ICUs and a pediatric ICU. All patients undergoing non-tunneled CVC placement were included in the study. Data was collected on CLABSI, line days, and serious adverse events in the year prior to and following policy implementation on 9/01/08.
Results
A total of 813 supervised central lines were self-reported by residents in four departments. Statistical analysis was performed using paired Wilcoxon signed rank tests. There were reductions in median CLABSI rate (3.52 vs. 2.26; p = 0.015), number of CLBSI per month (16.0 to 10.0; p = 0.012), and line days (4495 vs. 4193; p = 0.019). No serious adverse events reported to the Pennsylvania Patient Safety Authority.
Conclusions
Implementation of a new CVC resident oversight and credentialing policy has been significantly associated with an institution-wide reduction in the rate of CLABSI per 1,000 central line days and total central line days. No serious adverse events were reported. Similar resident oversight policies may benefit other teaching institutions, and support concurrent organizational efforts to reduce hospital acquired infections.
doi:10.1186/1754-9493-5-15
PMCID: PMC3123176  PMID: 21639916
17.  Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision 
Critical Care  2009;13(2):R35.
Introduction
Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult intensive care unit (ICU) patients.
Methods
We used a Markov decision model to compare the cost effectiveness of A-CVCs relative to uncoated catheters. Four catheter types were evaluated: minocycline and rifampicin (MR)-coated catheters, silver, platinum and carbon (SPC)-impregnated catheters, and two chlorhexidine and silver sulfadiazine-coated catheters; one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per quality-adjusted life year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses.
Results
The baseline analysis, with no consideration of uncertainty, indicated all four types of A-CVC were cost-saving relative to uncoated catheters. MR-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life years, and cost savings (AUD $130,289). After considering uncertainty in the current evidence, the MR-coated catheters returned the highest incremental monetary net benefits of AUD $948 per catheter; however there was a 62% probability of error in this conclusion. Although the MR-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty.
Conclusions
Current evidence suggests that the cost effectiveness of using A-CVCs within the ICU is highly uncertain. Policies to prevent CR-BSI amongst ICU patients should consider the cost effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.
doi:10.1186/cc7744
PMCID: PMC2689469  PMID: 19284570
18.  Malfunctioning central venous catheters in children: a diagnostic approach 
Pediatric Radiology  2007;38(4):363-378.
Central venous access is increasingly becoming the domain of the radiologist, both in terms of the insertion of central venous catheters (CVCs) and in the subsequent management of these lines. This article seeks to provide an overview of the CVC types available for paediatric patients and a more detailed explanation of the spectrum of complications that may lead to catheter malfunction. A standard catheter contrast study or ‘linogram’ technique is described. The normal appearances of such a study and a detailed pictorial review of abnormal catheter studies are provided, together with a brief overview of how information from catheter investigations can guide the management of catheter complications.
doi:10.1007/s00247-007-0610-2
PMCID: PMC2292495  PMID: 17932667
Central venous catheter; Complications; Children
19.  Central venous catheter-associated bloodstream infections occurring in Canadian intensive care units: A six-month cohort study 
Objective
To determine the rate and risk factors associated with central venous catheter (CVC)-associated bloodstream infections (BSIs) in Canadian intensive care units (ICUs).
Design
A prospective, active six-month cohort with a nested case-control study.
Setting
Forty-one ICUs located in 19 Canadian hospitals.
Methods
Data were collected using a standardized format on all CVCs and patients when a CVC was inserted for more than 48 h. Results of microbiological studies and therapeutic interventions were recorded when a BSI occurred.
Results
There were 182 BSIs from 3696 CVC insertions in 2531 patients. Coagulase-negative staphylococci were responsible for 73% of the BSIs. Mean rates of CVC-associated BSIs per 1000 CVC days were 6.9, 6.8 and 5.0 in adult, neonatal and pediatric ICUs, respectively. Significant factors associated with BSI included duration of CVC insertion (OR=1.2, 95% CI 1.1 to 1.3), receiving total parenteral nutrition (OR=4.1, 95% CI 1.2 to 14.3) and having one or more CVCs (OR=3.1, 95% CI 1.5 to 6.5). In the case-control study, 80% of the variance in a backward elimination logistic regression analysis was explained by duration of CVC insertion (OR=1.2 per day), receiving chemotherapy (OR=6.1), more than one CVC insertion during the study (OR=3.5), insertion of a CVC with two or more lumens (OR=2.3), using the CVC to administer total parenteral nutrition (OR=1.6) and having a surgical wound other than a clean wound (OR=1.6).
Conclusion
The present study identified risk factors explaining 80% of the variance associated with BSIs and is one of the largest reports on the rate of CVC-associated BSIs occurring in the ICU setting.
PMCID: PMC2095065  PMID: 18418495
Bacteremia; Central venous catheter; Intensive care unit; Risk factor
20.  How correct is the correct length for central venous catheter insertion 
Background and Aim:
Central venous catheters (CVC) are important in the management of critically ill patients. Incorrect positioning may lead to many serious complications. Chest radiograph is a convenient means of determining the correct position of the catheter tip. The present study was designed to evaluate the depth of CVC placed through the right and left internal jugular vein (IJV) in order to achieve optimum placement of the catheter tip.
Materials and Methods:
A total of 107 patients in whom CVCs were put through either the right or left IJV through a central approach were included in this prospective study. Catheter tip position was observed in the post procedure chest radiograph. It was considered correct if the tip was just below the carina in the left-sided catheters and just above carina in the right-sided catheters. The catheters were repositioned based on the chest radiographs. The catheter depth leading to optimum tip placement was noted.
Results:
In males, catheter repositioning was required in 13 of 58 patients (22.41%) in the right IJV catheters, whereas in 2 of 13 patients (15.38%) in the left IJV catheters. In females, repositioning was required in 12 of 25 patients (48%) in the right IJV catheters and 2 of 11 patients (18.18%) in the left IJV catheters. Repositioning rate was higher in females (14/36) compared with males (15/71), which was statistically significant (P = 0.05, 95% CI). Repositioning rates were significantly higher in females (12/25) as compared with males (13/58) in the right IJV catheters (P = 0.019, 95% CI).
Conclusion:
By cannulating the IJV through a central approach, the catheters can be fixed at a length of 12-13 cm in males and 11-12 cm in females in the right IJV and at a length of 13-14 cm in males and 12-13 cm in females in the left IJV in order to achieve correct positioning.
doi:10.4103/0972-5229.58543
PMCID: PMC2823099  PMID: 20040815
Carina; central venous catheters; right and left internal jugular vein
21.  Improved Antibiotic-Impregnated Catheters with Extended-Spectrum Activity against Resistant Bacteria and Fungi 
Minocycline-rifampin-impregnated central venous catheters (M/R CVCs) have been shown to be efficacious in reducing catheter-related bloodstream infections (CRBSI) and inhibiting the biofilm adherence of resistant Gram-positive and Gram-negative pathogens, with the exception of Pseudomonas aeruginosa and Candida spp. To expand the spectrum of antimicrobial activity, a novel second-generation M/R catheter was developed by adding chlorhexidine (CHX-M/R). CVCs and peripherally inserted central catheters (PICCs) were impregnated with CHX-M/R and compared with first-generation M/R catheters, CHX-silver sulfadiazine-treated CVCs (CHX/SS-CVCs), chlorhexidine-treated PICCs, and uncoated catheters. A biofilm catheter colonization model was used to assess the efficacy of catheters against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecium (VRE), P. aeruginosa, Candida albicans, and Candida glabrata. CHX-M/R-impregnated CVCs were the only antimicrobial catheters that completely inhibited the biofilm colonization of all resistant bacterial and fungal organisms tested at all time intervals, and they were significantly superior to uncoated catheters (all P values were ≤0.003). Furthermore, CHX-M/R-coated CVCs had a significantly more effective and prolonged (up to 3 weeks) antimicrobial activity against MRSA and P. aeruginosa than M/R, CHX/SS, and uncoated CVCs (P < 0.0001). Similarly, CHX-M/R-coated PICCs were also superior to M/R-coated and CHX-coated PICCs in preventing biofilms of MRSA, VRE, P. aeruginosa, and Candida species (P value = 0.003 for all). Our study shows that novel CHX-M/R-coated catheters have unique properties in completely inhibiting biofilm colonization of MRSA, VRE, P. aeruginosa, and fungi in a manner superior to that of M/R- and chlorhexidine-treated catheters.
doi:10.1128/AAC.05836-11
PMCID: PMC3264266  PMID: 22123686
22.  Incidence and Acute Complications of Asymptomatic Central Venous Catheter–Related Deep Venous Thrombosis in Critically Ill Children 
The Journal of pediatrics  2012;162(2):387-391.
Objective
To determined the current incidence and acute complications of asymptomatic central venous catheter (CVC)-related deep venous thrombosis (DVT) in critically ill children.
Study design
We performed a prospective cohort study in 3 pediatric intensive care units. A total of 101 children with newly inserted untunneled CVC were included. CVC-related DVT was diagnosed using compression ultrasonography with color Doppler.
Results
Asymptomatic CVC-related DVT was diagnosed in 16 (15.8%) children, which equated to 24.7 cases per 1000 CVC-days. Age was independently associated with DVT. Compared with children aged <1 year, children aged >13 years had significantly higher odds of DVT (aOR, 14.1, 95% CI, 1.9–105.8; P = .01). Other patient demographics, interventions (including anticoagulant use), and CVC characteristics did not differ between children with and without DVT. Mortality-adjusted duration of mechanical ventilation, a surrogate for pulmonary embolism, was statistically similar in the 2 groups (22 ± 9 days in children with DVT vs 23 ± 7 days in children without DVT; P = .34). Mortality-adjusted intensive care unit and hospital lengths of stay also were similar in the 2 groups.
Conclusion
Asymptomatic CVC-related DVT is common in critically ill children. However, the acute complications do not seem to differ between children with and without DVT. Larger studies are needed to confirm these results. Future studies should also investigate the chronic complications of asymptomatic CVC-related DVT.
doi:10.1016/j.jpeds.2012.06.059
PMCID: PMC3575007  PMID: 22883418
23.  Medical-grade honey does not reduce skin colonization at central venous catheter-insertion sites of critically ill patients: a randomized controlled trial 
Critical Care  2012;16(5):R214.
Introduction
Catheter-related bloodstream infections (CRBSIs) associated with short-term central venous catheters (CVCs) in intensive care unit (ICU) patients are a major clinical problem. Bacterial colonization of the skin at the CVC insertion site is an important etiologic factor for CRBSI. The aim of this study was to assess the efficacy of medical-grade honey in reducing bacterial skin colonization at insertion sites.
Methods
A prospective, single-center, open-label randomized controlled trial was performed at the ICU of a university hospital in The Netherlands to assess the efficacy of medical-grade honey to reduce skin colonization of insertion sites. Medical-grade honey was applied in addition to standard CVC-site dressing and disinfection with 0.5% chlorhexidine in 70% alcohol. Skin colonization was assessed on a daily basis before CVC-site disinfection. The primary end point was colonization of insertion sites with >100 colony-forming units at the last sampling before removal of the CVC or transfer of the patient from the ICU. Secondary end points were quantitative levels of colonization of the insertion sites and colonization of insertion sites stratified for CVC location.
Results
Colonization of insertion sites was not affected by the use of medical-grade honey, as 44 (34%) of 129 and 36 (34%) of 106 patients in the honey and standard care groups, respectively, had a positive skin culture (P = 0.98). Median levels of skin colonization at the last sampling were 1 (0 to 2.84) and 1 (0 to 2.70) log colony-forming units (CFUs)/swab for the honey and control groups, respectively (P = 0.94). Gender, days of CVC placement, CVC location, and CVC type were predictive for a positive skin culture. Correction for these variables did not change the effect of honey on skin-culture positivity.
Conclusions
Medical-grade honey does not affect colonization of the skin at CVC insertion sites in ICU patients when applied in addition to standard disinfection with 0.5% chlorhexidine in 70% alcohol.
Trial registration
Netherlands Trial Registry, NTR1652.
doi:10.1186/cc11849
PMCID: PMC3682318  PMID: 23111148
24.  Safety and Effectiveness of Central Venous Catheterization in Patients with Cancer: Prospective Observational Study 
Journal of Korean Medical Science  2010;25(12):1748-1753.
This study investigated the safety and effectiveness of each type of central venous catheters (CVC) in patients with cancer. We prospectively enrolled patients with cancer who underwent catherization involving a subclavian venous catheter (SVC), peripherally inserted central venous catheter (PICC), or chemo-port (CP) in our department. From March 2007 to March 2009, 116 patients underwent 179 episodes of catherization. A SVC was inserted most frequently (46.4%). Fifty-four complications occurred (30.1%): infection in 23 cases, malpositioning or migration of the tip in 18 cases, thrombosis in eight cases, and bleeding in five cases. Malpositioning or migration of the tip occurred more frequently with a PICC (P<0.001); infection occurred more often with a tunneled catheter (P=0.028) and was observed more often in young patients (P=0.023). The catheter life span was longer for patients with solid cancer (P=0.002) than for those with hematologic cancer, with a CP (P<0.001) than a PICC or SVC, and for an indwelling catheter with image guidance (P=0.014) than a blind procedure. In conclusion, CP is an effective tool for long term use and the fixation of tip is important for the management of PICC.
doi:10.3346/jkms.2010.25.12.1748
PMCID: PMC2995228  PMID: 21165289
Catheterization, Central Venous; Complications; Neoplasms
25.  Computer Algorithms To Detect Bloodstream Infections 
Emerging Infectious Diseases  2004;10(9):1612-1620.
Automated bloodstream infection surveillance using electronic data is an accurate alternative to surveillance using manually collected data.
We compared manual and computer-assisted bloodstream infection surveillance for adult inpatients at two hospitals. We identified hospital-acquired, primary, central-venous catheter (CVC)-associated bloodstream infections by using five methods: retrospective, manual record review by investigators; prospective, manual review by infection control professionals; positive blood culture plus manual CVC determination; computer algorithms; and computer algorithms and manual CVC determination. We calculated sensitivity, specificity, predictive values, plus the kappa statistic (κ) between investigator review and other methods, and we correlated infection rates for seven units. The κ value was 0.37 for infection control review, 0.48 for positive blood culture plus manual CVC determination, 0.49 for computer algorithm, and 0.73 for computer algorithm plus manual CVC determination. Unit-specific infection rates, per 1,000 patient days, were 1.0–12.5 by investigator review and 1.4–10.2 by computer algorithm (correlation r = 0.91, p = 0.004). Automated bloodstream infection surveillance with electronic data is an accurate alternative to surveillance with manually collected data.
doi:10.3201/eid1009.030978
PMCID: PMC3320282  PMID: 15498164
surveillance; bloodstream infection; information system; computer data processing; algorithms; infection control; central-venous catheter; research

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