Preventing Arterial Catheter-Associated Bloodstream Infections: Common Sense and Chlorhexidine* James D. Chalmers, MD Stefano Aliberti, MD Tayside Respiratory Research Group University of Dundee Dundee, United Kingdom; and Department of Health Science University of Milan Bicocca Clinica Pneumologica, AC San Gerardo Monza, Italy
associated with arterial catheters (7). They studied data from 30,841 arterial catheters inserted in patients with critical illness or following surgery. The definition of catheter-related bloodstream infection was appropriate, including correlating a catheter culture with a positive blood culture and signs and symptoms consistent with sepsis. The primary outcome was to determine the prevalence of arterial catheter-related infection (7). A major finding of the analysis was if clinicians actively look for arterial catheter infections, they will find more than expected. The rate of diagnosis of arterial catheter-associated ntravascular catheters are a frequent cause of infection was 0.7 cases/1,000 catheter days in those studies that hospital-acquired infections with at least 80,000 cases of only performed cultures when infection was "suspected to be catheter-related infection reported in ICUs in the United from the catheter" almost doubling to 1.26/1,000 catheter days States annually (1, 2). Estimates suggest that the true rate of when cultures were routinely performed from arterial catheters infections is closer to 250,000 annually when intravascular in patients with suspected infection. Although lower than the devices throughout hospitals are taken into account (1,2). The prevalence reported with central venous catheters, this supports attributable mortality has been reported at 11.5% with up to the view that arterial catheters are an underrecognized source of an additional 12 days of ICU stay attributed to catheter-related infection and should always be considered a potential source (7). infections (2, 3). This represents an important source of preThe key question, of course, is how do we prevent the ventable patient morbidity and mortality. development of catheter-associated infections? The analysis All vascular access devices carry a risk of infection, with the by O'Horo et al (7) was unable to establish what sterile prelowest risk associated with peripheral venous catheters (0.5 cautions during insertion are eftective in preventing these cases per 1,000 d) and the highest risk associated with central infections, and no preprocedure cleaning regime was shown venous catheters (reported to be 2.7 per 1,000 catheter days to be clearly superior. There was, however, a significant benin one systematic review, and between 1 and 3.1 per 1,000 d efit demonstrated of using chlorhexidine-impregnated dressacross European studies) (1,4). ings (risk ratio [RR], 0.35; 95% CI, 0.31-0.91) based on three studies (8-10). This is the only part of the analysis that was In contrast to central venous catheters where a large effort based on randomized controlled trial data and would strongly has been committed to developing bundles of care to reduce support this practice. Although there has been concern over infection rates (5, 6), less is known about arterial catheter the prevalence of contact dermatitis associated with use of the infections. As arterial catheters are frequently used both in chlorhexidine dressings, the frequency of this, at 1.1% in one the ICU and in an increasing number of care settings outside study (10), appears modest and guidelines recommend use of the ICU (such as, coronary care units and high dependency these dressings where existing methods of reducing catheterunits), understanding the prevalence and risk factors for arteassociated infections have not been effective (11). rial catheter-associated infections is important. In this issue of Critical Care Medicine, O'Horo et al (7) report In keeping with guidelines recommendations, the analysis a systematic review and meta-analysis of published observational clearly demonstrates that the femoral site should be avoided studies describing the prevalence of bloodstream infections whenever possible for arterial catheter placement (7, 11). Femoral catheters were associated with a near doubling of the risk of bloodstream infection (RR, 1.94; 1.32-2.84) in this 'See also p. 1334. analysis. Cuidelines also suggest that if use of the femoral site Key Words: arterial; bacteremia; catheter; healthcare-associated infections; infection is required, then full aseptic precautions as for central venous Dr. Chalmers holds grants from the Wellcome Trust, MRG, Chief Sciencatheters should be observed (11). tists Office, Tenovus Scotland, and Bayer HealthCare. He received fees Other sensible measures which could not be addressed in for lectures from Glaxosmithkline, Astrazeneca, and Chiesi. His institution consulted for Bayer HealthCare. Dr. Aliberti consulted for Bayer; lectured the present study include removing the catheter as soon as it for Zambón, Boehringer Ingelheim, Rizer, Novartis, BRAHMS, GlaxoSis no longer needed, as there is a direct link between the duramithKline, Menarini, Merck Sharp & Dohme, Nycomed, Abbott, and Bayer; tion of catheterization and infection risk. In addition to these and received royalties from McGraw Hill. recommendations, the increasing availability and familiarity Copyright © 2014 by the Society of Critical Care Medicine and Lippincott with bedside ultrasound makes ultrasound-guided procedures Williams & Wilkins increasingly the norm. Ultrasound-guided vascular access has DOI: 10.1097/CCM.0000000000000240
I
Critical Care Medicine
www.ccmjournal.org
1533
Editorials
been shown to shorten time of the procedure, reduce the number of failed puncture attempts, and minimize complications of catheterization, including infections (11). This can be considered for radial artery catheterization. The 2011 update of the Centre for Disease control guidelines for the prevention of intravascular catheter-related infections makes several recommendations that are now reinforced by the present data (12). These include the following: • Use of the radial, brachial, or dorsalis pedis sites and avoidance of the femoral and axillary sites. • Use of a minimum of cap, mask, sterile gloves, and fenestrated drape for insertion. • Maximal sterile procedures for axillary or femoral insertion. • Replace catheters only when clinically indicated and do not routinely replace catheters to prevent infection. • Removal as soon as the catheter is no longer needed. • Using disposable transducers and replacing these along with the other components of the system at 96-hour intervals. Experience from guidelines with central venous catheters shows that guideline compliance is often suboptimal and varies greatly between ICUs. A survey of 25 ICUs in the United States, for example, found only 28% required maximal sterile precautions for central venous catheter insertion. Sixteen percent of units routinely replaced catheters to reduce infection rates, against the guideline recommendation to avoid this (13). There are limited data regarding arterial catheter guideline compliance specifically, but what published data exists suggests practice is also suboptimal (14). The message of this work is clear—arterial catheters are a source of infection like all other vascular devices, and sensible precautions and practices can reduce the prevalence of hospital-acquired infections. When managing arterial catheters, use some common sense and some chlorhexidine.
REFERENCES 1. Maki DG, Kluger DM, Crnich CJ: The risk of bloodstream infection in adults with different intravascular devices: A systematic review
1534
www.ccmjournal.org
of 200 published prospective studies. Mayo Clin Proc 2006; 81:1159-1171 2. Soufir L, Timsit JF, Mahe C, et al: Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol 1999; 20:396-401 3. Renaud B, Brun-Buisson C; ICU-Bacteremia Study Group: Outcomes of primary and catheter-related bacteremia. A cohort and case-control study in critically ill patients. Am J Respir Crit Care Med 2001; 163:1584-1590 4. Suetens C, Morales I, Savey A, et al: European surveillance of ICU-acquired infections (HELICS-ICU): Methods and main results. J Hosp Infect 2007; 65(Suppl 2):171 -173 5. Pronovost PJ, Goeschel CA, Colantuoni E, et al: Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ 2010; 340:c309 6. Marsteller JA, Sexton JB, Hsu YJ, et al: A muiticenter, phased, cluster-randomized controiied trial to reduce central line-associated bloodstream infections in intensive care units. Crit Care Med 2012; 40:2933-2939 7. O'Horo JC, Maki DG, Krupp AE, et al: Arterial Catheters as a Source of Bloodstream Infection: A Systematic Review and Meta-Analysis. Crit Care Med 2014; 42:1334-1339 8. Lucet JC, Bouadma L, Zahar JR, et al: Infectious risk associated with arterial catheters compared with central venous catheters. Crit Care Med 2010; 38:1030-1035 9. Timsit JF, Schwebel C, Bouadma L, et al; Dressing Study Group: Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. JAMA 2009; 301:1231 -1241 10. Timsit JF, Mimoz O, Mourvillier B, et al: Randomized controlled trial of chiorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 201 2; 186:1272-1278 11. Maecken T, Grau T: Ultrasound imaging in vascular access. Crit Care Med 2007; 35:S178-S185 12. O'Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee: Guidelines for the prevention of intravascular catheter-related infections. Am J infect Control 2011 ; 39:S1-34 13. Warren DK, Yokoe DS, Climo MW, et al: Preventing catheter-associated bloodstream infections: A survey of policies for insertion and care of central venous catheters from hospitals in the prevention epicenter program. Infect Control Hosp Epidemiol 2006; 27:8-13 14. Reynolds H, Dulhunty J, Tower M, et al: A snapshot of guideline compliance reveals room for improvement: A survey of peripheral arterial catheter practices in Australian operating theatres. J Adv Nurs 2013; 69:1584-1594
June 2014 • Volume 42 • Number 6
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
associated with arterial catheters (7). They studied data from 30,841 arterial catheters inserted in patients with critical illness or following surgery. The definition of catheter-related bloodstream infection was appropriate, including correlating a catheter culture with a positive blood culture and signs and symptoms consistent with sepsis. The primary outcome was to determine the prevalence of arterial catheter-related infection (7). A major finding of the analysis was if clinicians actively look for arterial catheter infections, they will find more than expected. The rate of diagnosis of arterial catheter-associated ntravascular catheters are a frequent cause of infection was 0.7 cases/1,000 catheter days in those studies that hospital-acquired infections with at least 80,000 cases of only performed cultures when infection was "suspected to be catheter-related infection reported in ICUs in the United from the catheter" almost doubling to 1.26/1,000 catheter days States annually (1, 2). Estimates suggest that the true rate of when cultures were routinely performed from arterial catheters infections is closer to 250,000 annually when intravascular in patients with suspected infection. Although lower than the devices throughout hospitals are taken into account (1,2). The prevalence reported with central venous catheters, this supports attributable mortality has been reported at 11.5% with up to the view that arterial catheters are an underrecognized source of an additional 12 days of ICU stay attributed to catheter-related infection and should always be considered a potential source (7). infections (2, 3). This represents an important source of preThe key question, of course, is how do we prevent the ventable patient morbidity and mortality. development of catheter-associated infections? The analysis All vascular access devices carry a risk of infection, with the by O'Horo et al (7) was unable to establish what sterile prelowest risk associated with peripheral venous catheters (0.5 cautions during insertion are eftective in preventing these cases per 1,000 d) and the highest risk associated with central infections, and no preprocedure cleaning regime was shown venous catheters (reported to be 2.7 per 1,000 catheter days to be clearly superior. There was, however, a significant benin one systematic review, and between 1 and 3.1 per 1,000 d efit demonstrated of using chlorhexidine-impregnated dressacross European studies) (1,4). ings (risk ratio [RR], 0.35; 95% CI, 0.31-0.91) based on three studies (8-10). This is the only part of the analysis that was In contrast to central venous catheters where a large effort based on randomized controlled trial data and would strongly has been committed to developing bundles of care to reduce support this practice. Although there has been concern over infection rates (5, 6), less is known about arterial catheter the prevalence of contact dermatitis associated with use of the infections. As arterial catheters are frequently used both in chlorhexidine dressings, the frequency of this, at 1.1% in one the ICU and in an increasing number of care settings outside study (10), appears modest and guidelines recommend use of the ICU (such as, coronary care units and high dependency these dressings where existing methods of reducing catheterunits), understanding the prevalence and risk factors for arteassociated infections have not been effective (11). rial catheter-associated infections is important. In this issue of Critical Care Medicine, O'Horo et al (7) report In keeping with guidelines recommendations, the analysis a systematic review and meta-analysis of published observational clearly demonstrates that the femoral site should be avoided studies describing the prevalence of bloodstream infections whenever possible for arterial catheter placement (7, 11). Femoral catheters were associated with a near doubling of the risk of bloodstream infection (RR, 1.94; 1.32-2.84) in this 'See also p. 1334. analysis. Cuidelines also suggest that if use of the femoral site Key Words: arterial; bacteremia; catheter; healthcare-associated infections; infection is required, then full aseptic precautions as for central venous Dr. Chalmers holds grants from the Wellcome Trust, MRG, Chief Sciencatheters should be observed (11). tists Office, Tenovus Scotland, and Bayer HealthCare. He received fees Other sensible measures which could not be addressed in for lectures from Glaxosmithkline, Astrazeneca, and Chiesi. His institution consulted for Bayer HealthCare. Dr. Aliberti consulted for Bayer; lectured the present study include removing the catheter as soon as it for Zambón, Boehringer Ingelheim, Rizer, Novartis, BRAHMS, GlaxoSis no longer needed, as there is a direct link between the duramithKline, Menarini, Merck Sharp & Dohme, Nycomed, Abbott, and Bayer; tion of catheterization and infection risk. In addition to these and received royalties from McGraw Hill. recommendations, the increasing availability and familiarity Copyright © 2014 by the Society of Critical Care Medicine and Lippincott with bedside ultrasound makes ultrasound-guided procedures Williams & Wilkins increasingly the norm. Ultrasound-guided vascular access has DOI: 10.1097/CCM.0000000000000240
I
Critical Care Medicine
www.ccmjournal.org
1533
Editorials
been shown to shorten time of the procedure, reduce the number of failed puncture attempts, and minimize complications of catheterization, including infections (11). This can be considered for radial artery catheterization. The 2011 update of the Centre for Disease control guidelines for the prevention of intravascular catheter-related infections makes several recommendations that are now reinforced by the present data (12). These include the following: • Use of the radial, brachial, or dorsalis pedis sites and avoidance of the femoral and axillary sites. • Use of a minimum of cap, mask, sterile gloves, and fenestrated drape for insertion. • Maximal sterile procedures for axillary or femoral insertion. • Replace catheters only when clinically indicated and do not routinely replace catheters to prevent infection. • Removal as soon as the catheter is no longer needed. • Using disposable transducers and replacing these along with the other components of the system at 96-hour intervals. Experience from guidelines with central venous catheters shows that guideline compliance is often suboptimal and varies greatly between ICUs. A survey of 25 ICUs in the United States, for example, found only 28% required maximal sterile precautions for central venous catheter insertion. Sixteen percent of units routinely replaced catheters to reduce infection rates, against the guideline recommendation to avoid this (13). There are limited data regarding arterial catheter guideline compliance specifically, but what published data exists suggests practice is also suboptimal (14). The message of this work is clear—arterial catheters are a source of infection like all other vascular devices, and sensible precautions and practices can reduce the prevalence of hospital-acquired infections. When managing arterial catheters, use some common sense and some chlorhexidine.
REFERENCES 1. Maki DG, Kluger DM, Crnich CJ: The risk of bloodstream infection in adults with different intravascular devices: A systematic review
1534
www.ccmjournal.org
of 200 published prospective studies. Mayo Clin Proc 2006; 81:1159-1171 2. Soufir L, Timsit JF, Mahe C, et al: Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol 1999; 20:396-401 3. Renaud B, Brun-Buisson C; ICU-Bacteremia Study Group: Outcomes of primary and catheter-related bacteremia. A cohort and case-control study in critically ill patients. Am J Respir Crit Care Med 2001; 163:1584-1590 4. Suetens C, Morales I, Savey A, et al: European surveillance of ICU-acquired infections (HELICS-ICU): Methods and main results. J Hosp Infect 2007; 65(Suppl 2):171 -173 5. Pronovost PJ, Goeschel CA, Colantuoni E, et al: Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ 2010; 340:c309 6. Marsteller JA, Sexton JB, Hsu YJ, et al: A muiticenter, phased, cluster-randomized controiied trial to reduce central line-associated bloodstream infections in intensive care units. Crit Care Med 2012; 40:2933-2939 7. O'Horo JC, Maki DG, Krupp AE, et al: Arterial Catheters as a Source of Bloodstream Infection: A Systematic Review and Meta-Analysis. Crit Care Med 2014; 42:1334-1339 8. Lucet JC, Bouadma L, Zahar JR, et al: Infectious risk associated with arterial catheters compared with central venous catheters. Crit Care Med 2010; 38:1030-1035 9. Timsit JF, Schwebel C, Bouadma L, et al; Dressing Study Group: Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. JAMA 2009; 301:1231 -1241 10. Timsit JF, Mimoz O, Mourvillier B, et al: Randomized controlled trial of chiorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 201 2; 186:1272-1278 11. Maecken T, Grau T: Ultrasound imaging in vascular access. Crit Care Med 2007; 35:S178-S185 12. O'Grady NP, Alexander M, Burns LA, et al; Healthcare Infection Control Practices Advisory Committee: Guidelines for the prevention of intravascular catheter-related infections. Am J infect Control 2011 ; 39:S1-34 13. Warren DK, Yokoe DS, Climo MW, et al: Preventing catheter-associated bloodstream infections: A survey of policies for insertion and care of central venous catheters from hospitals in the prevention epicenter program. Infect Control Hosp Epidemiol 2006; 27:8-13 14. Reynolds H, Dulhunty J, Tower M, et al: A snapshot of guideline compliance reveals room for improvement: A survey of peripheral arterial catheter practices in Australian operating theatres. J Adv Nurs 2013; 69:1584-1594
June 2014 • Volume 42 • Number 6
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
