Strategies To Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals 2022 Update
Strategies To Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals 2022 Update
doi:10.1017/ice.2022.87
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
2 Niccolò Buetti et al
Essential Practices
Before insertion
1. Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement (Quality of Evidence: LOW)
2. Require education and competency assessment of HCP involved in insertion, care, and maintenance of CVCs about CLABSI prevention (Quality of
Evidence: MODERATE)74–78
3. Bathe ICU patients aged >2 months with a chlorhexidine preparation on a daily basis (Quality of Evidence: HIGH)86–90
At insertion
1. In ICU and non-ICU settings, a facility should have a process in place, such as a checklist, to ensure adherence to infection prevention practices at the
time of CVC insertion (Quality of Evidence: MODERATE)101
2. Perform hand hygiene prior to catheter insertion or manipulation (Quality of Evidence: MODERATE)102–107
3. The subclavian site is preferred to reduce infectious complications when the catheter is placed in the ICU setting (Quality of Evidence: HIGH)33,37,108–110
4. Use an all-inclusive catheter cart or kit (Quality of Evidence: MODERATE)118
5. Use ultrasound guidance for catheter insertion (Quality of Evidence: HIGH)119,120
6. Use maximum sterile barrier precautions during CVC insertion (Quality of Evidence: MODERATE)123–128
7. Use an alcoholic chlorhexidine antiseptic for skin preparation (Quality of Evidence: HIGH)42,129–134
After insertion
1. Ensure appropriate nurse-to-patient ratio and limit use of float nurses in ICUs (Quality of Evidence: HIGH)34,35
2. Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age (Quality of Evidence: HIGH)45,135–142
3. For non-tunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic at least every 7
days or immediately if the dressing is soiled, loose, or damp. Change gauze dressings every 2 days or earlier if the dressing is soiled, loose, or damp
(Quality of Evidence: MODERATE)145–148
4. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (Quality of Evidence: MODERATE)150–154
5. Remove nonessential catheters (Quality of Evidence: MODERATE)
6. Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals up to 7 days (Quality
of Evidence: HIGH)164
7. Perform surveillance for CLABSI in ICU and non-ICU settings (Quality of Evidence: HIGH)13,165,166
Additional Approaches
1. Use antiseptic- or antimicrobial-impregnated CVCs (Quality of Evidence: HIGH in adult patients38,39,169–171 and Quality of Evidence: MODERATE in pediatric
patients)172,173
2. Use antimicrobial lock therapy for long-term CVCs (Quality of Evidence: HIGH)177–184
3. Use recombinant tissue plasminogen activating factor (rt-PA) once weekly after hemodialysis in patients undergoing hemodialysis through a CVC (Quality
of Evidence: HIGH)192
4. Utilize infusion or vascular access teams for reducing CLABSI rates (Quality of Evidence: LOW)193,194
5. Use antimicrobial ointments for hemodialysis catheter insertion sites (Quality of Evidence: HIGH)197–201
6. Use an antiseptic-containing hub/connector cap/port protector to cover connectors (Quality of Evidence: MODERATE)202–208
Approaches that Should Not Be Considered a Routine Part of CLABSI Prevention
1. Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (Quality of Evidence: HIGH)209–213
2. Do not routinely replace CVCs or arterial catheters (Quality of Evidence: HIGH)214
Unresolved Issues
1. Routine use of needleless connectors as a CLABSI prevention strategy before an assessment of risks, benefits, and education regarding proper use215–219
2. Surveillance of other types of catheters (eg, peripheral arterial or peripheral venous catheters)11,21,22
3. Standard, nonantimicrobial transparent dressings and CLABSI risk.
4. The impact of using chlorhexidine-based products on bacterial resistance to chlorhexidine
5. Sutureless securement
6. Impact of silver zeolite-impregnated umbilical catheters in preterm infants (applicable in countries where it is approved for use in children)227
7. Necessity of mechanical disinfection of a catheter hub, needleless connector, and injection port before accessing the catheter when antiseptic-containing
caps are being used
Note. CLABSI, central line-associated bloodstream infection; CVC, central venous catheter; HCP, healthcare personnel; ICU, intensive care unit.
intervals of up to 7 days. Previously, this interval was no longer • Sutureless securement of catheters was not discussed in the pre-
than 4 days. vious version of this section.
Additional approaches
Intended use
• Antimicrobial ointment for the catheter site, which is geared
toward the population of hemodialysis patients, has been moved This document was developed following the process outlined in the
to “additional practices” given the focus on a specific population. Handbook for SHEA-Sponsored Guidelines and Expert Guidance
• Despite currently being supported by high-level evidence, Documents.2 No guideline or expert guidance document can
antiseptic-containing caps remain an “additional practice” anticipate all clinical situations, and this document is not meant
because they are not considered superior to the manual disinfec- to be a substitute for individual clinical judgment by qualified
tion, an essential practice. professionals.
• The importance of infusion teams has been highlighted by This document is based on a synthesis of evidence, theoretical
listing it under “additional practices” (previously considered rationale, current practices, practical considerations, writing-
unresolved). group consensus, and consideration of potential harm, where
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 3
Category Definition
HIGH Highly confident that the true effect lies close to that of the estimated size and direction of the effect. Evidence is rated as high quality when
there are a wide range of studies with no major limitations, there is little variation between studies, and the summary estimate has a narrow
confidence interval.
MODERATE The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different.
Evidence is rated as moderate quality when there are only a few studies and some have limitations but not major flaws, there is some
variation between studies, and/or the confidence interval of the summary estimate is wide.
LOW The true effect may be substantially different from the estimated size and direction of the effect. Evidence is rated as low quality when
supporting studies have major flaws, there is important variation between studies, the confidence interval of the summary estimate is very
wide, and/or there are no rigorous studies.
a
Based on the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) “Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control
Practices Advisory Committee Recommendations Categorization Scheme for Infection Control and Prevention Guideline Recommendations” (October 2019), the Grades of Recommendation,
Assessment, Development, and Evaluation (GRADE),265 and the Canadian Task Force on Preventive Health Care.266
applicable. A summary list of recommendations is provided along All panel members complied with SHEA and IDSA policies on
with their relevant rationales (see Table 1). conflict-of-interest disclosure.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
4 Niccolò Buetti et al
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 5
an effect on CLABSI rates.70 After catheter insertion, maintenance <1,000 g who are <7 days postnatal age, and they appear
bundles have been proposed to ensure optimal catheter care.71 rare in older infants.97–99
More data are needed to determine which components of the d. Widespread use of chlorhexidine may be associated
maintenance bundle are essential in reducing risk.72,73 with decreased chlorhexidine susceptibility, although
the clinical relevance of this finding is not well
defined.100
Before insertion
At insertion
1. Provide easy access to an evidence-based list of indications
for CVC use to minimize unnecessary CVC placement 1. In ICU and non-ICU settings, a facility should have a process
(Quality of Evidence: LOW) in place, such as a checklist, to ensure adherence to infection
2. Require education and competency assessment of healthcare prevention practices at the time of CVC insertion (Quality of
personnel (HCP) involved in insertion, care, and mainte- Evidence: MODERATE)101
nance of CVCs about CLABSI prevention (Quality of a. Ensure and document adherence to aseptic technique
Evidence: MODERATE)74–78 i. Checklists have been suggested to ensure optimal inser-
a. Include the indications for catheter use, appropriate inser- tion practices. If used, the documentation should be done
tion and maintenance, the risk of CLABSI, and general infec- by someone other than the inserter.
tion prevention strategies. ii. Observation of CVC insertion should be done by a nurse,
b. Ensure that all HCP involved in catheter insertion and main- physician, or other HCP who has received appropriate
tenance complete an educational program on essential prac- education (see above) to ensure that aseptic technique
tices to prevent CLABSI before performing these duties.79,80 is maintained.
Periodic retraining with a competency assessment may be of iii. HCP should be empowered to stop the procedure if
benefit.81 breaches in aseptic technique are observed.
c. Periodically assess HCP knowledge of and adherence to pre- 2. Perform hand hygiene prior to catheter insertion or manipu-
ventive measures. lation (Quality of Evidence: MODERATE)102–107
d. Require all HCP who insert a CVC to undergo a credential- a. Use an alcohol-based waterless product or soap and water.
ing process (as established by the individual healthcare insti- i. Use of gloves does not obviate hand hygiene.
tution) to ensure their competency before independently 3. The subclavian site is preferred to reduce infectious compli-
inserting a CVC and aseptic technique for accessing and cations when the catheter is placed in the ICU setting (Quality
maintaining the CVC thereafter. of Evidence: HIGH)33,37,108–110
e. Re-educate when an institution changes components of the a. In the non-ICU setting, the risk of infection between the dif-
infusion system that requires a change in practice (eg, when ferent sites remains unclear. Importantly, in emergent set-
an institution’s change of the needleless connector requires a tings, ensuring life-saving vascular access in the fastest
change in nursing practice). possible way may determine the choice of access site.
f. Use simulation training for proper catheter insertion and b. In children and infants, femoral vein catheterization may
maintenance if available.82–85 be considered if upper body sites are contraindicated.111
3. Bathe ICU patients >2 months of age with a chlorhexidine Tunneled femoral vein catheters, with an exit site outside
preparation on a daily basis (Quality of Evidence: the diaper area in the mid-thigh, may be safer and provide
HIGH)86–90 additional risk reduction.112,113
a. In long-term acute-care hospitals (LTACHs), daily c. Controversy exists regarding infectious and noninfectious
chlorhexidine bathing may also be considered as a preventive complications associated with different short-term CVC
measure.91 access sites.33 The risk and benefit of different insertion
b. The role of chlorhexidine bathing in non-ICU patients sites must be considered on an individual basis with
remains unclear.92,93 One cluster-randomized study found regard to infectious and noninfectious complications.33
a significant reduction in device-associated bacteremia with Among others, this applies to patients currently receiving
CHG bathing in this patient population93; however, some or likely to require hemodialysis in whom the subclavian
of these patients also received methicillin-resistant site is avoided due to risk of stenosis.
Staphylococcus aureus (MRSA) decolonization, making d. Do not use peripherally inserted central venous catheters
it difficult to draw firm conclusions regarding CHG bath- (PICCs) as a strategy to reduce the risk of CLABSI. Risk
ing alone. Several studies have suggested benefit among of infection with PICCs in hospitalized patients approaches
adult hematology-oncology patients; however, a similar that of other CVCs.114 However, the majority of CLABSIs
reduction was not observed for pediatric patients with due to PICCs occur in non-ICU settings.115
similar conditions.94,95 Accordingly, potential benefits e. Midline catheters are increasingly being used as an alterna-
and risks, such as increases in resistance and cost, need tive to CVCs for short-term vascular access, with some
to be carefully considered. observational studies suggesting lower bloodstream infec-
c. The safety and efficacy of routine use of chlorhexidine tion risk associated with midline catheters versus
bathing in infants <2 months of postnatal age remains PICCs116 and versus CVCs,117 respectively. Randomized
unclear.96 Although life-threatening skin injuries from controlled trials comparing the risk of bloodstream infec-
CHG have been reported in very young or very preterm tions and other complications associated with these devi-
infants, they typically occur in infants with a birthweight ces are needed.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
6 Niccolò Buetti et al
4. Use an all-inclusive catheter cart or kit (Quality of Evidence: dressing is soiled, loose, or damp. Change gauze dressings
MODERATE)118 every 2 days or earlier if the dressing is soiled, loose, or damp.
a. A catheter cart or kit that contains all necessary components (Quality of Evidence: MODERATE)145–148
for aseptic catheter insertion should be available and easily a. Less frequent, clinically indicated dressing changes may be
accessible in all units where CVCs are inserted. used for NICU patients or others at high risk of serious com-
5. Use ultrasound guidance for catheter insertion (Quality of plications from catheter dislodgement.149
Evidence: HIGH)119,120 b. If there is excessive bleeding or drainage from the catheter
a. Ultrasound-guided internal jugular and femoral vein cath- exit site, use gauze dressings instead of transparent dressings
eterization reduces the risk of noninfectious complications until drainage resolves.
associated with CVC placement121 but the use of ultrasound 4. Disinfect catheter hubs, needleless connectors, and injection
may lead to a breach in aseptic technique.122 ports before accessing the catheter (Quality of Evidence:
b. It is unclear whether ultrasound-guided subclavian vein MODERATE)150–154
insertion reduces risk of infectious complications. a. Before accessing catheter hubs, needleless connectors, or
6. Use maximum sterile barrier precautions during CVC inser- injection ports, vigorously apply mechanical friction with
tion (Quality of Evidence: MODERATE)123–128 an alcoholic chlorhexidine preparation, or 70% alcohol.
a. Use maximum sterile barrier precautions: Alcoholic chlorhexidine may have additional residual activ-
i. A mask, cap, sterile gown, and sterile gloves are to be ity compared to alcohol for this purpose and is therefore
worn by all HCP involved in the catheter insertion preferred.155
procedure. b. Apply mechanical friction for a minimum of 5 seconds to
ii. The patient is to be covered with a large (“full-body”) reduce contamination.156,157 It is unclear whether this dura-
sterile drape during catheter insertion. tion of disinfection can be generalized to needleless connec-
b. These measures should also be followed when exchanging a tors not tested in these studies.
catheter over a guidewire. c. Monitor compliance with hub-connector-port disinfection
c. A prospective, randomized study in surgical patients showed because approximately half of such catheter components
no additional benefit for maximum sterile barrier precau- are colonized under conditions of standard practice.152,156,158
tions126; nevertheless, most available evidence suggests risk 5. Remove nonessential catheters (Quality of Evidence:
reduction with this intervention. MODERATE)
7. Use an alcoholic chlorhexidine antiseptic for skin prepara- a. Assess the need for continued intravascular access on a daily
tion (Quality of Evidence: HIGH)42,129–134 basis during multidisciplinary rounds. Remove catheters not
a. Before catheter insertion, apply an alcoholic chlorhexidine required for patient care. Decreasing CVC utilization
solution containing at least 2% chlorhexidine gluconate to reduces CRBSI risk.159 However, reducing CVC utilization
the insertion site. may result in increased use of other intravascular catheters
i. The antiseptic solution must be allowed to dry before with corresponding infection risk.
making the skin puncture. b. Audits to determine whether CVCs are routinely removed
ii. Alcoholic chlorhexidine for skin antisepsis to prevent after their intended use may be helpful.160,161 Both simple
CLABSI in NICU patients should be used when the ben- and multifaceted interventions are effective at reducing
efits are judged to outweigh potential risk. unnecessary CVC use.162,163
6. Routine replacement of administration sets not used for
After insertion blood, blood products, or lipid formulations can be per-
formed at intervals up to 7 days (Quality of Evidence:
1. Ensure appropriate nurse-to-patient ratio and limit use of HIGH)164
float nurses in ICUs (Quality of Evidence: HIGH)34,35 a. The optimal replacement of intermittently used administra-
a. Observational studies suggest that an adequate nurse-to- tion sets is unresolved.
patient ratio must be maintained in ICUs where nurses 7. Perform surveillance for CLABSI in ICU and non-ICU set-
are managing patients with CVCs and that the number of tings (Quality of Evidence: HIGH)13,165,166
float nurses working in the ICU environment should be a. Measure unit-specific incidence of CLABSI (eg, CLABSI per
minimized. 1,000 catheter days) and report the data on a regular basis to
2. Use chlorhexidine-containing dressings for CVCs in patients the units, physician and nursing leadership, and hospital
over 2 months of age (Quality of Evidence: HIGH)45,135–142 administrators overseeing the units.
a. It is unclear whether there is additional benefit with use of a b. Compare CLABSI incidence to historical data for individual
chlorhexidine-containing dressing if daily chlorhexidine units and to national rates (ie, NHSN).167
bathing is already established and vice-versa. c. Audit surveillance as necessary to minimize variation in
b. For long-term catheters (eg, hemodialysis catheters) in interobserver reliability.48,168
well-healed access sites, it is unclear whether use of a
chlorhexidine dressing reduces risk of infectious compli-
Additional approaches for preventing CLABSI
cations.140,143,144
c. For children under 2 months of age, use of chlorhexidine Several additional approaches are currently available for use.
dressings remains unclear, particularly in very preterm or Perform a CLABSI risk assessment before considering implemen-
low birthweight infants.98 tation of any of these approaches, taking potential adverse events
3. For nontunneled CVCs in adults and children, change trans- and costs into consideration. Although it is reasonable to evaluate
parent dressings and perform site care with a chlorhexidine- the utility of technology-based interventions when CLABSI rates
based antiseptic at least every 7 days or immediately if the are above the institutional- or unit-based threshold, this is also
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 7
an opportunity to review practices and consider behavioral 4. Utilize infusion or vascular access teams for reducing
changes that may be instituted to reduce CLABSI risk. These addi- CLABSI rates (Quality of Evidence: LOW)193,194
tional approaches are recommended for use in locations and/or a. Studies have shown that an infusion/vascular access team
populations within the hospital with unacceptably high CLABSI responsible for insertion and maintenance of peripheral
rates despite implementation of the essential CLABSI prevention intravenous catheters reduces the risk of bloodstream infec-
strategies listed above. These measures may not be indicated if tions195; however, few studies have been performed regard-
institutional goals have been consistently achieved. ing the impact of intravenous therapy teams on CLABSI
rates.196
1. Use antiseptic- or antimicrobial-impregnated CVCs (Quality 5. Use antimicrobial ointments for hemodialysis catheter inser-
of Evidence: HIGH in adult patients38,39,169–171 and MODERATE tion sites (Quality of Evidence: HIGH)197–201
in pediatric patients172,173) a. Apply polysporin “triple” (where available) or povidone-
a. The risk of CLABSI is reduced with some currently marketed iodine ointment to hemodialysis catheter insertion if com-
antiseptic-impregnated (eg, chlorhexidine-silver sulfadi- patible with the catheter material.
azine) catheters and antimicrobial-impregnated (eg, mino- b. Ingredients in ointments may interact with the chemical
cycline-rifampin) catheters. Use such catheters under the composition of some catheters. Thus, ensure the selected
following conditions: ointment will not interact with the catheter material before
i. Hospital units or patient populations have a CLABSI rate any such product is applied to the catheter insertion/exit site.
above institutional goals despite compliance with essen- For example, ointments containing glycol should not be
tial CLABSI prevention practices. Some evidence sug- applied to insertion/exit sites of polyurethane catheters.
gests that use of antimicrobial CVCs, along with other c. Mupirocin ointment should not be applied to the catheter
preventive technologies, may have no additional benefit insertion site due to the risks of facilitating mupirocin resis-
in patient care units that have already established a low tance and the potential damage to polyurethane catheters.
incidence of catheter infections.174,175 6. Use an antiseptic-containing hub/connector cap/port
ii. Patients have limited venous access and a history of protector to cover connectors (Quality of Evidence:
recurrent CLABSI. MODERATE)202–208
iii. Patients are at heightened risk of severe sequelae from a a. The utility of routinely disinfecting hub connectors and ports
CLABSI (eg, patients with recently implanted intravas- when using antiseptic-containing hub/connector cap/port
cular devices such as a prosthetic heart valve or aortic protectors is unknown.
graft).
b. Monitor patients for adverse effects such as anaphylaxis.176
c. Many studies investigating antimicrobial-impregnated cath- Approaches that should not be considered a routine part of
eters were performed before infection preventive bundles CLABSI prevention
were routine. Whether such catheters have an impact on
CLABSI in such settings remains unknown. 1. Do not use antimicrobial prophylaxis for short-term or tun-
2. Use antimicrobial lock therapy for long-term CVCs (Quality neled catheter insertion or while catheters are in situ (Quality
of Evidence: HIGH)177–184 of Evidence: HIGH)209–213
a. Antibiotic and antiseptic locks are created by filling the a. Systemic antimicrobial prophylaxis is not recommended.
lumen of the catheter with a supratherapeutic concentration 2. Do not routinely replace CVCs or arterial catheters (Quality
of an antibiotic solution and leaving the solution in place of Evidence: HIGH)214
until the catheter hub is re-accessed. Such an approach a. Routine catheter replacement is not recommended.
can reduce the risk of CLABSI. The optimal antimicrobial
agent or combination of agents, their concentration, and Unresolved issues
duration of lock therapy are matters of ongoing research.
Due to concerns regarding the potential for the emergence 1. Routine use of needleless connectors as a CLABSI prevention
of resistance in exposed organisms, use antimicrobial locks strategy before an assessment of risks, benefits, and educa-
as a preventative strategy for the following: tion regarding proper use215–219
i. Patients with long-term hemodialysis catheters who a. Multiple devices are currently available but the optimal
have a history of recurrent CLABSI.185 design for preventing infections is unresolved. The original
ii. Prophylaxis for patients with limited venous access and a purpose of needleless connectors was to prevent needlestick
history of recurrent CLABSI. injuries during intermittent use. No data are available
iii. Patients who are at heightened risk of severe sequelae regarding their use with continuous infusions. Needle-free
from a CLABSI (eg, patients with recently implanted connectors with 3-way stopcocks may increase the risk of
intravascular devices such as a prosthetic heart valve catheter infections.220
or aortic graft). i. Use of silver-coated catheter connectors may be associated
b. To minimize systemic toxicity, aspirate rather than flush the with reduced intraluminal contamination in ex vivo cath-
antimicrobial lock solution after the dwell time has eters and CLABSI.221,222 Clinical evidence is limited
elapsed.186–189 The potential of adverse effects associated regarding the risk reduction with their routine use or
with ethanol locks should be carefully considered before use of other antimicrobial catheter connectors.
use.190,191 2. Surveillance of other types of catheters (eg, peripheral
3. Use recombinant tissue plasminogen activating factor arterial or venous catheters)11,21,22
(rt-PA) once weekly after hemodialysis in patients undergoing a. Peripheral arterial catheters, short-term peripheral venous
hemodialysis through a CVC (Quality of Evidence: HIGH)192 catheters and midline catheters are not included in most
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
8 Niccolò Buetti et al
surveillance systems although they are associated with risk of Section 5: Performance measures
bloodstream infection. Future surveillance systems should
Internal reporting
consider including bloodstream infections associated with
these types of catheters. These performance measures are intended to support internal hos-
b. If considering further infection prevention interventions pital quality improvement efforts229,230 and do not necessarily
due to concern for an increase in infections, hospitals address external reporting needs.
may want to consider extending their surveillance pro- The process and outcome measures suggested here are derived
grams to include all types of catheters used to gauge the size from published guidelines, other relevant literature, and the opin-
of the problem. ion of the authors. Report process and outcome measures to senior
3. Standard, nonantimicrobial transparent dressings and hospital leadership, nursing leadership, and clinicians who care for
CLABSI risk patients at risk for CLABSI.
a. A meta-analysis reported an association between CLABSI
and transparent dressing use; however, the source studies Process measures (Table 3)
for the meta-analysis reporting this association were of
low quality.223 1. Compliance with CVC insertion guidelines as documented
4. The impact of using chlorhexidine-based products on bacte- on an insertion checklist
rial resistance to chlorhexidine a. Assess compliance with the checklist in all hospital settings
a. Widespread use of chlorhexidine-based products (eg, use of where CVCs are inserted (eg, ICUs, ED, OR, radiology, gen-
chlorhexidine bathing, antisepsis, and dressings) may pro- eral patient care units) and assign HCP familiar with CVCs
mote reduced chlorhexidine susceptibility.224 However, test- to this task.
ing for chlorhexidine susceptibility is not standardized. The b. Documenting compliance using the insertion checklist
clinical impact of reduced chlorhexidine susceptibility is upholds accountability and compliance with the proper pro-
unknown. cedure steps and identifies gaps to be mitigated. The Institute
5. Sutureless securement for Healthcare Improvement (IHI) provides an example of a
a. The impact of sutureless securement devices in reducing central catheter checklist.231
CLABSI is unknown.225,226 c. Documentation of CVC insertion procedures in compliance
6. Impact of silver zeolite-impregnated umbilical catheters in with appropriate hand hygiene, use of maximal sterile
preterm infants (applicable in countries where it is approved barrier precautions, and use of chlorhexidine-based cutane-
for use in children)227 ous antisepsis of the insertion site:
a. One randomized study suggests that antimicrobial-impreg- i. Numerator: Number of CVC insertions that have doc-
nated umbilical catheters appear to be safe and effective in umented the use of all 3 interventions (hand hygiene,
NICU patients.228 maximal barrier precautions, and chlorhexidine-based
7. Necessity of mechanical disinfection of a catheter hub, nee- cutaneous antiseptic use) performed at the time of
dleless connector, and injection port before accessing the CVC insertion.
catheter when antiseptic-containing caps are being used. ii. Denominator: Number of all CVC insertions.
a. It is unknown whether the application and removal of an iii. Multiply by 100 so that the measure is expressed as a
antiseptic-containing cap provides the same benefit to percentage.
reducing risk of CLABSI as manual disinfection. Future 2. Compliance with documentation of daily assessment regard-
research is needed to determine if using such a cap will obvi- ing the need for continuing CVC access.
ate the need for manual disinfection before accessing a a. Measure the percentage of patients with a CVC where there
catheter. is documentation of daily assessment:
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 9
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
10 Niccolò Buetti et al
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 11
17. Rhee Y, Heung M, Chen B, Chenoweth CE. Central line-associated blood- 38. Raad I, Darouiche R, Dupuis J, et al. Central venous catheters coated
stream infections in non-ICU inpatient wards: a 2-year analysis. Infect with minocycline and rifampin for the prevention of catheter-related col-
Control Hosp Epidemiol 2015;36:424–430. onization and bloodstream infections. A randomized, double-blind trial.
18. Nguyen DB, Shugart A, Lines C, et al. National Healthcare Safety Network The Texas Medical Center Catheter Study Group. Ann Intern Med 1997;
(NHSN) Dialysis Event Surveillance Report for 2014. Clin J Am Soc 127:267–274.
Nephrol 2017;12:1139–1146. 39. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term silicone central
19. Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs contribute venous catheters impregnated with minocycline and rifampin decrease
to intraoperative bacterial transmission. Anesth Analg 2012;114: rates of catheter-related bloodstream infection in cancer patients: a pro-
1236–1248. spective randomized clinical trial. J Clin Oncol 2004;22:3163–171.
20. Zakhour R, Chaftari AM, Raad, II. Catheter-related infections in patients 40. Lorente L, Lecuona M, Jimenez A, et al. Efficiency of chlorhexidine-silver
with haematological malignancies: novel preventive and therapeutic strat- sulfadiazine-impregnated venous catheters at subclavian sites. Am J Infect
egies. Lancet Infect Dis 2016;16:e241–e250. Control 2015;43:711–714.
21. Mermel LA. Short-term peripheral venous catheter-related blood- 41. Richards B, Chaboyer W, Bladen T, Schluter PJ. Effect of central venous
stream infections: a systematic review. Clin Infect Dis 2017;65: catheter type on infections: a prospective clinical trial. J Hosp Infect
1757–1762. 2003;54:10–17.
22. O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source 42. Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidine-
of bloodstream infection: a systematic review and meta-analysis. Crit Care alcohol versus povidone iodine-alcohol, with and without skin scrubbing,
Med 2014;42:1334–1339. for prevention of intravascular-catheter-related infection (CLEAN): an
23. Almuneef MA, Memish ZA, Balkhy HH, Hijazi O, Cunningham G, open-label, multicentre, randomised, controlled, two-by-two factorial
Francis C. Rate, risk factors, and outcomes of catheter-related blood- trial. Lancet 2015;386:2069–2077.
stream infection in a paediatric intensive care unit in Saudi Arabia. 43. Yasuda H, Sanui M, Abe T, et al. Comparison of the efficacy of three top-
J Hosp Infect 2006;62:207–213. ical antiseptic solutions for the prevention of catheter colonization: a mul-
24. Alonso-Echanove J, Edwards JR, Richards MJ, et al. Effect of nurse staffing ticenter randomized controlled study. Crit Care 2017;21:320.
and antimicrobial-impregnated central venous catheters on the risk for 44. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated
bloodstream infections in intensive care units. Infect Control Hosp sponges and less frequent dressing changes for prevention of catheter-
Epidemiol 2003;24:916–925. related infections in critically ill adults: a randomized controlled trial.
25. Lorente L, Henry C, Martin MM, Jimenez A, Mora ML. Central venous JAMA 2009;301:1231–1241.
catheter–related infection in a prospective and observational study of 45. Timsit JF, Mimoz O, Mourvillier B, et al. Randomized controlled trial of
2,595 catheters. Crit Care 2005;9:R631–R635. chlorhexidine dressing and highly adhesive dressing for preventing cath-
26. Rey C, Alvarez F, De-La-Rua V, et al. Intervention to reduce catheter- eter-related infections in critically ill adults. Am J Respir Crit Care Med
related bloodstream infections in a pediatric intensive care unit. 2012;186:1272–1278.
Intensive Care Med 2011;37:678–685. 46. National Healthcare Safety Network. Bloodstream Infection event
27. Lorente L, Jimenez A, Naranjo C, et al. Higher incidence of catheter- (central line-associated bloodstream infection and non–central line-asso-
related bacteremia in jugular site with tracheostomy than in femoral site. ciated bloodstream infection. Centers for Disease Control and
Infect Control Hosp Epidemiol 2010;31:311–313. Prevention website. https://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_
28. Callister D, Limchaiyawat P, Eells SJ, Miller LG. Risk factors for central CLABScurrent.pdf. Updated January 2022. Accessed March 22, 2022.
line-associated bloodstream infections in the era of prevention bundles. 47. Grooth HJ, Timsit JF, Mermel L, et al. Validity of surrogate endpoints
Infect Control Hosp Epidemiol 2015;36:214–216. assessing central venous catheter-related infection: evidence from
29. Milstone AM, Reich NG, Advani S, et al. Catheter dwell time and CLABSIs individual- and study-level analyses. Clin Microbiol Infect 2020;26:
in neonates with PICCs: a multicenter cohort study. Pediatrics 2013;132: 563–571.
e1609–e1615. 48. Niedner MF. The harder you look, the more you find: catheter-associated
30. Templeton A, Schlegel M, Fleisch F, et al. Multilumen central venous cath- bloodstream infection surveillance variability. Am J Infect Control 2010;
eters increase risk for catheter-related bloodstream infection: prospective 38:585–595.
surveillance study. Infection 2008;36:322–327. 49. Tomlinson D, Mermel LA, Ethier MC, Matlow A, Gillmeister B, Sung L.
31. Pongruangporn M, Ajenjo MC, Russo AJ, et al. Patient- and device- Defining bloodstream infections related to central venous catheters
specific risk factors for peripherally inserted central venous catheter– in patients with cancer: a systematic review. Clin Infect Dis 2011;
related bloodstream infections. Infect Control Hosp Epidemiol 2013;34: 53:697–710.
184–189. 50. Mayer J, Greene T, Howell J, Ying J, Rubin MA, Trick WE, et al.
32. Chopra V, Ratz D, Kuhn L, Lopus T, Chenoweth C, Krein S. PICC- Agreement in classifying bloodstream infections among multiple
associated bloodstream infections: prevalence, patterns, and predictors. reviewers conducting surveillance. Clin Infect Dis 2012;55:364–370.
Am J Med 2014;127:319–328. 51. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the
33. Parienti JJ, Mongardon N, Megarbane B, et al. Intravascular complica- diagnosis and management of intravascular catheter-related infection:
tions of central venous catheterization by insertion site. N Engl J Med 2009 Update by the Infectious Diseases Society of America. Clin Infect
2015;373:1220–1229. Dis 2009;49:1–45.
34. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of 52. O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the preven-
understaffing in central venous catheter-associated bloodstream infec- tion of intravascular catheter-related infections. MMWR Recom Rep
tions. Infect Control Hosp Epidemiol 1996;17:150–158. 2002;51:1–29.
35. Cimiotti JP, Haas J, Saiman L, Larson EL. Impact of staffing on blood- 53. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention
stream infections in the neonatal intensive care unit. Arch Pediatr of intravascular catheter-related infections. Clin Infect Dis 2011;52:
Adolesc Med 2006;160:832–836. e162–e193.
36. Leistner R, Thurnagel S, Schwab F, Piening B, Gastmeier P, Geffers C. The 54. Masse J, Elkalioubie A, Blazejewski C, et al. Colonization pressure as a risk
impact of staffing on central venous catheter-associated bloodstream factor of ICU-acquired multidrug-resistant bacteria: a prospective obser-
infections in preterm neonates—results of nation-wide cohort study in vational study. Eur J Clin Microbiol Infect Dis 2017;36:797–805.
Germany. Antimicrob Resist Infect Control 2013;2:11. 55. Saint S. Chapter 16. Prevention of intravascular catheterassociated infec-
37. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and sub- tions. In: Making Health Care Safer. Agency for Healthcare Research and
clavian venous catheterization in critically ill patients: a randomized con- Quality website. www.ahrq.gov/clinic/ptsafety/. Published 2001. Accessed
trolled trial. JAMA 2001;286:700–707. March 22, 2022.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
12 Niccolò Buetti et al
56. Huang EY, Chen C, Abdullah F, et al. Strategies for the prevention of on incidence of infections acquired in intensive care. Lancet 2000;355:
central venous catheter infections: an American Pediatric Surgical 1864–1868.
Association Outcomes and Clinical Trials Committee systematic review. 76. Coopersmith CM, Rebmann TL, Zack JE, et al. Effect of an education pro-
J Pediatr Surg 2011;46:2000–2011. gram on decreasing catheter-related bloodstream infections in the surgical
57. OTILUS. Preventing central line-associated bloodstream infection: global intensive care unit. Crit Care Med 2002;30:59–64.
challenges, a global perspective. The Joint Commission website. https:// 77. Warren DK, Zack JE, Cox MJ, Cohen MM, Fraser VJ. An educational
www.jointcommission.org/-/media/tjc/documents/resources/hai/clabsi_ intervention to prevent catheter-associated bloodstream infections
monographpdf.pdf. Updated May 2012. Accessed March 22, 2022. in a nonteaching, community medical center. Crit Care Med 2003;31:
58. Barnes S, Olmsted RN, Monsees E, et al. Guide to preventing central 1959–1963.
line-associated bloodstream infections. Association for Professionals in 78. Warren DK, Zack JE, Mayfield JL, et al. The effect of an education pro-
Infection Control and Epidemiology (APIC) website. https://apic.org/ gram on the incidence of central venous catheter–associated bloodstream
Resource_/TinyMceFileManager/2015/APIC_CLABSI_WEB.pdf. Published infection in a medical ICU. Chest 2004;126:1612–1618.
2015. Accessed March 22, 2022. 79. Lobo RD, Levin AS, Oliveira MS, et al. Evaluation of interventions to
59. Gorski LA, Hadaway L, Hagle ME, et al. Infusion Therapy Standards of reduce catheter-associated bloodstream infection: continuous tailored
Practice, Eighth Edition. J Infusion Nurs 2021;44:S1–S224. education versus one basic lecture. Am J Infect Control 2010;38:440–448.
60. Bloodstream infection event (central line-associated bloodstream infec- 80. Cherry MG, Brown JM, Neal T, Ben Shaw N. What features of educational
tion and non–central line-associated bloodstream infection). Centers interventions lead to competence in aseptic insertion and maintenance of
for Disease Control and Prevention website. https://www.cdc.gov/nhsn/ CV catheters in acute care? Med Teach 2010;32:198–218.
pdfs/pscmanual/4psc_clabscurrent.pdf. Published 2019. Accessed March 81. Joint Commission Resources. Assessing Hospital Staff Competence.
22, 2022. Oakbrook Terrace, IL: Joint Commission International; 2007.
61. Tejedor SC, Garrett G, Jacob JT, et al. Electronic documentation of central 82. Barsuk JH, Cohen ER, Potts S, et al. Dissemination of a simulation-based
venous catheter days: validation is essential. Infect Control Hosp Epidemiol mastery learning intervention reduces central line-associated bloodstream
2013;34:900–907. infections. BMJ Qual Saf 2014;23:749–756.
62. Woeltje KF, McMullen KM, Butler AM, Goris AJ, Doherty JA. Electronic 83. Cartier V, Inan C, Zingg W, Delhumeau C, Walder B, Savoldelli GL.
surveillance for healthcare-associated central line-associated bloodstream Simulation-based medical education training improves short and long-
infections outside the intensive care unit. Infect Control Hosp Epidemiol term competency in, and knowledge of central venous catheter insertion:
2011;32:1086–1090. a before and after intervention study. Eur J Anaesthesiol 2016;33:568–574.
63. Pronovost PJ, Watson SR, Goeschel CA, Hyzy RC, Berenholtz SM. 84. Khouli H, Jahnes K, Shapiro J, et al. Performance of medical residents in
Sustaining reductions in central line-associated bloodstream infections sterile techniques during central vein catheterization: randomized trial of
in michigan intensive care units: a 10-year analysis. Am J Med Qual efficacy of simulation-based training. Chest 2011;139:80–87.
2016;31:197–202. 85. Ma IW, Brindle ME, Ronksley PE, Lorenzetti DL, Sauve RS, Ghali WA.
64. Centers for Disease Control and Prevention. Vital signs: central line-asso- Use of simulation-based education to improve outcomes of central venous
ciated bloodstream infections—United States, 2001, 2008, and 2009. catheterization: a systematic review and meta-analysis. Acad Med 2011;
Morb Mortal Wkly Rep 2011;60:243–248. 86:1137–1147.
65. Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream 86. Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein
infections through the use of a central venous line bundle: epidemiologic RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated
and economic consequences. Am J Infect Control 2011;39:640–646. bloodstream infections in medical intensive care unit patients. Arch Intern
66. Halton KA, Cook D, Paterson DL, Safdar N, Graves N. Cost-effectiveness Med 2007;167:2073–2079.
of a central venous catheter care bundle. PLoS One 2010;5:e12815. 87. Milstone AM, Elward A, Song X, et al. Daily chlorhexidine bathing to
67. Tang HJ, Lin HL, Lin YH, Leung PO, Chuang YC, Lai CC. The impact of reduce bacteraemia in critically ill children: a multicentre, cluster-rando-
central line insertion bundle on central line-associated bloodstream infec- mised, crossover trial. Lancet 2013;381:1099–1106.
tion. BMC Infect Dis 2014;14:356. 88. Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine
68. Ista E, van der Hoven B, Kornelisse RF, et al. Effectiveness of insertion and bathing on hospital-acquired infection. N Engl J Med 2013;368:533–542.
maintenance bundles to prevent central line-associated bloodstream 89. Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and
infections in critically ill patients of all ages: a systematic review and healthcare-associated infections: a randomized clinical trial. JAMA
meta-analysis. Lancet Infect Dis 2016;16:724–734. 2015;313:369–378.
69. Richter JP, McAlearney AS. Targeted implementation of the 90. Afonso E, Blot K, Blot S. Prevention of hospital-acquired bloodstream
Comprehensive Unit-Based Safety Program through an assessment of infections through chlorhexidine gluconate-impregnated washcloth bath-
safety culture to minimize central line-associated bloodstream infections. ing in intensive care units: a systematic review and meta-analysis of rand-
Health Care Manage Rev 2018;43:42–49. omised crossover trials. Euro Surveill 2016;21:30400.
70. Furuya EY, Dick A, Perencevich EN, Pogorzelska M, Goldmann D, Stone 91. Munoz-Price LS, Hota B, Stemer A, Weinstein RA. Prevention of blood-
PW. Central-line bundle implementation in US intensive care units and stream infections by use of daily chlorhexidine baths for patients at a
impact on bloodstream infections. PLoS One 2011;6:e15452. long-term acute-care hospital. Infect Control Hosp Epidemiol 2009;30:
71. Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line- 1031–1035.
associated bloodstream infections by implementation of a postinsertion 92. Medina A, Serratt T, Pelter M, Brancamp T. Decreasing central line-
care bundle. Am J Infect Control 2010;38:430–433. associated bloodstream infections in the non-ICU population. J Nurs
72. Miller MR, Niedner MF, Huskins WC, et al. Reducing PICU central line- Care Qual 2014;29:133–140.
associated bloodstream infections: 3-year results. Pediatrics 2011;128: 93. Huang SS, Septimus E, Kleinman K, et al. Chlorhexidine versus routine
e1077–e1083. bathing to prevent multidrug-resistant organisms and all-cause blood-
73. O’Neil C, Ball K, Wood H, et al. A central-line care maintenance bundle stream infections in general medical and surgical units (ABATE
for the prevention of central line-associated bloodstream infection in Infection trial): a cluster-randomised trial. Lancet 2019;393:1205–1215.
non–intensive care unit settings. Infect Control Hosp Epidemiol 2016;37: 94. Tien KL, Sheng WH, Shieh SC, et al. Chlorhexidine bathing to prevent
692–698. central line-associated bloodstream infections in hematology units: a pro-
74. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in- spective, controlled cohort study. Clin Infect Dis 2020;71:556–563.
training can decrease the risk for vascular catheter infection. Ann 95. Zerr DM, Milstone AM, Dvorak CC, et al. Chlorhexidine gluconate bath-
Intern Med 2000;132:641–648. ing in children with cancer or those undergoing hematopoietic stem cell
75. Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, transplantation: a double-blinded randomized controlled trial from the
Pittet D. Impact of a prevention strategy targeted at vascular-access care Children’s Oncology Group. Cancer 2020;127:56–66.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 13
96. Milstone AM, Bamford P, Aucott SW, Tang N, White KR, Bearer CF. compared with central venous catheters in adults: a systematic review
Chlorhexidine inhibits L1 cell adhesion molecule-mediated neurite out- and meta-analysis. Infect Control Hosp Epidemiol 2013;34:908–918.
growth in vitro. Pediatr Res 2014;75:8–13. 115. Ajenjo MC, Morley JC, Russo AJ, et al. Peripherally inserted central
97. Kieran EA, O’Sullivan A, Miletin J, Twomey AR, Knowles SJ, O’Donnell venous catheter-associated bloodstream infections in hospitalized adult
CPF. 2% chlorhexidine-70% isopropyl alcohol versus 10% povidone- patients. Infect Control Hosp Epidemiol 2011;32:125–130.
iodine for insertion site cleaning before central-line insertion in preterm 116. Swaminathan L, Flanders S, Horowitz J, Zhang Q, O’Malley M, Chopra V.
infants: a randomised trial. Arch Dis Child Fetal Neonatal Ed 2018;103: Safety and outcomes of midline catheters vs peripherally inserted central
F101–F106. catheters for patients with short-term indications: a multicenter study.
98. Neri I, Ravaioli GM, Faldella G, Capretti MG, Arcuri S, Patrizi A. JAMA Intern Med 2022;182:50–58.
Chlorhexidine-induced chemical burns in very-low-birthweight infants. 117. Mushtaq A, Navalkele B, Kaur M, et al. Comparison of complications in
J Pediatr 2017;191:262–265. midlines versus central venous catheters: Are midlines safer than central
99. Chandonnet CJ, Toole C, Young V, et al. Safety of biweekly chlorhexidine venous lines? Am J Infect Control 2018;46:788–792.
gluconate bathing in infants 36 to 48 weeks’ postmenstrual age. Am J Crit 118. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-
Care 2019;28:451–459. related bloodstream infections in the intensive care unit. Crit Care Med
100. Kampf G. Acquired resistance to chlorhexidine—is it time to establish an 2004;32:2014–2020.
‘antiseptic stewardship’ initiative? J Hosp Infect 2016;94:213–227. 119. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-
101. Wichmann D, Belmar Campos CE, et al. Efficacy of introducing a check- guided catheterisation of the internal jugular vein: a prospective compari-
list to reduce central venous line associated bloodstream infections in the son with the landmark technique in critical care patients. Crit Care
ICU caring for adult patients. BMC Infect Dis 2018;18:267. 2006;10:R162.
102. Elgohari S, Wilson J, Saei A, Sheridan EA, Lamagni T. Impact of 120. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guid-
national policies on the microbial aetiology of surgical site infections in ance versus anatomical landmarks for internal jugular vein catheteriza-
acute NHS hospitals in England: analysis of trends between 2000 and tion. Cochrane Database Syst Rev 2015;1:CD006962.
2013 using multicentre prospective cohort data. Epidemiol Infect 2017; 121. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for
145:957–969. central venous cannulation: meta-analysis. BMJ 2003;327:361.
103. Yilmaz G, Koksal I, Aydin K, Caylan R, Sucu N, Aksoy F. Risk factors of 122. Buetti N, Mimoz O, Mermel L, et al. Ultrasound guidance and risk for
catheter-related bloodstream infections in parenteral nutrition catheteri- central venous catheter-related infections in the ICU. A post hoc analysis
zation. J Parenter Enteral Nutr 2007;31:284–287. of individual data of three multicentric randomized trials. Clin Infect Dis
104. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. 2021;73(5):e1054–e1061.
Recommendations of the Healthcare Infection Control Practices Advisory 123. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis
Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task and epidemiology of catheter-related infection with pulmonary artery
Force. Society for Healthcare Epidemiology of America/Association for Swan-Ganz catheters: a prospective study utilizing molecular subtyping.
Professionals in Infection Control/Infectious Diseases Society of America. Am J Med 1991;91:197S–205S.
MMWR Recomm Rep 2002;51:1–45. 124. Raad, II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous cath-
105. Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection eter-related infections by using maximal sterile barrier precautions during
with improved hand hygiene in intensive care units of a tertiary-care hos- insertion. Infect Control Hosp Epidemiol 1994;15:231–238.
pital in Argentina. Am J Infect Control 2005;33:392–397. 125. Hu KK, Lipsky BA, Veenstra DL, Saint S. Using maximal sterile barriers to
106. Capretti MG, Sandri F, Tridapalli E, Galletti S, Petracci E, Faldella G. prevent central venous catheter-related infection: a systematic evidence-
Impact of a standardized hand hygiene program on the incidence of noso- based review. Am J Infect Control 2004;32:142–146.
comial infection in very low birth weight infants. Am J Infect Control 126. Ishikawa Y, Kiyama T, Haga Y, et al. Maximal sterile barrier precautions
2008;36:430–435. do not reduce catheter-related bloodstream infections in general surgery
107. van der Kooi T, Sax H, Pittet D, et al. Prevention of hospital infections by units: a multi-institutional randomized controlled trial. Ann Surg
intervention and training (PROHIBIT): results of a pan-European cluster- 2010;251:620–623.
randomized multicentre study to reduce central venous catheter-related 127. Burrell AR, McLaws ML, Murgo M, Calabria E, Pantle AC, Herkes R.
bloodstream infections. Intensive Care Med 2018;44:48–60. Aseptic insertion of central venous lines to reduce bacteraemia. Med J
108. Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulenti D, Haidich Aust 2011;194:583–587.
AB. Cumulative evidence of randomized controlled and observational 128. Lee DH, Jung KY, Choi YH. Use of maximal sterile barrier precautions
studies on catheter-related infection risk of central venous catheter inser- and/or antimicrobial-coated catheters to reduce the risk of central venous
tion site in ICU patients: a pairwise and network meta-analysis. Crit Care catheter-related bloodstream infection. Infect Control Hosp Epidemiol
Med 2017;45:e437–e448. 2008;29:947–950.
109. Parienti JJ. Catheter-related bloodstream infection in jugular versus sub- 129. Garland JS, Buck RK, Maloney P, et al. Comparison of 10% povidone-
clavian central catheterization. Crit Care Med 2017;45:e734–e735. iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral
110. Timsit JF, Bouadma L, Mimoz O, et al. Jugular versus femoral short-term intravenous catheter colonization in neonates: a prospective trial. Pediatr
catheterization and risk of infection in intensive care unit patients. Causal Infect Dis J 1995;14:510–516.
analysis of two randomized trials. Am J Respir Crit Care Med 2013; 130. Humar A, Ostromecki A, Direnfeld J, et al. Prospective randomized trial
188:1232–1239. of 10% povidone-iodine versus 0.5% tincture of chlorhexidine as cutane-
111. Ullman AJ, Bernstein SJ, Brown E, et al. The Michigan Appropriateness ous antisepsis for prevention of central venous catheter infection. Clin
Guide for Intravenous Catheters in Pediatrics: miniMAGIC. Pediatrics Infect Dis 2000;31:1001–1007.
2020;145:S269–S84. 131. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine com-
112. Chau A, Hernandez JA, Pimpalwar S, Ashton D, Kukreja K. Equivalent pared with povidone-iodine solution for vascular catheter-site care: a
success and complication rates of tunneled common femoral venous cath- meta-analysis. Ann Intern Med 2002;136:792–801.
eter placed in the interventional suite vs. at patient bedside. Pediatr Radiol 132. Lai NM, Lai NA, O’Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin
2018;48:889–894. antisepsis for reducing central venous catheter-related infections.
113. Gaballah M, Krishnamurthy G, Berman JI, et al. Lower extremity vascular Cochrane Database Syst Rev 2016;7:CD010140.
access in neonates and infants: a single institutional experience. J Vasc 133. Pages J, Hazera P, Megarbane B, et al. Comparison of alcoholic
Interv Radiol 2015;26:1660–1668. chlorhexidine and povidone-iodine cutaneous antiseptics for the preven-
114. Chopra V, O’Horo JC, Rogers MA, Maki DG, Safdar N. The risk of blood- tion of central venous catheter-related infection: a cohort and quasi-
stream infection associated with peripherally inserted central catheters experimental multicenter study. Intensive Care Med 2016;42:1418–1426.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
14 Niccolò Buetti et al
134. Masuyama T, Yasuda H, Sanui M, Lefor AK. Effect of skin antiseptic sol- 153. Munoz-Price LS, Dezfulian C, Wyckoff M, et al. Effectiveness of stepwise
utions on the incidence of catheter-related bloodstream infection: a interventions targeted to decrease central catheter-associated bloodstream
systematic review and network meta-analysis. J Hosp Infect 2021;110: infections. Crit Care Med 2012;40:1464–1469.
156–164. 154. Soothill JS, Bravery K, Ho A, Macqueen S, Collins J, Lock P. A fall in
135. Garland JS, Alex CP, Mueller CD, et al. A randomized trial comparing bloodstream infections followed a change to 2% chlorhexidine in 70% iso-
povidone-iodine to a chlorhexidine gluconate-impregnated dressing for propanol for catheter connection antisepsis: a pediatric single center
prevention of central venous catheter infections in neonates. Pediatrics before/after study on a hemopoietic stem cell transplant ward. Am J
2001;107:1431–1436. Infect Control 2009;37:626–630.
136. Levy I, Katz J, Solter E, et al. Chlorhexidine-impregnated dressing for pre- 155. Hong H, Morrow DF, Sandora TJ, Priebe GP. Disinfection of needleless
vention of colonization of central venous catheters in infants and children: connectors with chlorhexidine-alcohol provides long-lasting residual dis-
a randomized controlled study. Pediatr Infect Dis J 2005;24:676–679. infectant activity. Am J Infect Control 2013;41(8):e77–e79.
137. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent 156. Rupp ME, Yu S, Huerta T, et al. Adequate disinfection of a split-septum
vascular and epidural catheter colonization and infection: a meta-analysis. needleless intravascular connector with a 5-second alcohol scrub. Infect
J Antimicrob Chemother 2006;58:281–287. Control Hosp Epidemiol 2012;33:661–665.
138. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated 157. Simmons S, Bryson C, Porter S. “Scrub the hub”: cleaning duration and
sponges and less frequent dressing changes for prevention of catheter- reduction in bacterial load on central venous catheters. Crit Care Nurs Q
related infections in critically ill adults: a randomized controlled trial. 2011;34:31–35.
JAMA 2009;301:1231–1241. 158. Hankins R, Majorant OD, Rupp ME, et al. Microbial colonization of intra-
139. Ruschulte H, Franke M, Gastmeier P, et al. Prevention of central venous vascular catheter connectors in hospitalized patients. Am J Infect Control
catheter related infections with chlorhexidine gluconate impregnated 2019;47:1489–1492.
wound dressings: a randomized controlled trial. Ann Hematol 2009;88: 159. van der Kooi T, Sax H, Pittet D, et al. Prevention of hospital infections by
267–272. intervention and training (PROHIBIT): results of a pan-European cluster-
140. Camins BC, Richmond AM, Dyer KL, et al. A crossover intervention trial randomized multicentre study to reduce central venous catheter-related
evaluating the efficacy of a chlorhexidine-impregnated sponge in reducing bloodstream infections. Intensive Care Med 2018;44:48–60.
catheter-related bloodstream infections among patients undergoing 160. Rotz S, Sopirala MM. Assessment beyond central-line bundle: audits for
hemodialysis. Infect Control Hosp Epidemiol 2010;31:1118–1123. line necessity in infected central lines in a surgical intensive care unit. Am J
141. Ullman AJ, Cooke ML, Mitchell M, et al. Dressing and securement for Infect Control 2012;40:88–89.
central venous access devices (CVADs): a Cochrane systematic review. 161. Cload B, Day AG, Ilan R. Evaluation of unnecessary central venous cath-
Int J Nurs Stud 2016;59:177–196. eters in critically ill patients: a prospective observational study. Can J
142. Puig-Asensio M, Marra AR, Childs CA, Kukla ME, Perencevich EN, Anaesth 2010;57:830–835.
Schweizer ML. Effectiveness of chlorhexidine dressings to prevent cath- 162. Seguin P, Laviolle B, Isslame S, Coue A, Malledant Y. Effectiveness of
eter-related bloodstream infections. Does one size fit all? A systematic lit- simple daily sensitization of physicians to the duration of central
erature review and meta-analysis. Infect Control Hosp Epidemiol 2020; venous and urinary tract catheterization. Intensive Care Med 2010;36:
41:1388–1395. 1202–1206.
143. Righetti M, Palmieri N, Bracchi O, et al. Tegaderm CHG dressing signifi- 163. Faruqi A, Medefindt J, Dutta G, Philip SA, Tompkins D, Carey J. Effect of
cantly improves catheter-related infection rate in hemodialysis patients. J a multidisciplinary intervention on central-line utilization in an acute-
Vasc Access 2016;17:417–422. care hospital. Am J Infect Control 2012;40:e211–e115.
144. Apata IW, Hanfelt J, Bailey JL, Niyyar VD. Chlorhexidine-impregnated 164. Rickard CM, Marsh NM, Larsen EN, et al. Effect of infusion set replace-
transparent dressings decrease catheter-related infections in hemodialy- ment intervals on catheter-related bloodstream infections (RSVP): a
sis patients: a quality improvement project. J Vasc Access 2017;18: randomised, controlled, equivalence (central venous access device)-
103–108. non-inferiority (peripheral arterial catheter) trial. Lancet 2021;397:
145. Maki DG, Stolz SS, Wheeler S, Mermel LA. A prospective, randomized 1447–1458.
trial of gauze and two polyurethane dressings for site care of pulmonary 165. Gastmeier P, Geffers C, Brandt C, et al. Effectiveness of a nationwide
artery catheters: implications for catheter management. Crit Care Med nosocomial infection surveillance system for reducing nosocomial infec-
1994;22:1729–1737. tions. J Hosp Infect 2006;64:16–22.
146. Rasero L, Degl’Innocenti M, Mocali M. Comparison of two different time 166. Zingg W, Sax H, Inan C, et al. Hospital-wide surveillance of catheter-
interval protocols for central venous catheter dressing in bone marrow related bloodstream infection: from the expected to the unexpected.
transplant patients:results of a randomized, multicenter study. J Hosp Infect 2009;73:41–46.
Haematologica 2000;85:275–279. 167. Sunkesula VCK, Kundrapu S, Knighton S, Cadnum JL, Donskey CJ. A
147. Timsit JF, Bouadma L, Ruckly S, et al. Dressing disruption is a major risk Randomized trial to determine the impact of an educational patient
factor for catheter-related infections. Crit Care Med 2012;40:1707–1714. hand-hygiene intervention on contamination of hospitalized patient’s
148. Gavin NC, Webster J, Chan RJ, Rickard CM. Frequency of dressing hands with healthcare-associated pathogens. Infect Control Hosp
changes for central venous access devices on catheter-related infections. Epidemiol 2017;38:595–597.
Cochrane Database Syst Rev 2016;2:CD009213. 168. Lin MY, Hota B, Khan YM, et al. Quality of traditional surveillance for
149. Short KL. Implementation of a central-line maintenance bundle for dis- public reporting of nosocomial bloodstream infection rates. JAMA
lodgement and infection prevention in the NICU. Adv Neonatal Care 2010;304:2035–2041.
2019;19:145–150. 169. Wang H, Tong H, Liu H, et al. Effectiveness of antimicrobial-coated cen-
150. Salzman MB, Isenberg HD, Rubin LG. Use of disinfectants to reduce tral venous catheters for preventing catheter-related bloodstream infec-
microbial contamination of hubs of vascular catheters. J Clin Microbiol tions with the implementation of bundles: a systematic review and
1993;31:475–479. network meta-analysis. Ann Intensive Care 2018;8:71.
151. Luebke MA, Arduino MJ, Duda DL, et al. Comparison of the microbial 170. Chong HY, Lai NM, Apisarnthanarak A, Chaiyakunapruk N.
barrier properties of a needleless and a conventional needle-based intra- Comparative efficacy of antimicrobial central venous catheters in reduc-
venous access system. Am J Infect Control 1998;26:437–441. ing catheter-related bloodstream infections in adults: abridged cochrane
152. Casey AL, Worthington T, Lambert PA, Quinn D, Faroqui MH, Elliott TS. systematic review and network meta-analysis. Clin Infect Dis 2017;64:
A randomized, prospective clinical trial to assess the potential infection S131–S140.
risk associated with the PosiFlow needleless connector. J Hosp Infect 171. Novikov A, Lam MY, Mermel LA, Casey AL, Elliott TS, Nightingale P.
2003;54:288–293. Impact of catheter antimicrobial coating on species-specific risk of
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 15
catheter colonization: a meta-analysis. Antimicrob Resist Infect Control 190. Mermel LA, Alang N. Adverse effects associated with ethanol catheter lock
2012;1:40. solutions: a systematic review. J Antimicrob Chemother 2014;69:
172. Gilbert RE, Mok Q, Dwan K, et al. Impregnated central venous catheters 2611–2619.
for prevention of bloodstream infection in children (the CATCH trial): a 191. Wolf J, Connell TG, Allison KJ, et al. Treatment and secondary prophy-
randomised controlled trial. Lancet 2016;387:1732–1742. laxis with ethanol lock therapy for central line-associated bloodstream
173. Lai L, Yue X. Efficacy of antimicrobial-impregnated catheters for preven- infection in paediatric cancer: a randomised, double-blind, controlled
tion of bloodstream infections in pediatric patients: a meta-analysis. Front trial. Lancet Infect Dis 2018;18:854–863.
Pediatr 2021;9:632308. 192. Hemmelgarn BR, Moist LM, Lok CE, et al. Prevention of dialysis catheter
174. Cherry-Bukowiec JR, Denchev K, Dickinson S, et al. Prevention of cath- malfunction with recombinant tissue plasminogen activator. N Engl J Med
eter-related blood stream infection: back to basics? Surg Infect (Larchmt) 2011;364:303–312.
2011;12:27–32. 193. Miller JM, Goetz AM, Squier C, Muder RR. Reduction in nosocomial
175. Ullman AJ, Paterson RS, Schults JA, et al. Do antimicrobial and antith- intravenous device-related bacteremias after institution of an intravenous
rombogenic peripherally inserted central catheter (PICC) materials pre- therapy team. J Intravenous Nurs 1996;19:103–106.
vent catheter complications? An analysis of 42,562 hospitalized medical 194. Taylor T, Massaro A, Williams L, et al. Effect of a dedicated percutane-
patients. Infect Control Hosp Epidemiol 2021. doi: 10.1017/ice.2021.141. ously inserted central catheter team on neonatal catheter-related blood-
176. Guleri A, Kumar A, Morgan RJ, Hartley M, Roberts DH. Anaphylaxis to stream infection. Adv Neonatal Care 2011;11:122–128.
chlorhexidine-coated central venous catheters: a case series and review of 195. Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral
the literature. Surg Infect (Larchmt) 2012;13:171–174. venous catheter complications with an intravenous therapy team: a ran-
177. Carratala J, Niubo J, Fernandez-Sevilla A, et al. Randomized, double-blind domized controlled trial. Arch Intern Med 1998;158:473–477.
trial of an antibiotic-lock technique for prevention of gram-positive cen- 196. Carr PJ, Higgins NS, Cooke ML, Mihala G, Rickard CM. Vascular access
tral venous catheter-related infection in neutropenic patients with cancer. specialist teams for device insertion and prevention of failure. Cochrane
Antimicrob Agents Chemother 1999;43:2200–2204. Database Syst Rev 2018;3:CD011429.
178. Henrickson KJ, Axtell RA, Hoover SM, et al. Prevention of central venous 197. Levin A, Mason AJ, Jindal KK, Fong IW, Goldstein MB. Prevention of
catheter-related infections and thrombotic events in immunocompro- hemodialysis subclavian vein catheter infections by topical povidone-
mised children by the use of vancomycin/ciprofloxacin/heparin flush sol- iodine. Kidney Int 1991;40:934–938.
ution: a randomized, multicenter, double-blind trial. J Clin Oncol 198. Riu S, Ruiz CG, Martinez-Vea A, Peralta C, Oliver JA. Spontaneous rup-
2000;18:1269–1278. ture of polyurethane peritoneal catheter: a possible deleterious effect of
179. Safdar N, Maki DG. Use of vancomycin-containing lock or flush solutions mupirocin ointment. Nephrol Dialysis Transpl 1998;13:1870–1871.
for prevention of bloodstream infection associated with central venous 199. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW, Conly J.
access devices: a meta-analysis of prospective, randomized trials. Clin Hemodialysis infection prevention with polysporin ointment. J Am Soc
Infect Dis 2006;43:474–484. Nephrol 2003;14:169–179.
180. Labriola L, Crott R, Jadoul M. Preventing haemodialysis catheter-related 200. Battistella M, Bhola C, Lok CE. Long-term follow-up of the Hemodialysis
bacteraemia with an antimicrobial lock solution: a meta-analysis of Infection Prevention with Polysporin Ointment (HIPPO) study: a quality
prospective randomized trials. Nephrol Dialysis Transpl 2008;23: improvement report. Am J Kidney Dis 2011;57:432–441.
1666–1672. 201. James MT, Conley J, Tonelli M, Manns BJ, MacRae J, Hemmelgarn BR.
181. Snaterse M, Ruger W, Scholte Op Reimer WJ, Lucas C. Antibiotic-based Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter-
catheter lock solutions for prevention of catheter-related bloodstream related infections. Ann Intern Med 2008;148:596–605.
infection: a systematic review of randomised controlled trials. J Hosp 202. Oto J, Imanaka H, Konno M, Nakataki E, Nishimura M. A prospective
Infect 2010;75:1–11. clinical trial on prevention of catheter contamination using the hub pro-
182. Oliveira C, Nasr A, Brindle M, Wales PW. Ethanol locks to prevent tection cap for needleless injection device. Am J Infect Control 2011;39:
catheter-related bloodstream infections in parenteral nutrition: a meta- 309–313.
analysis. Pediatrics 2012;129:318–329. 203. Sweet MA, Cumpston A, Briggs F, Craig M, Hamadani M. Impact of alco-
183. Zacharioudakis IM, Zervou FN, Arvanitis M, Ziakas PD, Mermel LA, hol-impregnated port protectors and needleless neutral pressure connec-
Mylonakis E. Antimicrobial lock solutions as a method to prevent central tors on central line-associated bloodstream infections and contamination
line-associated bloodstream infections: a meta-analysis of randomized of blood cultures in an inpatient oncology unit. Am J Infect Control
controlled trials. Clin Infect Dis 2014;59:1741–1749. 2012;40:931–934.
184. Sheng KX, Zhang P, Li JW, et al. Comparative efficacy and safety of lock 204. Wright MO, Tropp J, Schora DM, et al. Continuous passive disinfection of
solutions for the prevention of catheter-related complications including catheter hubs prevents contamination and bloodstream infection. Am J
infectious and bleeding events in adult haemodialysis patients: a system- Infect Control 2013;41:33–38.
atic review and network meta-analysis. Clin Microbiol Infect 2020;26: 205. Loftus RW, Brindeiro BS, Kispert DP, et al. Reduction in intraoperative
545–552. bacterial contamination of peripheral intravenous tubing through the
185. Arechabala MC, Catoni MI, Claro JC, et al. Antimicrobial lock solutions use of a passive catheter care system. Anesth Analg 2012;115:
for preventing catheter-related infections in haemodialysis. Cochrane 1315–1323.
Database Syst Rev 2018;4:CD010597. 206. Hymes JL, Mooney A, Van Zandt C, Lynch L, Ziebol R, Killion D. Dialysis
186. Opilla MT, Kirby DF, Edmond MB. Use of ethanol lock therapy to reduce catheter-related bloodstream infections: a cluster-randomized trial of
the incidence of catheter-related bloodstream infections in home paren- the ClearGuard HD antimicrobial barrier cap. Am J Kidney Dis 2017;69:
teral nutrition patients. J Parenter Enteral Nutr 2007;31:302–305. 220–227.
187. Slobbe L, Doorduijn JK, Lugtenburg PJ, et al. Prevention of catheter- 207. Brunelli SM, Van Wyck DB, Njord L, Ziebol RJ, Lynch LE, Killion DP.
related bacteremia with a daily ethanol lock in patients with tunnelled Cluster-randomized trial of devices to prevent catheter-related blood-
catheters: a randomized, placebo-controlled trial. PLoS One 2010;5: stream infection. J Am Soc Nephrol 2018;29:1336–1343.
e10840. 208. Flynn JM, Larsen EN, Keogh S, Ullman AJ, Rickard CM. Methods for
188. Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock therapy for the microbial needleless connector decontamination: a systematic review
prevention of central venous access device infections in pediatric patients and meta-analysis. Am J Infect Control 2019;47:956–962.
with intestinal failure. J Parenter Enteral Nutr 2011;35:67–73. 209. McKee R, Dunsmuir R, Whitby M, Garden OJ. Does antibiotic
189. Heng AE, Abdelkader MH, Diaconita M, et al. Impact of short term use of prophylaxis at the time of catheter insertion reduce the incidence of
interdialytic 60% ethanol lock solution on tunneled silicone catheter dys- catheter-related sepsis in intravenous nutrition? J Hosp Infect 1985;
function. Clin Nephrol 2011;75:534–541. 6:419–425.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
16 Niccolò Buetti et al
210. Ranson MR, Oppenheim BA, Jackson A, Kamthan AG, Scarffe JH. 229. Bizzarro MJ, Sabo B, Noonan M, et al. A quality improvement initiative to
Double-blind placebo controlled study of vancomycin prophylaxis for reduce central line-associated bloodstream infections in a neonatal inten-
central venous catheter insertion in cancer patients. J Hosp Infect sive care unit. Infect Control Hosp Epidemiol 2010;31:241–248.
1990;15:95–102. 230. Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous mea-
211. Sandoe JA, Kumar B, Stoddart B, et al. Effect of extended perioperative surement, and collaboration to eliminate central catheter-associated
antibiotic prophylaxis on intravascular catheter colonization and infec- bloodstream infections. Crit Care Med 2010;38:S292–S298.
tion in cardiothoracic surgery patients. J Antimicrob Chemother 2003;52: 231. Central-line insertion checklist: Virginia Mason Medical Center example.
877–879. Institute for Healthcare Improvement website. http://www.ihi.org/resources/
212. Karanlik H, Kurul S, Saip P, et al. The role of antibiotic prophylaxis in Pages/Tools/CentralLineInsertionChecklist.aspx. Accessed March 22, 2022.
totally implantable venous access device placement: results of a single- 232. Fakih MG, Jones K, Rey JE, et al. Sustained improvements in peripheral
center prospective randomized trial. Am J Surg 2011;202:10–15. venous catheter care in non-intensive care units: a quasi-experimental
213. van de Wetering MD, van Woensel JB, Lawrie TA. Prophylactic antibiot- controlled study of education and feedback. Infect Control Hosp
ics for preventing gram-positive infections associated with long-term cen- Epidemiol 2012;33:449–455.
tral venous catheters in oncology patients. Cochrane Database Syst Rev 233. Fakih MG, Jones K, Rey JE, et al. Peripheral venous catheter care in the
2013:CD003295. emergency department: education and feedback lead to marked improve-
214. Cook D, Randolph A, Kernerman P, et al. Central venous catheter replace- ments. Am J Infect Control 2013;41:531–536.
ment strategies: a systematic review of the literature. Crit Care Med 234. Fakih MG, Gould CV, Trautner BW, et al. Beyond infection: device uti-
1997;25:1417–1424. lization ratio as a performance measure for urinary catheter harm. Infect
215. Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related Control Hosp Epidemiol 2016;37:327–333.
bloodstream infection rates after the introduction of a new mechanical 235. Widmer AF, Nettleman M, Flint K, Wenzel RP. The clinical impact of
valve intravenous access port. Infect Control Hosp Epidemiol 2006; culturing central venous catheters. A prospective study. Arch Intern
27:67–70. Med 1992;152:1299–1302.
216. Field K, McFarlane C, Cheng AC, et al. Incidence of catheter-related 236. Raad, II, Baba M, Bodey GP. Diagnosis of catheter-related infections: the
bloodstream infection among patients with a needleless, mechanical role of surveillance and targeted quantitative skin cultures. Clin Infect Dis
valve-based intravenous connector in an Australian hematology-oncology 1995;20:593–597.
unit. Infect Control Hosp Epidemiol 2007;28:610–613. 237. Pittet D, Wenzel RP. Nosocomial bloodstream infections. Secular trends
217. Salgado CD, Chinnes L, Paczesny TH, Cantey JR. Increased rate of cath- in rates, mortality, and contribution to total hospital deaths. Arch Intern
eter-related bloodstream infection associated with use of a needleless Med 1995;155:1177–1184.
mechanical valve device at a long-term acute-care hospital. Infect 238. Fakih MG, Huang RH, Bufalino A, et al. The case for a population stand-
Control Hosp Epidemiol 2007;28:684–688. ardized infection ratio (SIR): a metric that marries the device SIR to the
218. Rupp ME, Sholtz LA, Jourdan DR, et al. Outbreak of bloodstream infec- standardized utilization ratio (SUR). Infect Control Hosp Epidemiol
tion temporally associated with the use of an intravascular needleless 2019;40:979–982.
valve. Clin Infect Dis 2007;44:1408–1414. 239. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcare-
219. Jarvis WR, Murphy C, Hall KK, et al. Health care-associated bloodstream associated infections: the role of the Society for Healthcare Epidemiology
infections associated with negative- or positive-pressure or displace- of America. Infect Control Hosp Epidemiol 2005;26:210–212.
ment mechanical valve needleless connectors. Clin Infect Dis 2009;49: 240. Aswani MS, Reagan J, Jin L, Pronovost PJ, Goeschel C. Variation in public
1821–1827. reporting of central line-associated bloodstream infections by state. Am J
220. Rosenthal VD. Impact of needle-free connectors compared with 3-way Med Qual 2011;26:387–395.
stopcocks on catheter-related bloodstream infection rates: a meta- 241. Talbot TR, Bratzler DW, Carrico RM, et al. Public reporting of healthcare-
analysis. Am J Infect Control 2020;48:281–284. associated surveillance data: recommendations from the healthcare infec-
221. Casey AL, Karpanen TJ, Nightingale P, Cook M, Elliott TS. tion control practices advisory committee. Ann Intern Med 2013;159:
Microbiological comparison of a silver-coated and a non-coated needle- 631–635.
less intravascular connector in clinical use. J Hosp Infect 2012;80:299–303. 242. Evans ME, Kralovic SM, Simbartl LA, Jain R, Roselle GA. Eight years
222. Jacob JT, Chernetsky Tejedor S, Dent Reyes M, et al. Comparison of a sil- of decreased methicillin-resistant Staphylococcus aureus healthcare-
ver-coated needleless connector and a standard needleless connector for associated infections associated with a Veterans’ Affairs prevention initia-
the prevention of central line-associated bloodstream infections. Infect tive. Am J Infect Control 2017;45:13–16.
Control Hosp Epidemiol 2015;36:294–301. 243. Hamill ME, Reed CR, Fogel SL, et al. Contact isolation precautions in
223. Webster J, Gillies D, O’Riordan E, Sherriff KL, Rickard CM. Gauze and trauma patients: an analysis of infectious complications. Surg Infect
tape and transparent polyurethane dressings for central venous catheters. (Larchmt) 2017;18:273–281.
Cochrane Database Syst Rev 2011:CD003827. 244. Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness
224. Batra R, Cooper BS, Whiteley C, Patel AK, Wyncoll D, Edgeworth JD. Guide for Intravenous Catheters (MAGIC): results from a multispecialty
Efficacy and limitation of a chlorhexidine-based decolonization strategy panel using the RAND/UCLA appropriateness method. Ann Intern Med
in preventing transmission of methicillin-resistant Staphylococcus aureus 2015;163:S1–S40.
in an intensive care unit. Clin Infect Dis 2010;50:210–217. 245. Fakih MG, Heavens M, Ratcliffe CJ, Hendrich A. First step to reducing
225. Rickard CM, Edwards M, Spooner AJ, et al. A 4-arm randomized infection risk as a system: evaluation of infection prevention processes
controlled pilot trial of innovative solutions for jugular central venous for 71 hospitals. Am J Infect Control 2013;41:950–954.
access device securement in 221 cardiac surgical patients. J Crit Care 2016; 246. Owings A, Graves J, Johnson S, Gilliam C, Gipson M, Hakim H.
36:35–42. Leadership line care rounds: application of the engage, educate, execute,
226. Karpanen TJ, Casey AL, Whitehouse T, et al. A clinical evaluation of two and evaluate improvement model for the prevention of central line-
central venous catheter stabilization systems. Ann Intensive Care 2019; associated bloodstream infections in children with cancer. Am J Infect
9:49. Control 2018;46:229–231.
227. Bertini G, Elia S, Ceciarini F, Dani C. Reduction of catheter-related blood- 247. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into
stream infections in preterm infants by the use of catheters with the practice: a model for large scale knowledge translation. BMJ 2008;337:
AgION antimicrobial system. Early Hum Dev 2013;89:21–25. a1714.
228. Bertini G, Elia S, Ceciarini F, Dani C. Reduction of catheter-related blood- 248. Safdar N, Abad C. Educational interventions for prevention of health-
stream infections in preterm infants by the use of catheters with the care-associated infection: a systematic review. Crit Care Med 2008;36:
AgION antimicrobial system. Early Hum Dev 2013;89:21–25. 933–940.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.
Infection Control & Hospital Epidemiology 17
249. Smith JS, Kirksey KM, Becker H, Brown A. Autonomy and self-efficacy as 258. Wheeler DS, Giaccone MJ, Hutchinson N, et al. A hospital-wide quality-
influencing factors in nurses’ behavioral intention to disinfect needleless improvement collaborative to reduce catheter-associated bloodstream
intravenous systems. J Infus Nurs 2011;34:193–200. infections. Pediatrics 2011;128:e995–e1004.
250. Hendy J, Barlow J. The role of the organizational champion in achieving 259. Marra AR, Cal RG, Durao MS, et al. Impact of a program to prevent cen-
health system change. Social Sci Med 2012;74:348–355. tral line-associated bloodstream infection in the zero tolerance era. Am J
251. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Infect Control 2010;38:434–439.
Promoting a culture of safety as a patient safety strategy: a systematic 260. Powers RJ, Wirtschafter DW. Decreasing central line-associated blood-
review. Ann Intern Med 2013;158:369–374. stream infection in neonatal intensive care. Clin Perinatol 2010;37:247–272.
252. Fakih MG, Krein SL, Edson B, Watson SR, Battles JB, Saint S. Engaging 261. Berhe M, Edmond MB, Bearman G. Measurement and feedback of infec-
healthcare workers to prevent catheter-associated urinary tract infection tion control process measures in the intensive care unit: Impact on com-
and avert patient harm. Am J Infect Control 2014;42:S223–S229. pliance. Am J Infect Control 2006;34:537–539.
253. Wathen C, Kshettry VR, Krishnaney A, et al. The association between 262. Assanasen S, Edmond M, Bearman G. Impact of 2 different levels of per-
operating room personnel and turnover with surgical site infection in formance feedback on compliance with infection control process mea-
more than 12,00 neurosurgical cases. Neurosurgery 2016;79:889–894. sures in 2 intensive care units. Am J Infect Control 2008;36:407–413.
254. Huang GC, Newman LR, Schwartzstein RM, et al. Procedural competence 263. Miller MR, Griswold M, Harris JM, 2nd, et al. Decreasing PICU catheter-
in internal medicine residents: validity of a central venous catheter inser- associated bloodstream infections: NACHRI’s quality transformation
tion assessment instrument. Acad Med 2009;84:1127–1134. efforts. Pediatrics 2010;125:206–213.
255. Evans LV, Dodge KL. Simulation and patient safety: evaluative checklists 264. Stevens TP, Schulman J. Evidence-based approach to preventing central
for central venous catheter insertion. Qual Saf Health Care 2010;19 suppl line-associated bloodstream infection in the NICU. Acta Paediatr Suppl
3:i42–i46. 2012;101:11–16.
256. Segreti J, Garcia-Houchins S, Gorski L, et al. Consensus conference 265. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus
on prevention of central line-associated bloodstream infections: 2009. J on rating quality of evidence and strength of recommendations. BMJ
Infus Nurs 2011;34:126–133. 2008;336:924–926.
257. Nailon RE, Rupp ME, Lyden E. A day in the life of a CVAD. J Infusion 266. Canadian Task Force on Preventive Health Care website. http://
Nurs 2019;42:125–131. canadiantaskforce.ca/methods/grade/. Accessed December 31, 2021.
Downloaded from https://www.cambridge.org/core. 20 Apr 2022 at 16:49:16, subject to the Cambridge Core terms of use.