Arterial Catheter Infections vs Central Lines

1
DYNAMICS AND PREVENTION
OF INTRAVASCULAR
CATHETER-RELATED
INFECTIONS
Dr. Leonard Mermel
Professor of Medicine
Warren Alpert Medical School of Brown University
Medical Director
Department of Epidemiology & Infection Control
Rhode Island Hospital
Adjunct Clinical Professor,
University of Rhode Island College of Pharmacy
Frequency of Intravascular
Catheter-Related Infections
Incidence vs Incidence Density
Incidence vs Incidence Density
CLABSI in two groups of 100 catheters each
Unit A Unit B
Incidence 1/100 caths 5/100 caths
1% 5%
Incidence 1/500 cath d 5/2500 cath d
Density 2.0/1000 cath d 2.0/1000 cath d
Duration of cath 5 days 25 days
CLABSI = Central Line-Associated BloodStream Infections
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Magnitude of the Problem
•  United States: 15 million of central
vascular catheter (CVC) days in
intensive care units (ICUs) each year
•  Catheter-associated bloodstream
infections (CRBSI)
! increase hospital costs
! increase length of stay
! no clear increase in mortality
Magnitude of the Problem
•  In ICUs: 80,000 CRBSIs/year
•  In entire hospitals: 250,000 CRBSIs/year
•  Goal: to eliminate CRBSI
In US, Central Line Associated
Bloodstream Infection (CLABSI)
Rates in ICUs are Going DOWN!
Good News!
But……What About Central
Line-Associated Infections
Outside of the ICU?ESCMID
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MMWR 3/1/11
What About Other Catheters?
Feature Article—Continuing Medical Education
Prospective study of peripheral arterial catheter infection and
comparison with concurrently sited central venous catheters*
David Boon Chai Koh, BN(Hons), GradCert(CritCareNurs);
John R. Gowardman, MBChB, FRACP, FJFICM; Claire M. Rickard, RN, PhD; Iain K. Robertson, MMedSci;
Andrew Brown, GradDip(CritCare), MClinNurs
*See also p. 620.
Registered Critical Care Nurse, Launceston Gen-
eral Hospital, Tasmania, Australia (DBCK); Senior Spe-
cialist, Intensive Care Medicine, Royal Brisbane and
Women’s Hospital, Herston, Senior Lecturer, University
of Queensland, Queensland, Associate Professor, Grif-
fith University, Nathan, Australia (JRG); Professor of
Nursing, Griffith University, Research Centre for Clini-
cal and Community Practice Innovation, Queensland,
Australia (CMR); Senior Research Fellow, School of
Human Life Sciences, University of Tasmania, Laun-
ceston TAS, Australia (IKR); Nurse Educator, Intensive/
Coronary Care Unit, Launceston General Hospital,
Launceston TAS, Australia (AB).
Supported, in part, by the Clifford Craig Medical
Research Trust at University of Tasmania PhD Scholar-
ship (DBCK). Statistical analysis was funded by the Clif-
ford Craig Medical Research Trust, Launceston, Australia.
For information regarding this article, E-mail:
john_gowardman@health.qld.gov.au
Copyright © 2007 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/01.CCM.0B013E3181611F74B
LEARNING OBJECTIVES
On completion of this article, the reader should be able to:
1. Explain the implications of arterial catheter line colonization.
2. Compare the incidence of arterial catheter line infections with central venous catheter infections.
3. Use this information in a clinical setting.
All authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining
to this educational activity.
All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial
relationships with, or financial interests in, any commercial companies pertaining to this educational activity.
Lippincott CME Institute, Inc., has identified and resolved all faculty and staff conflicts of interest regarding this educational
activity.
Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
Objective: Peripheral arterial catheters are perceived as having
low infective potential compared with other catheters and may be
overlooked as a cause of catheter-related bloodstream infection.
We aimed to measure colonization and rates of catheter-related
bloodstream infection in arterial catheters, to investigate risk
factors for arterial catheter colonization, and to compare arterial
catheter infection rates with those in concurrently sited and
managed central venous catheters.
Design: Prospective 24-month cohort study.
Setting: Eight-bed combined general intensive care and high-
dependency unit of a 350-bed Australian teaching hospital.
Patients: Three hundred twenty-one arterial catheters in 252
adult and pediatric patients were observed for 1,082 catheter days,
and 618 central venous catheters in 410 patients were observed for
4,040 catheter days. All catheters were inserted in, or presented to,
the intensive care unit. Both arterial catheters and central venous
catheters were inserted by trained personnel under aseptic condi-
tions, and management was standardized.
Interventions: None.
Measurements and Main Results: The incidence per 1,000 (95%
confidence interval) catheter days of colonization (>15 colonies) and
catheter-related bloodstream infection was 15.7 (9.5–25.9) and 0.92
(0.13–6.44) for arterial catheters and 16.8 (13.3–21.3) and 2.23 (1.12–
4.44) for central venous catheters. Arterial catheter colonization was not
significantly different than that in central venous catheters (hazard ratio,
1.17; 95% confidence interval, 0.41–3.36; p ‫؍‬ .77). Arterial catheter
colonization increased with dwell time and was similar to central venous
catheters over time. Femoral arterial catheters were colonized more
often than radial arterial catheters (hazard ratio, 5.08; 95% confidence
interval, 0.85, 30.3; p ‫؍‬ .075), and colonization was significantly higher
when the catheter was inserted in the operating theater or emergency
department (hazard ratio, 4.45; 95% confidence interval, 1.42–13.9; p ‫؍‬
.01) compared with the intensive care unit.
Conclusions: The incidence of catheter-related bloodstream
infection from arterial catheters was low. However, both arterial
catheter colonization and rates of catheter-related bloodstream
infection were similar to those in concurrently sited and identi-
cally managed central venous catheters. By inference, the arterial
catheter should be accorded the same degree of importance as
the central venous catheter as a potential source of sepsis. (Crit
Care Med 2008; 36:397–402)
KEY WORDS: peripheral arterial catheterization; arterial cathe-
ters; catheterization, central venous; intensive care; sepsis
397Crit Care Med 2008 Vol. 36, No. 2
Feature Article—Continuing Medical Education
Prospective study of peripheral arterial catheter infection and
comparison with concurrently sited central venous catheters*
David Boon Chai Koh, BN(Hons), GradCert(CritCareNurs);
John R. Gowardman, MBChB, FRACP, FJFICM; Claire M. Rickard, RN, PhD; Iain K. Robertson, MMedSci;
Andrew Brown, GradDip(CritCare), MClinNurs
*See also p. 620.
Registered Critical Care Nurse, Launceston Gen-
eral Hospital, Tasmania, Australia (DBCK); Senior Spe-
cialist, Intensive Care Medicine, Royal Brisbane and
Women’s Hospital, Herston, Senior Lecturer, University
of Queensland, Queensland, Associate Professor, Grif-
fith University, Nathan, Australia (JRG); Professor of
Nursing, Griffith University, Research Centre for Clini-
cal and Community Practice Innovation, Queensland,
Australia (CMR); Senior Research Fellow, School of
Human Life Sciences, University of Tasmania, Laun-
ceston TAS, Australia (IKR); Nurse Educator, Intensive/
Coronary Care Unit, Launceston General Hospital,
Launceston TAS, Australia (AB).
Supported, in part, by the Clifford Craig Medical
Research Trust at University of Tasmania PhD Scholar-
ship (DBCK). Statistical analysis was funded by the Clif-
ford Craig Medical Research Trust, Launceston, Australia.
john_gowardman@health.qld.gov.au
DOI: 10.1097/01.CCM.0B013E3181611F74B
LEARNING OBJECTIVES
On completion of this article, the reader should be able to:
1. Explain the implications of arterial catheter line colonization.
2. Compare the incidence of arterial catheter line infections with central venous catheter infections.
3. Use this information in a clinical setting.
All authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining
to this educational activity.
All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial
relationships with, or financial interests in, any commercial companies pertaining to this educational activity.
Lippincott CME Institute, Inc., has identified and resolved all faculty and staff conflicts of interest regarding this educational
activity.
Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
Objective: Peripheral arterial catheters are perceived as having
low infective potential compared with other catheters and may be
overlooked as a cause of catheter-related bloodstream infection.
We aimed to measure colonization and rates of catheter-related
bloodstream infection in arterial catheters, to investigate risk
factors for arterial catheter colonization, and to compare arterial
catheter infection rates with those in concurrently sited and
managed central venous catheters.
Design: Prospective 24-month cohort study.
Setting: Eight-bed combined general intensive care and high-
dependency unit of a 350-bed Australian teaching hospital.
Patients: Three hundred twenty-one arterial catheters in 252
adult and pediatric patients were observed for 1,082 catheter days,
and 618 central venous catheters in 410 patients were observed for
4,040 catheter days. All catheters were inserted in, or presented to,
the intensive care unit. Both arterial catheters and central venous
catheters were inserted by trained personnel under aseptic condi-
tions, and management was standardized.
Interventions: None.
Measurements and Main Results: The incidence per 1,000 (95%
confidence interval) catheter days of colonization (>15 colonies) and
catheter-related bloodstream infection was 15.7 (9.5–25.9) and 0.92
(0.13–6.44) for arterial catheters and 16.8 (13.3–21.3) and 2.23 (1.12–
4.44) for central venous catheters. Arterial catheter colonization was not
significantly different than that in central venous catheters (hazard ratio,
1.17; 95% confidence interval, 0.41–3.36; p ‫؍‬ .77). Arterial catheter
colonization increased with dwell time and was similar to central venous
catheters over time. Femoral arterial catheters were colonized more
often than radial arterial catheters (hazard ratio, 5.08; 95% confidence
interval, 0.85, 30.3; p ‫؍‬ .075), and colonization was significantly higher
when the catheter was inserted in the operating theater or emergency
department (hazard ratio, 4.45; 95% confidence interval, 1.42–13.9; p ‫؍‬
.01) compared with the intensive care unit.
Conclusions: The incidence of catheter-related bloodstream
infection from arterial catheters was low. However, both arterial
catheter colonization and rates of catheter-related bloodstream
infection were similar to those in concurrently sited and identi-
cally managed central venous catheters. By inference, the arterial
catheter should be accorded the same degree of importance as
the central venous catheter as a potential source of sepsis. (Crit
Care Med 2008; 36:397–402)
KEY WORDS: peripheral arterial catheterization; arterial cathe-
ters; catheterization, central venous; intensive care; sepsis
397Crit Care Med 2008 Vol. 36, No. 2
s, including Acute Physi-
ic Health Evaluation
plified Acute Physiology
CHE II diagnostic codes;
mental transfers; and AC
e, time). APACHE II and
hysiology Score II were
of clinical status of the
stematic recording of co-
undertaken. The reason
lso recorded. Similar data
ll CVCs and in all cases
rrently with those for the
regarding site of CVC in-
of lumens were not used
e data were recorded by
ng staff in a purpose-
and subsequently entered
Microsoft Access database
nt.
Sampling. IADs were re-
e ICU nurse using a sterile
CVCs and ACS, the distal
he IAD tip was removed
ing pack, which included
cissors, taking care not to
on removal. The tip was
ansferred to a sterile con-
ted to the microbiology
ysis using Maki and col-
uantitative method of tip
ical details, including all
ant patient blood culture
atory procedural require-
were then entered into the
Definitions. The following
fection were applied: col-
re Ն15 colony forming
BSI: catheter tip culture
g units plus a positive
within 48 hrs of IAD re-
(CIs) and p values were adjusted for confound-
ing by age, gender, APACHE II, and Simplified
Acute Physiology Score II (with box-cox trans-
formations of these variables used to correct
for skewed distributions). Time-to-event
graphs were drawn to illustrate the occur-
rence of these events over time. The p values
were adjusted for multiple comparisons were
relevant by the Holm method. Statistical anal-
yses were performed using STATA Statistics/
Data Analysis version 9.2 (StataCorp, College
Station, TX).
RESULTS
Patient Sample. Between July 1, 2004,
and June 30, 2006, 321 ACs were sited for
an average of 3.4 (ϮSD 3.5; median, 2.1;
interquartile range, 1.0–4.2) days in 252
patients (mean age, 62.5 Ϯ 18.7 yrs;
mean APACHE II score 19.3 Ϯ 10.2).
During the same period, 618 CVCs were
sited for an average of 6.5 (ϮSD 4.9; me-
dian, 5.1; interquartile range, 2.9–8.9)
days in 410 patients (mean age, 61.5 Ϯ
16.5 yrs; mean APACHE II score, 21.4 Ϯ
17.9). Seventy-four (29.4%) of the 252
patients with ACs died within 6 wks of
incidence rate of AC colonization was not
different than that of CVCs (HR, 1.17,
95% CI, 0.41–3.36; p ϭ .773) compared
using Cox proportional hazards regres-
Figure 1. Proportion of arterial (AC) and central
venous catheters (CVC) remaining uncolonized on
removal. The incidence rate of AC colonization was
not different than that of CVCs (hazard ratio, 1.17;
95% confidence interval, 0.41–3.36; p ϭ .773).
Table 1. Colonization and catheter-related bloodstream infection (CR-BSI) associated with arterial and
central venous catheters
Catheter Site
No. of
Catheters
Total
Catheter-Days
Colonization CR-BSI
No. Ratea
%b
No. Ratea
%b
Arterial catheters 321 1082 17 15.71 5.3 1 0.92 0.31
Central venous catheters 618 4040 68 16.83 11.0 9 2.23 1.46
a
Unadjusted rate per 1000 catheter days; b
percentage of catheters.
Mermel
Mermel, L
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Pathogens Involved
Used to be:
Coagulase negative staphylococci
Staphylococcus aureus
Candida albicans
Gram-negatives
Changing……
clabsi definition in neutropenic patients 173
table 1. Distribution of Pathogens in Central Line–Associated Bloodstream Infections
(CLABSIs) among Patients with and without Neutropenia
Organism
Nonneutropenic
(n p 244a
)
Neutropenic
(n p 66a
) P
Coagulase-negative staphylococci 46 (18.9) 12 (18.2) .901
Staphylococcus aureus (total) 36 (14.8) 6 (9.1) .234
Methicillin-resistant S. aureus 23 (9.5) 5 (7.6) .642
Methicillin-susceptible S. aureus 13 (5.3) 1 (1.5) .323b
Enterococcus species (total) 37 (15.2) 15 (22.7) .145
E. faecalis 22 (9.0) 3 (4.5) .237
E. faecium 15 (6.1) 12 (18.2) .002
Vancomycin-resistant enterococci 12 (4.5) 11 (16.7) .001
Streptococcus species 0 (0) 12 (18.2) !.001b
Candida species 81 (33.2) 4 (6.1) !.001
Escherichia coli 6 (2.5) 15 (22.7) !.001b
Enterobacteriaceae (excluding E. coli) 53 (21.7) 2 (3.0) !.001
Klebsiella species 25 (10.2) 2 (3.0) .065
Enterobacter species 13 (5.3) 0 (0) .355b
Serratia species 8 (3.3) 0 (0) .857
Citrobacter species 4 (1.6) 0 (0) .999b
Other 3 (1.2)c
0 (0) .999b
Pseudomonas species 14 (5.7) 1 (1.5) .266b
Acinetobacter species 5 (2.0) 0 (0) .999b
Other 8 (3.3)d
8 (12.1)e
.017b
note. Data are no. (%). Boldface type indicates statistical significance.
a
Refers to the number of CLABSIs determined using standard surveillance definitions.
Because some infections were polymicrobial, the total number of isolates exceeds the
total number of CLABSIs. There were 286 isolates among 244 CLABSIs in the nonneu-
tropenic group and 74 isolates among 66 CLABSIs in the neutropenic group.
b
Fisher exact test.
c
Includes Morganella, Providentia, and Proteus.
d
Includes Bacillus (2), Corynebacterium, Pantoea, Eubacterium, Lactobacillus, Leuconostoc,
and Staphylococcus lugdunensis.
e
Includes Bacillus, Clostridium, Corynebacterium, Fusarium, Rothia, Stenotrophomonas
(2), and Stomatococcus.
of hospital admission, are listed in Table 2, stratified by
whether the BSI would be attributed to translocation or con-
sidered a CLABSI in our modified definition. Ten of 14 BSIs
in patients with multiple myeloma who received chemother-
apy and autologous peripheral blood stem cell transplant were
caused by organisms attributed in our modified definition to
translocation, compared with 1 of 7 BSIs in patients with
acute lymphocytic leukemia.
By the standard NHSN definition, the CLABSI rate in hos-
pital B (2.12 per 1,000 line-days), which has large transplant
and oncology populations, was higher than that in hospital
A (1.95 per 1,000 line-days). By the modified definition, hos-
pital B had a lower rate (1.79 per 1,000 line-days) than hos-
pital A (1.95 per 1,000 line-days). There were 73 NHSN-
defined CLABSIs (not all with neutropenia), with an infection
rate of 2.66 per 1,000 line-days in the 3 hematology-oncology
and bone marrow transplant units of hospital B. Application
of the modified definition decreased the number of CLABSIs
to 42 and the infection rate to 1.53 per 1,000 line-days in
these units.
discussion
We found significant differences in the microbiology of
NHSN-defined CLABSIs in nonneutropenic patients com-
pared with that in patients with neutropenia following che-
motherapy. The organisms that were overrepresented in the
neutropenic group include common residents of the gastro-
intestinal tract. These findings provide supporting evidence
that many BSIs meeting the NHSN criteria for CLABSI in
the setting of neutropenia may represent translocation of gut
organisms and also support the efforts by the NHSN to mod-
ify the CLABSI definition. The lack of relapse of CLABSI in
any patient whose line was not removed during or imme-
diately following treatment of the BSI, particularly for E. coli
and streptococcal BSIs, also suggests a source of infection
other than the catheter.
On the basis of our findings, we propose that the organisms
to attribute to translocation and exclude from the CLABSI
definition in the setting of neutropenia and mucosal disrup-
tion include E. coli, streptococci, and enterococci. Half (33/
Steinberg et, ICHE 2013, 34:171
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Pathogen-Specific Outcome of
Catheter-Related Bloodstream
Infection
•  Coagulase-negative Staph are most
common causes of CRBSI, but…
•  Majority of complications from CRBSI
due to S. aureus or Candida
Arnow et al CID 1993, 16:778
Preventive Strategies
Should be Based on
Understanding Pathogenesis
Which of the following would you
recommend regarding the site of CVC
placement?
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6
1.  Recommend femoral vein insertion, this
site appears to have a lower risk of
infection and thrombosis compared with
other sites.
2.  Recommend subclavian vein insertion,
this site appears to have a lower risk of
infection compared with other sites.
3.  Recommend internal jugular vein
insertion, this site appears to have a
lower risk of infection compared with
other sites.
1.  Recommend femoral vein insertion,
infection and thrombosis compared with
other sites.
2.  Recommend subclavian vein insertion,
infection compared with other sites.
3.  Recommend internal jugular vein
insertion, this site appears to have a
lower risk of infection compared with
other sites.
Crit Care Med 2012 Vol. 40, No. 5 1627
Healthcare-associated infec-
tions are among the most
common complications af-
fecting hospitalized patients
(1), particularly in the intensive care set-
ting (2). Among those, catheter-associated
infections are common (3, 4), costly (5),
and potentially lethal (6). Thus, efforts to
prevent catheter-associated infections are
likely to be cost effective.
In intensive care units, most central
venous catheters (CVCs) are short-term,
nontunneled devices for which an extralu-
minal source of infection may predominate
(7, 8). Consequently, reducing the biobur-
den of microbes at the insertion site has
been a key infection control intervention
(9).Meta-analysisofrandomizedcontrolled
trials favors the use of chlorhexidine over
povidone-iodine for optimal cutaneous
antisepsis (10). The insertion site, namely
subclavian, internal jugular, or femoral, in-
fluences the risk of infection (11–15), but
insertion site has received less rigorous
scrutiny than antiseptic products or new
technologies (10, 16–18). Two systematic
reviews (19, 20) on this topic comprised
only a small single trial (21). Pronovost
et al (22) considered avoiding femoral
catheterization as one of five evidence-
based procedures recommended to prevent
up to 66% of device-associated infec-
tions, and the Centers for Disease Control
and Prevention guidelines for preventing
intravascular catheter-related infections
Objective: Catheter-associated infections are common, costly,
and potentially lethal. The impact of catheter insertion site on in-
fection risk remains controversial. We aimed to establish whether
nontunneled central venous catheters inserted in the subclavian
vein are associated with lower risk of catheter-associated infec-
tion compared to femoral or internal jugular vein insertion.
Data Sources: We searched MEDLINE (2000–2011), EMBASE
(2000–2011), and Cochrane Library plus meta-analyses, gray lit-
erature, reference lists, and articles recommended by experts.
Study Selection and Extraction: We selected peer-reviewed,
randomized, or prospective cohort studies with systematic cath-
eter culture using semiquantitative or quantitative catheter culture
techniques and data available for catheter-associated infection
by insertion site. Two reviewers independently performed study
selection, assessed study quality, and extraction. Discrepancies
were resolved by discussion and consensus. Outcomes were mean
catheter duration and catheter-associated infection expressed as
incidence density per 1000 catheter days.
Data Synthesis: Ten studies (3250 subclavian, 3053 internal
jugular, and 1554 femoral vein) met the inclusion criteria, one of
which was randomized (136 subclavian vein and 134 femoral vein).
Subclavian vein catheters were left in place significantly longer than
alternative catheters (mean difference: 2 days, 95% confidence in-
terval [0.9–3.1], I2
= 92%, p < .001). The subclavian vein site was
associated with fewer catheter-associated infections (1.3 compared
to 2.7 per 1000 catheter days for alternative sites, incidence density
ratio 0.50; 95% confidence interval [0.33– 0.74], I2
= 0%, p < .001).
The same was true when comparisons were stratified by alterna-
tive sites (subclavian vein vs. internal jugular vein, incidence density
ratio 0.46; 95% confidence interval [0.30–0.70], I2
= 0%; subclavian
vein vs. femoral vein, incidence density ratio 0.27; 95% confidence
interval [0.15–0.48], I2
= 31%).
Conclusion: Shortcomings in study design, including channel-
ing, confounding bias, and study heterogeneity, may limit the in-
terpretation of our preliminary study results. Our analysis suggests
that the subclavian site may be associated with a lower risk of
catheter-associated infection. However, a large, randomized, con-
trolled trial comparing each catheter site complication is warrant-
ed before the subclavian site can be unequivocally recommended
as a first choice for central venous catheter insertion. (Crit Care
Med 2012; 40:1627–1634)
KEY WORDS: catheterization; femoral; infection; jugular; subclavian
Review Articles
Meta-analysis of subclavian insertion and nontunneled central
venous catheter-associated infection risk reduction in critically
ill adults*
Jean-Jacques Parienti, MD, PhD; Damien du Cheyron, MD, PhD; Jean-François Timsit, MD, PhD;
Ousmane Traoré, MD; Pierre Kalfon, MD; Olivier Mimoz, MD, PhD; Leonard A. Mermel, DO, ScM, AM (Hon)
*See also p. 1687.
From the Biostatistics and Clinical Research Unit
(JJP), Department of Medical Intensive Care (DdC),
CHU Caen, Université Caen, Caen, France; Institut
National de la Santé et de la Recherche Médicale
(JJP), Université Pierre et Marie Curie-Paris 6, Paris,
France; INSERM U823 (JFT), Grenoble; France; and
Medical Intensive Care Unit (JFT), Grenoble, France;
Department of Microbiology (OT), CHU Clermont-
Ferrand, France; Department of General Intensive
Care (PK), Louis Pasteur Hospital, Chartres, France;
Department of Surgical Intensive Care (OM), CHU
Poitiers, France; Department of Medicine (LAM),
Warren Alpert Medical School of Brown University and
Division of Infectious Diseases, Rhode Island Hospital,
Providence, RI.
Supported by authors’ institution.
Dr. Parienti is principal investigator of a random-
ized controlled trial comparing the three sites for cath-
eterization in the intensive care unit and supported by a
grant from the Clinical Research Hospital Program from
the French Ministry of Health (PHRC 2010). Dr. Timsit
consulted for 3M, Ethicon, has speaking/honoraria from
3M, Ethicon, and received grant support from Ethicon.
Dr. Mermel consulted for AshAccess, CareFusion,
Catheter Connections, Cormedix, Semprus, and ICU
Medical, Roche. The remaining authors have not dis-
closed any potential conflicts of interest.
parienti-jj@chu-caen.fr
DOI: 10.1097/CCM.0b013e31823e99cb
Crit Care Med 2012 Vol. 40, No. 5 1627
Healthcare-associated infec-
tions are among the most
common complications af-
fecting hospitalized patients
(1), particularly in the intensive care set-
ting (2). Among those, catheter-associated
infections are common (3, 4), costly (5),
and potentially lethal (6). Thus, efforts to
prevent catheter-associated infections are
likely to be cost effective.
In intensive care units, most central
venous catheters (CVCs) are short-term,
nontunneled devices for which an extralu-
minal source of infection may predominate
(7, 8). Consequently, reducing the biobur-
den of microbes at the insertion site has
been a key infection control intervention
(9).Meta-analysisofrandomizedcontrolled
trials favors the use of chlorhexidine over
povidone-iodine for optimal cutaneous
antisepsis (10). The insertion site, namely
subclavian, internal jugular, or femoral, in-
fluences the risk of infection (11–15), but
insertion site has received less rigorous
scrutiny than antiseptic products or new
technologies (10, 16–18). Two systematic
reviews (19, 20) on this topic comprised
only a small single trial (21). Pronovost
et al (22) considered avoiding femoral
catheterization as one of five evidence-
based procedures recommended to prevent
up to 66% of device-associated infec-
tions, and the Centers for Disease Control
and Prevention guidelines for preventing
intravascular catheter-related infections
Objective: Catheter-associated infections are common, costly,
and potentially lethal. The impact of catheter insertion site on in-
fection risk remains controversial. We aimed to establish whether
nontunneled central venous catheters inserted in the subclavian
vein are associated with lower risk of catheter-associated infec-
tion compared to femoral or internal jugular vein insertion.
Data Sources: We searched MEDLINE (2000–2011), EMBASE
(2000–2011), and Cochrane Library plus meta-analyses, gray lit-
erature, reference lists, and articles recommended by experts.
Study Selection and Extraction: We selected peer-reviewed,
randomized, or prospective cohort studies with systematic cath-
eter culture using semiquantitative or quantitative catheter culture
techniques and data available for catheter-associated infection
by insertion site. Two reviewers independently performed study
selection, assessed study quality, and extraction. Discrepancies
were resolved by discussion and consensus. Outcomes were mean
catheter duration and catheter-associated infection expressed as
incidence density per 1000 catheter days.
Data Synthesis: Ten studies (3250 subclavian, 3053 internal
jugular, and 1554 femoral vein) met the inclusion criteria, one of
which was randomized (136 subclavian vein and 134 femoral vein).
Subclavian vein catheters were left in place significantly longer than
alternative catheters (mean difference: 2 days, 95% confidence in-
terval [0.9–3.1], I2
= 92%, p < .001). The subclavian vein site was
associated with fewer catheter-associated infections (1.3 compared
to 2.7 per 1000 catheter days for alternative sites, incidence density
ratio 0.50; 95% confidence interval [0.33– 0.74], I2
= 0%, p < .001).
The same was true when comparisons were stratified by alterna-
tive sites (subclavian vein vs. internal jugular vein, incidence density
ratio 0.46; 95% confidence interval [0.30–0.70], I2
= 0%; subclavian
vein vs. femoral vein, incidence density ratio 0.27; 95% confidence
interval [0.15–0.48], I2
= 31%).
Conclusion: Shortcomings in study design, including channel-
ing, confounding bias, and study heterogeneity, may limit the in-
terpretation of our preliminary study results. Our analysis suggests
that the subclavian site may be associated with a lower risk of
catheter-associated infection. However, a large, randomized, con-
trolled trial comparing each catheter site complication is warrant-
ed before the subclavian site can be unequivocally recommended
as a first choice for central venous catheter insertion. (Crit Care
Med 2012; 40:1627–1634)
KEY WORDS: catheterization; femoral; infection; jugular; subclavian
Review Articles
Meta-analysis of subclavian insertion and nontunneled central
venous catheter-associated infection risk reduction in critically
ill adults*
Jean-Jacques Parienti, MD, PhD; Damien du Cheyron, MD, PhD; Jean-François Timsit, MD, PhD;
Ousmane Traoré, MD; Pierre Kalfon, MD; Olivier Mimoz, MD, PhD; Leonard A. Mermel, DO, ScM, AM (Hon)
*See also p. 1687.
From the Biostatistics and Clinical Research Unit
(JJP), Department of Medical Intensive Care (DdC),
CHU Caen, Université Caen, Caen, France; Institut
National de la Santé et de la Recherche Médicale
(JJP), Université Pierre et Marie Curie-Paris 6, Paris,
France; INSERM U823 (JFT), Grenoble; France; and
Medical Intensive Care Unit (JFT), Grenoble, France;
Department of Microbiology (OT), CHU Clermont-
Ferrand, France; Department of General Intensive
Care (PK), Louis Pasteur Hospital, Chartres, France;
Department of Surgical Intensive Care (OM), CHU
Poitiers, France; Department of Medicine (LAM),
Warren Alpert Medical School of Brown University and
Division of Infectious Diseases, Rhode Island Hospital,
Providence, RI.
Supported by authors’ institution.
Dr. Parienti is principal investigator of a random-
ized controlled trial comparing the three sites for cath-
eterization in the intensive care unit and supported by a
grant from the Clinical Research Hospital Program from
the French Ministry of Health (PHRC 2010). Dr. Timsit
consulted for 3M, Ethicon, has speaking/honoraria from
3M, Ethicon, and received grant support from Ethicon.
Dr. Mermel consulted for AshAccess, CareFusion,
Catheter Connections, Cormedix, Semprus, and ICU
Medical, Roche. The remaining authors have not dis-
closed any potential conflicts of interest.
parienti-jj@chu-caen.fr
DOI: 10.1097/CCM.0b013e31823e99cb
Note: mostly non-
randomized
studies; most
before introduction
of routine barrier
precautions for
insertion;
Parienti, du
Cheyron, Timsit,
Traoré, Kalfon,
Mimoz , Mermel,
Crit Care Med
2012
Catheter-associated infection risk of subclavian compared to alternative insertion sites
ESCMID
©
by author

7
Barrier Precautions
•  Use barrier precautions for central
venous catheter insertion
– mask, gown, gloves, hat, eye protection
and large sheet drape
Efficacy of Barrier Precautions
During CVC Insertion
Barrier precautions
Minimal Maximal
Cath colonization 7.2% 2.3%*
Cath sepsis 3.6% 0.6%*
*p<0.05
Raad et al, ICHE 1994
Skin disinfection
•  Disinfect the skin prior to catheter
insertion
Meta-Analysis: Prospective, Randomized Studies of
Alcoholic Chlorhexidine vs Povidone-Iodine Cutaneous
Antisepsis
Maiwald & Chan PLOS ONE 2012
Cath colonization
CRBSI

8
Extra measures
•  Bathe patients daily with chlorhexidine-
based product rather than soap and water
•  Use chlorhexidine-containing dressings
at catheter insertion sites
Problem:
•  Use alcoholic chlorhexidine to clean the
skin prior to catheter insertion
•  Bathe patients daily with chlorhexidine-
based product rather than soap and water
•  Use chlorhexidine-containing dressings
at catheter insertion sites
Real potential of development of
Chlorhexidine resistance!!
Catheter Hubs and Connectors
•  Clean catheter hubs and connectors
before accessing them
•  Consider alcohol-impregnated port
protector
Impregnated catheters
• consider use in individual patients or
patient populations with a high incidence
of CLABSI despite compliance with basic
infection control practice
• balance pro and con of using more
chlorhexidine and local antibiotics

9
Meta-Analysis of CRBSI in Prospective, Randomized Clinical Trials
Casey, Mermel, et al, Lancet ID 2008
First generation CSS: chlorhexidine and silver on external surface
Second generation CSS: as first generation + chlorhexidine on internal surface
Meta-Analysis of CRBSI in Prospective, Randomized Clinical Trials
Minocyclin-Rifampin impregnated
Casey, Mermel, et al, Lancet ID 2008
Recommendations
•  Line cart or kit with all components needed
for aseptic catheter insertion
•  Checklist for catheter insertion
•  Maximal barrier precautions for CVC insertion
•  Disinfect skin before catheter insertion
•  Minimize femoral line placement
•  Catheter insertion & maintenance using a
hospital-wide approach to infection
prevention by ‘bundling’ multiple evidence-
based strategies
Brief report
Idle central venous catheter-days pose infection risk for patients
after discharge from intensive care
Gabrielle Burdeu RN, Grad Dip Crit Care a,
*, Judy Currey RN, PhD a
,
David Pilcher MBBS, MRCP, FRACP, FCICM b,c
a
School of Nursing and Midwifery, Deakin University, Burwood, Victoria, Australia
b
Department of Intensive Care, The Alfred, Melbourne, Victoria, Australia
c
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Key Words:
Sepsis
Idle days
Evidence-based practice
Catheter-related infection
This prospective observational study measured idle central venous catheter (CVC)-days (no medical
indication), and ward clinicians’ adherence to evidence-based practices for preventing short-term central
lineeassociated bloodstream infections (CLABSIs). In 340 patients discharged from ICU over a 1-year
period, 208 of 794 CVC-days (26.2%) were idle. Interventions to prevent CLABSIs were poorly imple-
mented. Ward clinicians need education regarding risk management strategies to prevent CLABSIs, and
clear accountability processes for prompt catheter removal are recommended.
Crown Copyright Ó 2014 Published by Elsevier Inc. on behalf of the Association for Professionals in
Infection Control and Epidemiology, Inc. All rights reserved.
Central venous catheters (CVCs) are vital for assessing and
managing critically ill patients in the intensive care unit (ICU). The
use of CVCs comes with inherent risks, most notably central linee
associated blood stream infections (CLABSIs), which are associated
with increased morbidity, mortality and health care costs.1
Imple-
menting practices to reduce CLABSIs have been confined mostly to
ICUs, putting patients discharged from ICUs to wards with a CVC in
place at risk for development of CLABSI. Recent US data show 20.1
million CVC-days and 23,000 CLABSIs in non-ICU wards in 2009.2
Guidelines strongly recommend prompt removal of CVCs
(category 1A),3
because the risk of developing CLABSIs increases
with each day of prolonged use.4
Idle CVC-days represent continued
use of CVCs without justification by medical indications. Investi-
gating the number of idle CVC-days, along with the use of post-
insertion interventions known to prevent CLABSIs,3
will identify the
scope of the problem and enable the development of specifically
targeted interventions to implement evidence-based practices.
Thus, the aims of this study were to quantify idle CVC-days in pa-
tients discharged from ICUs to general wards, and describe the use
of evidence-based postinsertion nursing interventions to reduce
CLABSIs.
METHODS
Following hospital Ethics Committee approval, a prospective
observational design was used to quantify the number of idle
CVC-days and the use of evidence-based interventions known to
prevent CLABSIs. The setting was a 460-bed quaternary hospital
with a 36-bed ICU. All patients discharged from the ICU with an
uncuffed CVC (cardiopulmonary catheter sheath or multilumen
catheter) for short-term therapy or monitoring were included. Pa-
tients with a cuffed, implanted, or tunneled CVC for long-term
therapy, such as chemotherapy, were excluded.
Between October 2009 and October 2010, outreach ICU nurses
conducted daily assessments until CVC removal as part of their
usual role. An idle CVC-day was defined as a day of CVC insertion
without a documented or observable medical indication for use
(Table 1). Evidence-based postinsertion nursing management
practices included the use of an occlusive dressing, use of a bio-
patch, anchored lines, particulate matter absent in lumens and
connectors, documentation of CVC line change due date, and a
process for maintaining lumen patency (infusion or prescribed
flush).3
RESULTS AND DISCUSSION
Of the 1,650 patients discharged from the ICU to wards, 340
(21%) had a short-term CVC in place. The median duration of ward-
based CVC use was 2.34 days (interquartile range, 1-3 days; range,
1-15 days). A total of 794 daily assessments were conducted by
* Address correspondence to Gabrielle Burdeu, RN, Grad Dip Crit Care, 59
Wandsworth Rd, Surrey Hills, Victoria 3127, Australia.
E-mail address: gabby.burdeu@deakin.edu.au (G. Burdeu).
This study was funded by a June Allen Scholarship from the Nurses Board
Victoria.
Conflict of interest: None to report.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of
Infection Control
0196-6553/$36.00 - Crown Copyright Ó 2014 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2013.11.011
American Journal of Infection Control 42 (2014) 453-5
Brief report
Idle central venous catheter-days pose infection risk for patients
after discharge from intensive care
Gabrielle Burdeu RN, Grad Dip Crit Care a,
*, Judy Currey RN, PhD a
,
David Pilcher MBBS, MRCP, FRACP, FCICM b,c
a
School of Nursing and Midwifery, Deakin University, Burwood, Victoria, Australia
b
Department of Intensive Care, The Alfred, Melbourne, Victoria, Australia
c
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Key Words:
Sepsis
Idle days
Evidence-based practice
Catheter-related infection
This prospective observational study measured idle central venous catheter (C
indication), and ward clinicians’ adherence to evidence-based practices for preven
lineeassociated bloodstream infections (CLABSIs). In 340 patients discharged fr
period, 208 of 794 CVC-days (26.2%) were idle. Interventions to prevent CLABS
mented. Ward clinicians need education regarding risk management strategies to
clear accountability processes for prompt catheter removal are recommended.
Crown Copyright Ó 2014 Published by Elsevier Inc. on behalf of the Associati
Infection Control and Epidemiology, I
Central venous catheters (CVCs) are vital for assessing and
managing critically ill patients in the intensive care unit (ICU). The
use of CVCs comes with inherent risks, most notably central linee
associated blood stream infections (CLABSIs), which are associated
with increased morbidity, mortality and health care costs.1
Imple-
menting practices to reduce CLABSIs have been confined mostly to
METHODS
Following hospital Ethics Committee app
observational design was used to quantify
CVC-days and the use of evidence-based inte
prevent CLABSIs. The setting was a 460-bed
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of Infection Control 42 (2014) 453-5
Daily assessment of catheter use
208/794 days = 26% of the time
CVCs were idle!

10
Remove catheters
as soon as possible!!
Compendium & Guidelines for
Prevention of Intravascular
Catheter-Related Infections
•  Marschall J, Mermel L, et al.
ICHE 2014
•  O’Grady N, et al. Clin Infect Dis 2011

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