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  • Guideline Summary
  • NGC:008683
  • 1996 (revised 2011)

Guidelines for the prevention of intravascular catheter-related infections, 2011.

O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph A, Rupp ME, Saint S, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections, 2011. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2011. 83 p. [370 references]

This is the current release of the guideline.

This guideline updates a previously released version: O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections [published erratum appears in MMWR Weekly 2002 Aug 16;51(32):71]. MMWR Recomm Rep 2002 Aug 9;51(RR-10):1-29.

Age Group

UMLS Concepts (what is this?)

SNOMEDCT_US
Antibiotic (255631004), Antibiotic prophylaxis (422181004), Anticoagulant (372862008), Anticoagulant (81839001), Arterial catheter (303727009), Bacitracin (370330005), Bacitracin (5220000), Bacteremia (5758002), Bandage (63995005), Chlorhexidine (373568007), Chlorhexidine (96316004), Contaminated equipment (90583005), Coronary artery infusion catheter (467955008), Cross infection (36406009), Gramicidin (387524003), Gramicidin (91479004), Hemodialysis catheter (450866001), Infection associated with catheter (440653007), Infection control procedure (77248004), Intravenous administration set (705994005), Iodine (325330005), Iodine (44588005), Isopropyl alcohol 70% injection swab (356858000), Peripherally inserted central catheter (398176008), Polymyxin B (372824005), Polymyxin B (6960003), Replacement of catheter (103713001), Site of intravenous insertion (406148008)

Major Recommendations

Definitions for the categories of the recommendations (IA-II, Unresolved issue) are provided at the end of the "Major Recommendations" field.

Education, Training, and Staffing

  1. Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections (Yoo et al., 2001; Warren et al., 2003; Warren et al., 2004; Warren et al., 2006; Higuera et al., 2005; Coopersmith et al., 2002; Coopersmith et al., 2004; Sherertz et al., 2000; Eggimann et al., 2000). Category IA
  2. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters (Yoo et al., 2001; Warren et al., 2003; Warren et al., 2004; Warren et al., 2006; Higuera et al., 2005; Coopersmith et al., 2002; Coopersmith et al., 2004; Sherertz et al., 2000; Eggimann et al., 2000). Category IA
  3. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters (Sherertz et al., 2000; Eggimann et al., 2000; Nehme, 1980; Soifer et al., 1998; Tomford et al., 1984; Scalley, Van, & Cochran, 1992; Palefski & Stoddard, 2001; Miller et al., 1996; Hunter, 2003; Hawes, 2007; Brunelle, 2003; Bosma & Jewesson, 2002; Pierce & Baker, 2004; Tomford & Hershey, 1985; Davis et al., 1999). Category IA
  4. Ensure appropriate nursing staff levels in intensive care units (ICUs). Observational studies suggest that a higher proportion of "pool nurses" or an elevated patient-to-nurse ratio is associated with catheter-related bloodstream infections (CRBSIs) in ICUs where nurses are managing patients with central venous catheters (CVCs) (Alonso-Echanove et al., 2003; Fridkin et al., 1996; Robert et al., 2000). Category IB

Selection of Catheters and Sites

Peripheral Catheters and Midline Catheters

  1. In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. Category II
  2. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site (Maki, Goldman, & Rhame, 1973; Band & Maki, 1980). Category II
  3. Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators (Band & Maki, 1980; Tully et al., 1981; Ryder, 1995). Category IB
  4. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs (Band & Maki, 1980; Tully et al., 1981). Category IA
  5. Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of intravenous (IV) therapy will likely exceed six days. Category II
  6. Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection. If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually. Category II
  7. Remove peripheral venous catheters if the patient develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter (Maki & Ringer, 1991). Category IB

Central Venous Catheters

  1. Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement) (Mermel et al., 1991; Parienti et al., 2008; Moretti et al., 2005; Nagashima et al., 2006; Ruesch, Walder, & Tramer, 2002; Sadoyama & Gontijo Filho, 2003; Heard et al., 1998; Richet et al., 1990; Safdar, Kluger, & Maki, 2002; Lorente et al., 2006; Traore, Liotier, & Souweine, 2005; Joynt et al., 2000; Mian et al., 1997; Merrer et al., 2001; Goetz et al., 1998; Robinson et al., 1995; Trottier et al., 1995). Category IA
  2. Avoid using the femoral vein for central venous access in adult patients (Parienti et al., 2008; Merrer et al., 2001; Goetz et al., 1998; Lorente et al., 2005). Category 1A
  3. Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement (Merrer et al., 2001; Goetz et al., 1998; Robinson et al., 1995). Category IB
  4. No recommendation can be made for a preferred site of insertion to minimize infection risk for a tunneled CVC. Unresolved issue
  5. Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis (Trottier et al., 1995; Schillinger et al., 1991; Cimochowski et al., 1990; Barrett et al., 1988; Trerotola et al., 2000). Category IA
  6. Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis ("III. NKF-K/DOQI clinical practice guidelines," 2001). Category 1A
  7. Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique (Hind et al., 2003; Randolph et al., 1996; Froehlich et al., 2009; Lamperti et al., 2008; Schweickert et al., 2009). Category 1B
  8. Use a CVC with the minimum number of ports or lumens essential for the management of the patient (Clark-Christoff et al., 1992; Early et al., 1990; Hilton et al., 1988; Yeung, May, & Hughes, 1988). Category IB
  9. No recommendation can be made regarding the use of a designated lumen for parenteral nutrition. Unresolved issue
  10. Promptly remove any intravascular catheter that is no longer essential (Pronovost et al., 2006; Berenholtz et al., 2004; Lederle et al., 1992; Parenti et al., 1994). Category IA
  11. When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e., within 48 hours (Mermel et al., 1991; Abi-Said et al., 1999; Capdevila, Segarra, & Pahissa, 1998; Mermel & Maki, 1994; Raad et al., 1994). Category IB

Hand Hygiene and Aseptic Technique

  1. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained (Coopersmith et al., 2002; Boyce & Pittet, 2002; Bischoff et al., 2000; Pittet et al., 1999). Category IB
  2. Maintain aseptic technique for the insertion and care of intravascular catheters (Mermel et al., 1991; Abi-Said et al., 1999; Capdevila, Segarra, & Pahissa, 1998; Raad et al., 1994). Category IB
  3. Wear clean, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application of skin antiseptics. Category IC
  4. Sterile gloves should be worn for the insertion of arterial, central, and midline catheters (Mermel et al., 1991; Abi-Said et al., 1999; Capdevila, Segarra, & Pahissa, 1998; Raad et al., 1994). Category IA
  5. Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
  6. Wear either clean or sterile gloves when changing the dressing on intravascular catheters. Category IC

Maximal Sterile Barrier Precautions

  1. Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange (Sheretz et al., 2000; Mermel & Maki, 1994; Raad et al., 1994; Carrer et al., 2005). Category IB
  2. Use a sterile sleeve to protect pulmonary artery catheters during insertion (Cohen et al., 1998). Category IB

Skin Preparation

  1. Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion (Maki, Ringer, & Alvarado, 1991). Category IB
  2. Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives (Maki, Ringer, & Alvarado, 1991; Mimoz et al., 1996). Category IA
  3. No comparison has been made between using chlorhexidine preparations with alcohol and povidone-iodine in alcohol to prepare clean skin. Unresolved issue
  4. No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Unresolved issue
  5. Antiseptics should be allowed to dry according to the manufacturer's recommendation prior to placing the catheter (Maki, Ringer, & Alvarado, 1991; Mimoz et al., 1996). Category IB

Catheter Site Dressing Regimens

  1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site (Maki et al., 1994; Bijma et al., 1999; Madeo et al., 1998; Laura et al., 2000). Category IA
  2. If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved (Maki et al., 1994; Bijma et al., 1999; Madeo et al., 1998; Laura et al., 2000). Category II
  3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled (Maki et al., 1994; Bijma et al., 1999). Category IB
  4. Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance (Zakrzewska-Bode et al., 1995; Flowers et al., 1989). Category IB
  5. Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower) (Robbins, Cromwell, & Korones, 1999; Howell et al., 1995; Ivy et al., 2009). Category IB
  6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. Category II
  7. Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing (Laura et al., 2000; Timsit et al., 2009). Category IB
  8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. Category II
  9. No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. Unresolved issue
  10. Ensure that catheter site care is compatible with the catheter material (Rao & Oreopoulos, 1997; Riu et al., 1998). Category IB
  11. Use a sterile sleeve for all pulmonary artery catheters (Cohen et al., 1998). Category IB
  12. Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the central line–associated bloodstream infection (CLABSI) rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, and maximum sterile barrier (MSB) (Timsit et al., 2009; Garland et al., 2001; Ho & Litton, 2006; Levy et al., 2005). Category 1B
  13. No recommendation is made for other types of chlorhexidine dressings. Unresolved issue
  14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site (Lorenzen & Itkin, 1992; White, 1992; White & Ragland, 1994). Category IB
  15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category II

Patient Cleansing

Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI (Bleasdale et al., 2007; Munoz-Price et al., 2009; Popovich et al., 2009). Category II

Catheter Securement Devices

Use a sutureless securement device to reduce the risk of infection for intravascular catheters (Yamamoto et al., 2002). Category II

Antimicrobial/Antiseptic Impregnated Catheters and Cuffs

Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion (Brun-Buisson et al., 2004; Ostendorf et al., 2005; Rupp et al., 2005; Darouiche et al., 1999; Raad et al., 1997; Hanna et al., 2004; Bhutta et al., 2007; Chelliah et al., 2007). Category IA

Systemic Antibiotic Prophylaxis

Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI (van de Wetering & van Woensel, 2007). Category IB

Antibiotic/Antiseptic Ointments

Use povidone iodine antiseptic ointment or bacitracin/gramicidin/polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer's recommendation ("III. NKF-K/DOQI clinical practice guidelines," 2001; Maki & Band; 1981; Fukunaga et al., 2004; Johnson et al., 2002; Fong, 1993; Levin et al., 1991). Category IB

Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis

Use prophylactic antimicrobial lock solution in patients with long term catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique (Schwartz et al., 1990; Rackoff et al., 1995; Carratala et al., 1999; Jurewitsch et al., 1998; Henrickson et al., 2000; Garland et al., 2005; Daghistani et al., 1996; Barriga et al., 1997; Dogra et al., 2002; Allon, 2003; Elhassan et al., 2004; McIntyre et al., 2004; Betjes & van Agteren, 2004; Weijmer et al., 2005; Bleyer et al., 2005; Kim et al., 2006; Al-Hwiesh & Abdul-Rahman, 2007; Nori et al., 2006; Saxena et al., 2006). Category II

Anticoagulants

Do not routinely use anticoagulant therapy to reduce the risk of catheter-related infection in general patient populations (Randolph et al., 1998). Category II

Replacement of Peripheral and Midline Catheters

  1. There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults (Maki & Ringer, 1991; Tager et al., 1983; Lai, 1998). Category 1B
  2. No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated (Van Donk et al., 2009; Webster et al., 2008; Webster et al., 2010). Unresolved issue
  3. Replace peripheral catheters in children only when clinically indicated (Maki, Goldman, & Rhame, 1973; Band & Maki, 1980). Category 1B
  4. Replace midline catheters only when there is a specific indication. Category II

Replacement of CVCs, Including PICCs and Hemodialysis Catheters

  1. Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. Category IB
  2. Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Category II
  3. Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection. Category IB
  4. Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. Category IB
  5. Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. Category IB
  6. Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II

Umbilical Catheters

  1. Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency in the lower extremities, or thrombosis are present (Boo et al., 1999). Category II
  2. Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present (Boo et al., 1999). Category II
  3. No recommendation can be made regarding attempts to salvage an umbilical catheter by administering antibiotic treatment through the catheter. Unresolved issue
  4. Cleanse the umbilical insertion site with an antiseptic before catheter insertion. Avoid tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine-containing products (e.g., povidone iodine) can be used (Garland et al., 1995; Krauss, Albert, & Kannan, 1970; Landers et al., 1991; Cronin, Germanson, & Donowitz, 1990; Miller et al., 1989). Category IB
  5. Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance (Zakrzewska-Bode et al., 1995; Flowers et al., 1989). Category IA
  6. Add low-doses of heparin (0.25—1.0 U/ml) to the fluid infused through umbilical arterial catheters (Ankola & Atakent, 1993; David et al., 1981; Horgan et al, 1987). Category IB
  7. Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Optimally, umbilical artery catheters should not be left in place >5 days (Boo et al., 1999; Fletcher et al., 1994). Category II
  8. Umbilical venous catheters should be removed as soon as possible when no longer needed, but can be used up to 14 days if managed aseptically (Seguin et al., 1994; Loisel et al., 1996). Category II
  9. An umbilical catheter may be replaced if it is malfunctioning, and there is no other indication for catheter removal, and the total duration of catheterization has not exceeded 5 days for an umbilical artery catheter or 14 days for an umbilical vein catheter. Category II

Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric Patients

  1. In adults, use of the radial, brachial, or dorsalis pedis sites is preferred over the femoral or axillary sites of insertion to reduce the risk of infection (Lorente et al., 2006; Traore, Liotier, & Souweine, 2006; Martin et al., 2001; Koh et al., 2008). Category IB
  2. In children, the brachial site should not be used. The radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion (Lorente et al., 2006). Category II
  3. A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion (Traore, Liotier, & Souweine, 2005; Koh et al., 2008; Rijinders et al., 2003). Category IB
  4. During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. Category II
  5. Replace arterial catheters only when there is a clinical indication. Category II
  6. Remove the arterial catheter as soon as it is no longer needed. Category II
  7. Use disposable, rather than reusable, transducer assemblies when possible (Donowitz et al., 1979; Luskin et al., 1986; Maki & Hassemer, 1981; Mermel & Maki, 1989; Tenold et al., 1987). Category IB
  8. Do not routinely replace arterial catheters to prevent catheter-related infections (Eyer et al., 1990; Raad et al., 1993; Thomas et al., 1983; Leroy et al., 1989). Category II
  9. Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced (Mermel et al., 1991; Luskin et al., 1986). Category IB
  10. Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile (Donowitz et al., 1979; Fisher et al., 1981; Stamm et al., 1975; Weinstein et al., 1976). Category IA
  11. Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed flush system (i.e., continuous flush), rather than an open system (i.e., one that requires a syringe and stopcock), to maintain the patency of the pressure monitoring catheters (Mermel & Maki, 1989; Shinozaki et al., 1983). Category II
  12. When the pressure monitoring system is accessed through a diaphragm, rather than a stopcock, scrub the diaphragm with an appropriate antiseptic before accessing the system (Mermel & Maki, 1989). Category IA
  13. Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit (Mermel & Maki, 1989; Solomon et al., 1986; Weems et al., 1987). Category IA
  14. Sterilize reusable transducers according to the manufacturers' instructions if the use of disposable transducers is not feasible (Mermel & Maki, 1989; Solomon et al., 1986; Weems et al., 1987; Villarino et al., 1989; Beck-Sague et al., 1990). Category IA

Replacement of Administration Sets

  1. In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, (Gillies et al., 2005) but at least every 7 days (Sitges-Serra et al., 1985; Snydman et al., 1987; Maki et al., 1987; Josephson et al., 1985). Category IA
  2. No recommendation can be made regarding the frequency for replacing intermittently used administration sets. Unresolved issue
  3. No recommendation can be made regarding the frequency for replacing needles to access implantable ports. Unresolved issue
  4. Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion (Melly, Meng, & Schaffner, 1975; Mershon et al., 1986; Gilbert et al., 1986; Maki & Martin, 1975). Category IB
  5. Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed, per the manufacturer's recommendation (Bennett et al., 1995). Category IA
  6. No recommendation can be made regarding the length of time a needle used to access implanted ports can remain in place. Unresolved issue

Needleless Intravascular Catheter Systems

  1. Change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently than every 72 hours (Moretti et al., 2005; Arduino et al., 1997; Brown, Moss, & Elliott, 1997; Cookson et al., 1998; Seymour et al., 2000; Luebke et al., 1998; McDonald, Banerjee, & Jarvis, 1998; Mendelson et al., 1998). Category II
  2. Change needleless connectors no more frequently than every 72 hours or according to manufacturers' recommendations for the purpose of reducing infection rates (Arduino et al., 1997; Cookson et al., 1998; McDonald, Banerjee, & Jarvis, 1998; Mendelson et al., 1998). Category II
  3. Ensure that all components of the system are compatible to minimize leaks and breaks in the system (Do et al., 1999). Category II
  4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices (Cookson et al., 1998; McDonald, Banerjee, & Jarvis, 1998; Do et al., 1999; Soothill et al., 2009; Casey et al., 2007). Category IA
  5. Use a needleless system to access IV tubing. Category IC
  6. When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves (Rupp et al., 2007; Salgado et al., 2007; Maragakis et al., 2006; Field et al., 2007). Category II

Performance Improvement

Use hospital-specific or collaborative-based performance improvement initiatives in which multifaceted strategies are "bundled" together to improve compliance with evidence-based recommended practices (Eggimann et al., 2000; Pronovost et al., 2006; Berenholtz et al., 2004; Costello et al., 2008; Frankel et al., 2005; Galpern et al., 2008; McKee et al., 2008; Pronovost, Berenholtz, & Goeschel, 2008). Category IB

Definitions:

Recommendations Grading Scheme

Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies

Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence

Category IC. Required by state or federal regulations, rules, or standards

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale

Unresolved Issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Catheter-related bloodstream infections (CRBSI)

Guideline Category

Prevention

Clinical Specialty

Anesthesiology

Cardiology

Critical Care

Infectious Diseases

Internal Medicine

Nursing

Oncology

Pediatrics

Preventive Medicine

Pulmonary Medicine

Radiation Oncology

Surgery

Intended Users

Advanced Practice Nurses

Allied Health Personnel

Health Care Providers

Hospitals

Nurses

Physician Assistants

Physicians

Guideline Objective(s)

To provide evidence-based recommendations for preventing intravascular catheter-related infections

Target Population

Adults and children requiring the placement of intravascular catheters

Interventions and Practices Considered

Strategies for Prevention of Catheter-related Infections

  1. Education and training of staff
  2. Selection of site for catheter insertion
  3. Selection of catheter based on intended purpose, duration of use, known complications, and experience of catheter operator
  4. Hand hygiene and aseptic technique during catheter insertion
  5. Sterile barrier precautions
  6. Skin preparation with chlorhexidine, tincture of iodine, or 70% alcohol
  7. Catheter site dressing regimens
  8. Patient cleansing with 2% chlorhexidine wash
  9. Use of catheter securement devices
  10. Use of antimicrobial/antiseptic impregnated catheters and cuffs
  11. Systemic antibiotic prophylaxis (considered but not recommended routinely)
  12. Application of antibiotic/antiseptic ointment (e.g., povidone-iodine, bacitracin/gramicidin/polymyxin B) to catheter site
  13. Antibiotic lock prophylaxis
  14. Anticoagulant (considered but not recommended in general patient population)
  15. Scheduled replacement of catheters
  16. Special considerations for umbilical catheters and peripheral arterial catheters and pressure monitoring devices
  17. Replacement of administration sets
  18. Use of needleless infusion systems

Major Outcomes Considered

  • Incidence of and risk for intravascular catheter-related infection and phlebitis
  • Morbidity and mortality due to intravascular catheter-related infections
  • Healthcare costs associated with intravascular catheter-related infections

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Medline and PubMed were searched from 2000 to 2009 using the terms Catheter-Related Infections, prevention, Catheterization, Central Venous/adverse effects, methods, standards, Catheterization, Peripheral/adverse effects Catheterization, Peripheral/methods Catheterization, peripheral/standards, Handwashing/standards. The committee focused on human studies published in the English language.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Not stated

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, healthcare infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Diseases Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), American Society for Parenteral and Enteral Nutrition (ASPEN), Society of Interventional Radiology (SIR), American Academy of Pediatrics (AAP), Pediatric Infectious Diseases Society (PIDS), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Catheter-Related Infections published in 2002.

Rating Scheme for the Strength of the Recommendations

Recommendations Grading Scheme

Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies

Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence

Category IC. Required by state or federal regulations, rules, or standards

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale

Unresolved Issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists

Cost Analysis

Guideline developers reviewed published cost analyses.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

References Supporting the Recommendations

Abi-Said D, Raad I, Umphrey J, Gonzalez V, Richardson D, Marts K, Hohn D. Infusion therapy team and dressing changes of central venous catheters. Infect Control Hosp Epidemiol. 1999 Feb;20(2):101-5. PubMed External Web Site Policy

Al-Hwiesh AK, Abdul-Rahman IS. Successful prevention of tunneled, central catheter infection by antibiotic lock therapy using vancomycin and gentamycin. Saudi J Kidney Dis Transpl. 2007 Jun;18(2):239-47. PubMed External Web Site Policy

Allon M. Prophylaxis against dialysis catheter-related bacteremia with a novel antimicrobial lock solution. Clin Infect Dis. 2003 Jun 15;36(12):1539-44. PubMed External Web Site Policy

Alonso-Echanove J, Edwards JR, Richards MJ, Brennan P, Venezia RA, Keen J, Ashline V, Kirkland K, Chou E, Hupert M, Veeder AV, Speas J, Kaye J, Sharma K, Martin A, Moroz VD, Gaynes RP. Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units. Infect Control Hosp Epidemiol. 2003 Dec;24(12):916-25. PubMed External Web Site Policy

Ankola PA, Atakent YS. Effect of adding heparin in very low concentration to the infusate to prolong the patency of umbilical artery catheters. Am J Perinatol. 1993 May;10(3):229-32. PubMed External Web Site Policy

Arduino MJ, Bland LA, Danzig LE, McAllister SK, Aguero SM. Microbiologic evaluation of needleless and needle-access devices. Am J Infect Control. 1997 Oct;25(5):377-80. PubMed External Web Site Policy

Band JD, Maki DG. Steel needles used for intravenous therapy. Morbidity in patients with hematologic malignancy. Arch Intern Med. 1980 Jan;140(1):31-4. PubMed External Web Site Policy

Barrett N, Spencer S, McIvor J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheters. Nephrol Dial Transplant. 1988;3(4):423-5. PubMed External Web Site Policy

Barriga FJ, Varas M, Potin M, Sapunar F, Rojo H, Martinez A, Capdeville V, Becker A, Vial PA. Efficacy of a vancomycin solution to prevent bacteremia associated with an indwelling central venous catheter in neutropenic and non-neutropenic cancer patients. Med Pediatr Oncol. 1997 Mar;28(3):196-200. PubMed External Web Site Policy

Beck-Sague CM, Jarvis WR, Brook JH, Culver DH, Potts A, Gay E, Shotts BW, Hill B, Anderson RL, Weinstein MP. Epidemic bacteremia due to Acinetobacter baumannii in five intensive care units. Am J Epidemiol. 1990;132(4):723-33. PubMed External Web Site Policy

Bennett SN, McNeil MM, Bland LA, Arduino MJ, Villarino ME, Perrotta DM, Burwen DR, Welbel SF, Pegues DA, Stroud L, et al.. Postoperative infections traced to contamination of an intravenous anesthetic, propofol. N Engl J Med. 1995 Jul 20;333(3):147-54. PubMed External Web Site Policy

Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004 Oct;32(10):2014-20. PubMed External Web Site Policy

Betjes MG, van Agteren M. Prevention of dialysis catheter-related sepsis with a citrate-taurolidine-containing lock solution. Nephrol Dial Transplant. 2004 Jun;19(6):1546-51. PubMed External Web Site Policy

Bhutta A, Gilliam C, Honeycutt M, Schexnayder S, Green J, Moss M, Anand KJ. Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ. 2007 Feb 17;334(7589):362-5. PubMed External Web Site Policy

Bijma R, Girbes AR, Kleijer DJ, Zwaveling JH. Preventing central venous catheter-related infection in a surgical intensive-care unit. Infect Control Hosp Epidemiol. 1999 Sep;20(9):618-20. PubMed External Web Site Policy

Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med. 2000 Apr 10;160(7):1017-21. PubMed External Web Site Policy

Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007 Oct 22;167(19):2073-9. PubMed External Web Site Policy

Bleyer AJ, Mason L, Russell G, Raad II, Sherertz RJ. A randomized, controlled trial of a new vascular catheter flush solution (minocycline-EDTA) in temporary hemodialysis access. Infect Control Hosp Epidemiol. 2005 Jun;26(6):520-4. PubMed External Web Site Policy

Boo NY, Wong NC, Zulkifli SS, Lye MS. Risk factors associated with umbilical vascular catheter-associated thrombosis in newborn infants. J Paediatr Child Health. 1999 Oct;35(5):460-5. PubMed External Web Site Policy

Bosma TL, Jewesson PJ. An infusion program resource nurse consult service: our experience in a major Canadian teaching hospital. J Infus Nurs. 2002 Sep-Oct;25(5):310-5. PubMed External Web Site Policy

Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002 Dec;23(12 Suppl):S3-40. PubMed External Web Site Policy

Brown JD, Moss HA, Elliott TS. The potential for catheter microbial contamination from a needleless connector. J Hosp Infect. 1997 Jul;36(3):181-9. PubMed External Web Site Policy

Brun-Buisson C, Doyon F, Sollet JP, Cochard JF, Cohen Y, Nitenberg G. Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazine-coated catheters: a randomized controlled trial. Intensive Care Med. 2004 May;30(5):837-43. PubMed External Web Site Policy

Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections. J Infus Nurs. 2003 Nov-Dec;26(6):362-6. PubMed External Web Site Policy

Capdevila JA, Segarra A, Pahissa A. Catheter-related bacteremia in patients undergoing hemodialysis. Ann Intern Med. 1998 Apr 1;128(7):600. PubMed External Web Site Policy

Carratala J, Niubo J, Fernandez-Sevilla A, Juve E, Castellsague X, Berlanga J, Linares J, Gudiol F. Randomized, double-blind trial of an antibiotic-lock technique for prevention of gram-positive central venous catheter-related infection in neutropenic patients with cancer. Antimicrob Agents Chemother. 1999 Sep;43(9):2200-4. PubMed External Web Site Policy

Carrer S, Bocchi A, Bortolotti M, Braga N, Gilli G, Candini M, Tartari S. Effect of different sterile barrier precautions and central venous catheter dressing on the skin colonization around the insertion site. Minerva Anestesiol. 2005 May;71(5):197-206. PubMed External Web Site Policy

Casey AL, Burnell S, Whinn H, Worthington T, Faroqui MH, Elliott TS. A prospective clinical trial to evaluate the microbial barrier of a needleless connector. J Hosp Infect. 2007 Mar;65(3):212-8. PubMed External Web Site Policy

Chelliah A, Heydon KH, Zaoutis TE, Rettig SL, Dominguez TE, Lin R, Patil S, Feudtner C, St John KH, Bell LM, Coffin SE. Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients. Pediatr Infect Dis J. 2007 Sep;26(9):816-20. PubMed External Web Site Policy

Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron. 1990;54(2):154-61. PubMed External Web Site Policy

Clark-Christoff N, Watters VA, Sparks W, Snyder P, Grant JP. Use of triple-lumen subclavian catheters for administration of total parenteral nutrition. JPEN J Parenter Enteral Nutr. 1992 Sep-Oct;16(5):403-7. PubMed External Web Site Policy

Cohen Y, Fosse JP, Karoubi P, Reboul-Marty J, Dreyfuss D, Hoang P, Cupa M. The "hands-off" catheter and the prevention of systemic infections associated with pulmonary artery catheter: a prospective study. Am J Respir Crit Care Med. 1998 Jan;157(1):284-7. PubMed External Web Site Policy

Cookson ST, Ihrig M, O'Mara EM, Denny M, Volk H, Banerjee SN, Hartstein AI, Jarvis WR. Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device. Infect Control Hosp Epidemiol. 1998 Jan;19(1):23-7. PubMed External Web Site Policy

Coopersmith CM, Rebmann TL, Zack JE, Ward MR, Corcoran RM, Schallom ME, Sona CS, Buchman TG, Boyle WA, Polish LB, Fraser VJ. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med. 2002 Jan;30(1):59-64. PubMed External Web Site Policy

Coopersmith CM, Zack JE, Ward MR, Sona CS, Schallom ME, Everett SJ, Huey WY, Garrison TM, McDonald J, Buchman TG, Boyle WA, Fraser VJ, Polish LB. The impact of bedside behavior on catheter-related bacteremia in the intensive care unit. Arch Surg. 2004 Feb;139(2):131-6. PubMed External Web Site Policy

Costello JM, Morrow DF, Graham DA, Potter-Bynoe G, Sandora TJ, Laussen PC. Systematic intervention to reduce central line-associated bloodstream infection rates in a pediatric cardiac intensive care unit. Pediatrics. 2008 May;121(5):915-23. PubMed External Web Site Policy

Cronin WA, Germanson TP, Donowitz LG. Intravascular catheter colonization and related bloodstream infection in critically ill neonates. Infect Control Hosp Epidemiol. 1990 Jun;11(6):301-8. PubMed External Web Site Policy

Daghistani D, Horn M, Rodriguez Z, Schoenike S, Toledano S. Prevention of indwelling central venous catheter sepsis. Med Pediatr Oncol. 1996 Jun;26(6):405-8. PubMed External Web Site Policy

Darouiche RO, Raad II, Heard SO, Thornby JI, Wenker OC, Gabrielli A, Berg J, Khardori N, Hanna H, Hachem R, Harris RL, Mayhall G. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med. 1999 Jan 7;340(1):1-8. [19 references] PubMed External Web Site Policy

David RJ, Merten DF, Anderson JC, Gross S. Prevention of umbilical artery catheter clots with heparinized infusates. Dev Pharmacol Ther. 1981;2(2):117-26. PubMed External Web Site Policy

Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes. JAMA. 1999 Sep 1;282(9):867-74. PubMed External Web Site Policy

Do AN, Ray BJ, Banerjee SN, Illian AF, Barnett BJ, Pham MH, Hendricks KA, Jarvis WR. Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. J Infect Dis. 1999 Feb;179(2):442-8. PubMed External Web Site Policy

Dogra GK, Herson H, Hutchison B, Irish AB, Heath CH, Golledge C, Luxton G, Moody H. Prevention of tunneled hemodialysis catheter-related infections using catheter-restricted filling with gentamicin and citrate: a randomized controlled study. J Am Soc Nephrol. 2002 Aug;13(8):2133-9. PubMed External Web Site Policy

Donowitz LG, Marsik FJ, Hoyt JW, Wenzel RP. Serratia marcescens bacteremia from contaminated pressure transducers. JAMA. 1979 Oct 19;242(16):1749-51. PubMed External Web Site Policy

Early TF, Gregory RT, Wheeler JR, Snyder SO Jr, Gayle RG. Increased infection rate in double-lumen versus single-lumen Hickman catheters in cancer patients. South Med J. 1990 Jan;83(1):34-6. PubMed External Web Site Policy

Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet JC, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet. 2000 May 27;355(9218):1864-8. PubMed External Web Site Policy

Elhassan NO, Stevens TP, Gigliotti F, Hardy DJ, Cole CA, Sinkin RA. Vancomycin usage in central venous catheters in a neonatal intensive care unit. Pediatr Infect Dis J. 2004 Mar;23(3):201-6. PubMed External Web Site Policy

Eyer S, Brummitt C, Crossley K, Siegel R, Cerra F. Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med. 1990 Oct;18(10):1073-9. PubMed External Web Site Policy

Field K, McFarlane C, Cheng AC, Hughes AJ, Jacobs E, Styles K, Low J, Stow P, Campbell P, Athan E. Incidence of catheter-related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian hematology-oncology unit. Infect Control Hosp Epidemiol. 2007 May;28(5):610-3. PubMed External Web Site Policy

Fisher MC, Long SS, Roberts EM, Dunn JM, Balsara RK. Pseudomonas maltophilia bacteremia in children undergoing open heart surgery. JAMA. 1981 Oct 2;246(14):1571-4. PubMed External Web Site Policy

Fletcher MA, Brown DR, Landers S, Seguin J. Umbilical arterial catheter use: report of an audit conducted by the Study Group for Complications of Perinatal Care. Am J Perinatol. 1994 Mar;11(2):94-9. PubMed External Web Site Policy

Flowers RH 3rd, Schwenzer KJ, Kopel RF, Fisch MJ, Tucker SI, Farr BM. Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. A randomized, controlled trial. JAMA. 1989 Feb 10;261(6):878-83. PubMed External Web Site Policy

Fong IW. Prevention of haemodialysis and peritoneal dialysis catheter related infection by topical povidone-iodine. Postgrad Med J. 1993;69 Suppl 3:S15-7. PubMed External Web Site Policy

Frankel HL, Crede WB, Topal JE, Roumanis SA, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU. J Am Coll Surg. 2005 Sep;201(3):349-58. PubMed External Web Site Policy

Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 1996 Mar;17(3):150-8. PubMed External Web Site Policy

Froehlich CD, Rigby MR, Rosenberg ES, Li R, Roerig PL, Easley KA, Stockwell JA. Ultrasound-guided central venous catheter placement decreases complications and decreases placement attempts compared with the landmark technique in patients in a pediatric intensive care unit. Crit Care Med. 2009 Mar;37(3):1090-6. PubMed External Web Site Policy

Fukunaga A, Naritaka H, Fukaya R, Tabuse M, Nakamura T. Povidone-iodine ointment and gauze dressings associated with reduced catheter-related infection in seriously ill neurosurgical patients. Infect Control Hosp Epidemiol. 2004 Aug;25(8):696-8. PubMed External Web Site Policy

Galpern D, Guerrero A, Tu A, Fahoum B, Wise L. Effectiveness of a central line bundle campaign on line-associated infections in the intensive care unit. Surgery. 2008 Oct;144(4):492-5; discussion 495. PubMed External Web Site Policy

Garland JS, Alex CP, Henrickson KJ, McAuliffe TL, Maki DG. A vancomycin-heparin lock solution for prevention of nosocomial bloodstream infection in critically ill neonates with peripherally inserted central venous catheters: a prospective, randomized trial. Pediatrics. 2005 Aug;116(2):e198-205. PubMed External Web Site Policy

Garland JS, Alex CP, Mueller CD, Otten D, Shivpuri C, Harris MC, Naples M, Pellegrini J, Buck RK, McAuliffe TL, Goldmann DA, Maki DG. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics. 2001 Jun;107(6):1431-6. PubMed External Web Site Policy

Gilbert M, Gallagher SC, Eads M, Elmore MF. Microbial growth patterns in a total parenteral nutrition formulation containing lipid emulsion. JPEN J Parenter Enteral Nutr. 1986 Sep-Oct;10(5):494-7. PubMed External Web Site Policy

Gillies D, O'Riordan L, Wallen M, Morrison A, Rankin K, Nagy S. Optimal timing for intravenous administration set replacement. Cochrane Database Syst Rev. 2005;(4):CD003588. [36 references] PubMed External Web Site Policy

Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998 Nov;19(11):842-5. PubMed External Web Site Policy

Hanna H, Benjamin R, Chatzinikolaou I, Alakech B, Richardson D, Mansfield P, Dvorak T, Munsell MF, Darouiche R, Kantarjian H, Raad I. Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial. J Clin Oncol. 2004 Aug 1;22(15):3163-71. PubMed External Web Site Policy

Hawes ML. A proactive approach to combating venous depletion in the hospital setting. J Infus Nurs. 2007 Jan-Feb;30(1):33-44. PubMed External Web Site Policy

Heard SO, Wagle M, Vijayakumar E, McLean S, Brueggemann A, Napolitano LM, Edwards LP, O'Connell FM, Puyana JC, Doern GV. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. Arch Intern Med. 1998 Jan 12;158(1):81-7. [41 references] PubMed External Web Site Policy

Henrickson KJ, Axtell RA, Hoover SM, Kuhn SM, Pritchett J, Kehl SC, Klein JP. Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: A randomized, multicenter, double-blind trial. J Clin Oncol. 2000 Mar;18(6):1269-78. PubMed External Web Site Policy

Higuera F, Rosenthal VD, Duarte P, Ruiz J, Franco G, Safdar N. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. Crit Care Med. 2005 Sep;33(9):2022-7. PubMed External Web Site Policy

Hilton E, Haslett TM, Borenstein MT, Tucci V, Isenberg HD, Singer C. Central catheter infections: single- versus triple-lumen catheters. Influence of guide wires on infection rates when used for replacement of catheters. Am J Med. 1988 Apr;84(4):667-72. PubMed External Web Site Policy

Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003 Aug 16;327(7411):361. [6 references] PubMed External Web Site Policy

Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother. 2006 Aug;58(2):281-7. [29 references] PubMed External Web Site Policy

Horgan MJ, Bartoletti A, Polansky S, Peters JC, Manning TJ, Lamont BM. Effect of heparin infusates in umbilical arterial catheters on frequency of thrombotic complications. J Pediatr. 1987 Nov;111(5):774-8. PubMed External Web Site Policy

Howell PB, Walters PE, Donowitz GR, Farr BM. Risk factors for infection of adult patients with cancer who have tunnelled central venous catheters. Cancer. 1995 Mar 15;75(6):1367-75. PubMed External Web Site Policy

Hunter MR. Development of a Vascular Access Team in an acute care setting. J Infus Nurs. 2003 Mar-Apr;26(2):86-91. PubMed External Web Site Policy

III. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000. Am J Kidney Dis. 2001 Jan;37(1 Suppl 1):S137-81. PubMed External Web Site Policy

Ivy DD, Calderbank M, Wagner BD, Dolan S, Nyquist AC, Wade M, Nickels WM, Doran AK. Closed-hub systems with protected connections and the reduction of risk of catheter-related bloodstream infection in pediatric patients receiving intravenous prostanoid therapy for pulmonary hypertension. Infect Control Hosp Epidemiol. 2009 Sep;30(9):823-9. PubMed External Web Site Policy

Johnson DW, MacGinley R, Kay TD, Hawley CM, Campbell SB, Isbel NM, Hollett P. A randomized controlled trial of topical exit site mupirocin application in patients with tunnelled, cuffed haemodialysis catheters. Nephrol Dial Transplant. 2002 Oct;17(10):1802-7. PubMed External Web Site Policy

Josephson A, Gombert ME, Sierra MF, Karanfil LV, Tansino GF. The relationship between intravenous fluid contamination and the frequency of tubing replacement. Infect Control. 1985 Sep;6(9):367-70. PubMed External Web Site Policy

Joynt GM, Kew J, Gomersall CD, Leung VY, Liu EK. Deep venous thrombosis caused by femoral venous catheters in critically ill adult patients. Chest. 2000 Jan;117(1):178-83. PubMed External Web Site Policy

Jurewitsch B, Lee T, Park J, Jeejeebhoy K. Taurolidine 2% as an antimicrobial lock solution for prevention of recurrent catheter-related bloodstream infections. JPEN J Parenter Enteral Nutr. 1998 Jul-Aug;22(4):242-4. PubMed External Web Site Policy

Kim SH, Song KI, Chang JW, Kim SB, Sung SA, Jo SK, Cho WY, Kim HK. Prevention of uncuffed hemodialysis catheter-related bacteremia using an antibiotic lock technique: a prospective, randomized clinical trial. Kidney Int. 2006 Jan;69(1):161-4. PubMed External Web Site Policy

Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A. Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters. Crit Care Med. 2008 Feb;36(2):397-402. PubMed External Web Site Policy

Krauss AN, Albert RF, Kannan MM. Contamination of umbilical catheters in the newborn infant. J Pediatr. 1970 Dec;77(6):965-9. PubMed External Web Site Policy

Lai KK. Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours. Am J Infect Control. 1998 Feb;26(1):66-70. PubMed External Web Site Policy

Lamperti M, Caldiroli D, Cortellazzi P, Vailati D, Pedicelli A, Tosi F, Piastra M, Pietrini D. Safety and efficacy of ultrasound assistance during internal jugular vein cannulation in neurosurgical infants. Intensive Care Med. 2008 Nov;34(11):2100-5. PubMed External Web Site Policy

Landers S, Moise AA, Fraley JK, Smith EO, Baker CJ. Factors associated with umbilical catheter-related sepsis in neonates. Am J Dis Child. 1991 Jun;145(6):675-80. PubMed External Web Site Policy

Laura R, Degl'Innocenti M, Mocali M, Alberani F, Boschi S, Giraudi A, Arnaud MT, Zucchinali R, Paris MG, Dallara R, Thaler S, Perobelli G, Parfazi S, De Lazzer T, Peron G. Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a randomized, multicenter study. The Italian Nurse Bone Marrow Transplant Group (GITMO). Haematologica. 2000 Mar;85(3):275-9. PubMed External Web Site Policy

Lederle FA, Parenti CM, Berskow LC, Ellingson KJ. The idle intravenous catheter. Ann Intern Med. 1992 May 1;116(9):737-8. PubMed External Web Site Policy

Leroy O, Billiau V, Beuscart C, Santre C, Chidiac C, Ramage C, Mouton Y. Nosocomial infections associated with long-term radial artery cannulation. Intensive Care Med. 1989;15(4):241-6. PubMed External Web Site Policy

Levin A, Mason AJ, Jindal KK, Fong IW, Goldstein MB. Prevention of hemodialysis subclavian vein catheter infections by topical povidone-iodine. Kidney Int. 1991 Nov;40(5):934-8. [30 references] PubMed External Web Site Policy

Levy I, Katz J, Solter E, Samra Z, Vidne B, Birk E, Ashkenazi S, Dagan O. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J. 2005 Aug;24(8):676-9. PubMed External Web Site Policy

Loisel DB, Smith MM, MacDonald MG, Martin GR. Intravenous access in newborn infants: impact of extended umbilical venous catheter use on requirement for peripheral venous lines. J Perinatol. 1996 Nov-Dec;16(6):461-6. PubMed External Web Site Policy

Lorente L, Henry C, Martin MM, Jimenez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005;9(6):R631-5. PubMed External Web Site Policy

Lorente L, Jimenez A, Iribarren JL, Jimenez JJ, Martin MM, Mora ML. The micro-organism responsible for central venous catheter related bloodstream infection depends on catheter site. Intensive Care Med. 2006 Sep;32(9):1449-50. PubMed External Web Site Policy

Lorenzen AN, Itkin DJ. Surveillance of infection in home care. Am J Infect Control. 1992 Dec;20(6):326-9. PubMed External Web Site Policy

Luebke MA, Arduino MJ, Duda DL, Dudar TE, McAllister SK, Bland LA, Wesley JR. Comparison of the microbial barrier properties of a needleless and a conventional needle-based intravenous access system. Am J Infect Control. 1998 Aug;26(4):437-41. PubMed External Web Site Policy

Luskin RL, Weinstein RA, Nathan C, Chamberlin WH, Kabins SA. Extended use of disposable pressure transducers. A bacteriologic evaluation. JAMA. 1986 Feb 21;255(7):916-20. PubMed External Web Site Policy

Madeo M, Martin CR, Turner C, Kirkby V, Thompson DR. A randomized trial comparing Arglaes (a transparent dressing containing silver ions) to Tegaderm (a transparent polyurethane dressing) for dressing peripheral arterial catheters and central vascular catheters. Intensive Crit Care Nurs. 1998 Aug;14(4):187-91. PubMed External Web Site Policy

Maki DG, Band JD. A comparative study of polyantibiotic and iodophor ointments in prevention of vascular catheter-related infection. Am J Med. 1981 Mar;70(3):739-44. PubMed External Web Site Policy

Maki DG, Botticelli JT, LeRoy ML, Thielke TS. Prospective study of replacing administration sets for intravenous therapy at 48- vs 72-hour intervals. 72 hours is safe and cost-effective. JAMA. 1987 Oct 2;258(13):1777-81. PubMed External Web Site Policy

Maki DG, Goldman DA, Rhame FS. Infection control in intravenous therapy. Ann Intern Med. 1973 Dec;79(6):867-87. [266 references] PubMed External Web Site Policy

Maki DG, Hassemer CA. Endemic rate of fluid contamination and related septicemia in arterial pressure monitoring. Am J Med. 1981 Mar;70(3):733-8. PubMed External Web Site Policy

Maki DG, Martin WT. Nationwide epidemic of septicemia caused by contaminated infusion products. IV. Growth of microbial pathogens in fluids for intravenous infusions. J Infect Dis. 1975 Mar;131(3):267-72. PubMed External Web Site Policy

Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991 Aug 10;338(8763):339-43. [30 references] PubMed External Web Site Policy

Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial. Ann Intern Med. 1991 May 15;114(10):845-54. PubMed External Web Site Policy

Maki DG, Stolz SS, Wheeler S, Mermel LA. A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management. Crit Care Med. 1994 Nov;22(11):1729-37. PubMed External Web Site Policy

Maragakis LL, Bradley KL, Song X, Beers C, Miller MR, Cosgrove SE, Perl TM. Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol. 2006 Jan;27(1):67-70. PubMed External Web Site Policy

Martin C, Saux P, Papazian L, Gouin F. Long-term arterial cannulation in ICU patients using the radial artery or dorsalis pedis artery. Chest. 2001 Mar;119(3):901-6. PubMed External Web Site Policy

McDonald LC, Banerjee SN, Jarvis WR. Line-associated bloodstream infections in pediatric intensive-care-unit patients associated with a needleless device and intermittent intravenous therapy. Infect Control Hosp Epidemiol. 1998 Oct;19(10):772-7. PubMed External Web Site Policy

McIntyre CW, Hulme LJ, Taal M, Fluck RJ. Locking of tunneled hemodialysis catheters with gentamicin and heparin. Kidney Int. 2004 Aug;66(2):801-5. PubMed External Web Site Policy

McKee C, Berkowitz I, Cosgrove SE, Bradley K, Beers C, Perl TM, Winner L, Pronovost PJ, Miller MR. Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality. Pediatr Crit Care Med. 2008 Jan;9(1):40-6. PubMed External Web Site Policy

Melly MA, Meng HC, Schaffner W. Microbiol growth in lipid emulsions used in parenteral nutrition. Arch Surg. 1975 Dec;110(12):1479-81. PubMed External Web Site Policy

Mendelson MH, Short LJ, Schechter CB, Meyers BR, Rodriguez M, Cohen S, Lozada J, DeCambre M, Hirschman SZ. Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of staff, patient, and institutional outcomes. Infect Control Hosp Epidemiol. 1998 Jun;19(6):401-6. PubMed External Web Site Policy

Mermel LA, Maki DG. Epidemic bloodstream infections from hemodynamic pressure monitoring: signs of the times. Infect Control Hosp Epidemiol. 1989 Feb;10(2):47-53. PubMed External Web Site Policy

Mermel LA, Maki DG. Infectious complications of Swan-Ganz pulmonary artery catheters. Pathogenesis, epidemiology, prevention, and management. Am J Respir Crit Care Med. 1994 Apr;149(4 Pt 1):1020-36. [204 references] PubMed External Web Site Policy

Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med. 1991 Sep 16;91(3B):197S-205S. PubMed External Web Site Policy

Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H, Brun-Buisson C, Nitenberg G, French Catheter Study Group in Intensive Care.. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001 Aug 8;286(6):700-7. PubMed External Web Site Policy

Mershon J, Nogami W, Williams JM, Yoder C, Eitzen HE, Lemons JA. Bacterial/fungal growth in a combined parenteral nutrition solution. JPEN J Parenter Enteral Nutr. 1986 Sep-Oct;10(5):498-502. PubMed External Web Site Policy

Mian NZ, Bayly R, Schreck DM, Besserman EB, Richmand D. Incidence of deep venous thrombosis associated with femoral venous catheterization. Acad Emerg Med. 1997 Dec;4(12):1118-21. PubMed External Web Site Policy

Miller JM, Goetz AM, Squier C, Muder RR. Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team. J Intraven Nurs. 1996 Mar-Apr;19(2):103-6. PubMed External Web Site Policy

Miller KL, Coen PE, White WJ, Hurst WJ, Achey BE, Lang CM. Effectiveness of skin absorption of tincture of I in blocking radioiodine from the human thyroid gland. Health Phys. 1989 Jun;56(6):911-4. PubMed External Web Site Policy

Mimoz O, Pieroni L, Lawrence C, Edouard A, Costa Y, Samii K, Brun-Buisson C. Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Crit Care Med. 1996 Nov;24(11):1818-23. [23 references] PubMed External Web Site Policy

Moretti EW, Ofstead CL, Kristy RM, Wetzler HP. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. J Hosp Infect. 2005 Oct;61(2):139-45. PubMed External Web Site Policy

Munoz-Price LS, Hota B, Stemer A, Weinstein RA. Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute care hospital. Infect Control Hosp Epidemiol. 2009 Nov;30(11):1031-5. PubMed External Web Site Policy

Nagashima G, Kikuchi T, Tsuyuzaki H, Kawano R, Tanaka H, Nemoto H, Taguchi K, Ugajin K. To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization. J Infect Chemother. 2006 Dec;12(6):363-5. PubMed External Web Site Policy

Nehme AE. Nutritional support of the hospitalized patient. The team concept. JAMA. 1980 May 16;243(19):1906-8. PubMed External Web Site Policy

Nori US, Manoharan A, Yee J, Besarab A. Comparison of low-dose gentamicin with minocycline as catheter lock solutions in the prevention of catheter-related bacteremia. Am J Kidney Dis. 2006 Oct;48(4):596-605. PubMed External Web Site Policy

Ostendorf T, Meinhold A, Harter C, Salwender H, Egerer G, Geiss HK, Ho AD, Goldschmidt H. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients--a double-blind, randomised, prospective, controlled trial. Support Care Cancer. 2005 Dec;13(12):993-1000. PubMed External Web Site Policy

Palefski SS, Stoddard GJ. The infusion nurse and patient complication rates of peripheral-short catheters. A prospective evaluation. J Intraven Nurs. 2001 Mar-Apr;24(2):113-23. PubMed External Web Site Policy

Parenti CM, Lederle FA, Impola CL, Peterson LR. Reduction of unnecessary intravenous catheter use. Internal medicine house staff participate in a successful quality improvement project. Arch Intern Med. 1994 Aug 22;154(16):1829-32. PubMed External Web Site Policy

Parienti JJ, Thirion M, Megarbane B, Souweine B, Ouchikhe A, Polito A, Forel JM, Marque S, Misset B, Airapetian N, Daurel C, Mira JP, Ramakers M, du Cheyron D, Le Coutour X, Daubin C, Charbonneau P, Members of the Cathedia Study Group. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008 May 28;299(20):2413-22. PubMed External Web Site Policy

Pierce CA, Baker JJ. A nursing process model: quantifying infusion therapy resource consumption. J Infus Nurs. 2004 Jul-Aug;27(4):232-44. PubMed External Web Site Policy

Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999 Apr 26;159(8):821-6. PubMed External Web Site Policy

Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit. Infect Control Hosp Epidemiol. 2009 Oct;30(10):959-63. PubMed External Web Site Policy

Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-32. PubMed External Web Site Policy

Pronovost PJ, Berenholtz SM, Goeschel CA. Improving the quality of measurement and evaluation in quality improvement efforts. Am J Med Qual. 2008 Mar-Apr;23(2):143-6. PubMed External Web Site Policy

Raad I, Darouiche R, Dupuis J, Abi-Said D, Gabrielli A, Hachem R, Wall M, Harris R, Jones J, Buzaid A, Robertson C, Shenaq S, Curling P, Burke T, Ericsson C. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections. A randomized, double-blind trial. The Texas Medical Center Catheter Study Group. Ann Intern Med. 1997 Aug 15;127(4):267-74. PubMed External Web Site Policy

Raad I, Umphrey J, Khan A, Truett LJ, Bodey GP. The duration of placement as a predictor of peripheral and pulmonary arterial catheter infections. J Hosp Infect. 1993 Jan;23(1):17-26. PubMed External Web Site Policy

Raad II, Hohn DC, Gilbreath BJ, Suleiman N, Hill LA, Bruso PA, Marts K, Mansfield PF, Bodey GP. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994 Apr;15(4 Pt 1):231-8. PubMed External Web Site Policy

Rackoff WR, Weiman M, Jakobowski D, Hirschl R, Stallings V, Bilodeau J, Danz P, Bell L, Lange B. A randomized, controlled trial of the efficacy of a heparin and vancomycin solution in preventing central venous catheter infections in children. J Pediatr. 1995 Jul;127(1):147-51. PubMed External Web Site Policy

Randolph AG, Cook DJ, Gonzales CA, Andrew M. Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials. Chest. 1998 Jan;113(1):165-71. PubMed External Web Site Policy

Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med. 1996 Dec;24(12):2053-8. PubMed External Web Site Policy

Rao SP, Oreopoulos DG. Unusual complications of a polyurethane PD catheter. Perit Dial Int. 1997 Jul-Aug;17(4):410-2. PubMed External Web Site Policy

Richet H, Hubert B, Nitemberg G, Andremont A, Buu-Hoi A, Ourbak P, Galicier C, Veron M, Boisivon A, Bouvier AM, et al.. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol. 1990 Nov;28(11):2520-5. PubMed External Web Site Policy

Rijnders BJ, Van Wijngaerden E, Wilmer A, Peetermans WE. Use of full sterile barrier precautions during insertion of arterial catheters: a randomized trial. Clin Infect Dis. 2003 Mar 15;36(6):743-8. PubMed External Web Site Policy

Riu S, Ruiz CG, Martinez-Vea A, Peralta C, Oliver JA. Spontaneous rupture of polyurethane peritoneal catheter. A possible deleterious effect of mupirocin ointment. Nephrol Dial Transplant. 1998 Jul;13(7):1870-1. PubMed External Web Site Policy

Robbins J, Cromwell P, Korones DN. Swimming and central venous catheter-related infections in the child with cancer. J Pediatr Oncol Nurs. 1999 Jan;16(1):51-6. PubMed External Web Site Policy

Robert J, Fridkin SK, Blumberg HM, Anderson B, White N, Ray SM, Chan J, Jarvis WR. The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit. Infect Control Hosp Epidemiol. 2000 Jan;21(1):12-7. PubMed External Web Site Policy

Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD 2nd. Perforation of the great vessels during central venous line placement. Arch Intern Med. 1995 Jun 12;155(11):1225-8. PubMed External Web Site Policy

Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: internal jugular versus subclavian access--a systematic review. Crit Care Med. 2002 Feb;30(2):454-60. PubMed External Web Site Policy

Rupp ME, Lisco SJ, Lipsett PA, Perl TM, Keating K, Civetta JM, Mermel LA, Lee D, Dellinger EP, Donahoe M, Giles D, Pfaller MA, Maki DG, Sherertz R. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):570-80. PubMed External Web Site Policy

Rupp ME, Sholtz LA, Jourdan DR, Marion ND, Tyner LK, Fey PD, Iwen PC, Anderson JR. Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. Clin Infect Dis. 2007 Jun 1;44(11):1408-14. PubMed External Web Site Policy

Ryder MA. Peripheral access options. Surg Oncol Clin N Am. 1995 Jul;4(3):395-427. [181 references] PubMed External Web Site Policy

Sadoyama G, Gontijo Filho PP. Comparison between the jugular and subclavian vein as insertion site for central venous catheters: microbiological aspects and risk factors for colonization and infection. Braz J Infect Dis. 2003 Apr;7(2):142-8. PubMed External Web Site Policy

Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002 Nov;81(6):466-79. [185 references] PubMed External Web Site Policy

Salgado CD, Chinnes L, Paczesny TH, Cantey JR. Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital. Infect Control Hosp Epidemiol. 2007 Jun;28(6):684-8. PubMed External Web Site Policy

Saxena AK, Panhotra BR, Sundaram DS, Al-Hafiz A, Naguib M, Venkateshappa CK, Abu-Oun BA, Hussain SM, Al-Ghamdi AA. Tunneled catheters' outcome optimization among diabetics on dialysis through antibiotic-lock placement. Kidney Int. 2006 Nov;70(9):1629-35. PubMed External Web Site Policy

Scalley RD, Van CS, Cochran RS. The impact of an i.v. team on the occurrence of intravenous-related phlebitis. A 30-month study. J Intraven Nurs. 1992 Mar-Apr;15(2):100-9. PubMed External Web Site Policy

Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant. 1991;6(10):722-4. PubMed External Web Site Policy

Schwartz C, Henrickson KJ, Roghmann K, Powell K. Prevention of bacteremia attributed to luminal colonization of tunneled central venous catheters with vancomycin-susceptible organisms. J Clin Oncol. 1990 Sep;8(9):1591-7. PubMed External Web Site Policy

Schweickert WD, Herlitz J, Pohlman AS, Gehlbach BK, Hall JB, Kress JP. A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures. Crit Care Med. 2009 Apr;37(4):1217-21. PubMed External Web Site Policy

Seguin J, Fletcher MA, Landers S, Brown D, Macpherson T. Umbilical venous catheterizations: audit by the Study Group for Complications of Perinatal Care. Am J Perinatol. 1994 Jan;11(1):67-70. PubMed External Web Site Policy

Seymour VM, Dhallu TS, Moss HA, Tebbs SE, Elliot TS. A prospective clinical study to investigate the microbial contamination ofa needleless connector. J Hosp Infect. 2000 Jun;45(2):165-8. PubMed External Web Site Policy

Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B, Flynn L, Hayes S, Strong S, Cruz J, Bowton DL, Hulgan T, Haponik EF. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med. 2000 Apr 18;132(8):641-8. PubMed External Web Site Policy

Shinozaki T, Deane RS, Mazuzan JE Jr, Hamel AJ, Hazelton D. Bacterial contamination of arterial lines. A prospective study. JAMA. 1983 Jan 14;249(2):223-5. PubMed External Web Site Policy

Sitges-Serra A, Linares J, Perez JL, Jaurrieta E, Lorente L. A randomized trial on the effect of tubing changes on hub contamination and catheter sepsis during parenteral nutrition. JPEN J Parenter Enteral Nutr. 1985 May-Jun;9(3):322-5. PubMed External Web Site Policy

Snydman DR, Donnelly-Reidy M, Perry LK, Martin WJ. Intravenous tubing containing burettes can be safely changed at 72 hour intervals. Infect Control. 1987 Mar;8(3):113-6. PubMed External Web Site Policy

Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med. 1998 Mar 9;158(5):473-7. PubMed External Web Site Policy

Solomon SL, Alexander H, Eley JW, Anderson RL, Goodpasture HC, Smart S, Furman RM, Martone WJ. Nosocomial fungemia in neonates associated with intravascular pressure-monitoring devices. Pediatr Infect Dis. 1986 Nov-Dec;5(6):680-5. PubMed External Web Site Policy

Soothill JS, Bravery K, Ho A, Macqueen S, Collins J, Lock P. A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hemopoietic stem cell transplant ward. Am J Infect Control. 2009 Oct;37(8):626-30. PubMed External Web Site Policy

Stamm WE, Colella JJ, Anderson RL, Dixon RE. Indwelling arterial catheters as a source of nosocomial bacteremia. An outbreak caused by Flavobacterium Species. N Engl J Med. 1975 May 22;292(21):1099-102. PubMed External Web Site Policy

Tager IB, Ginsberg MB, Ellis SE, Walsh NE, Dupont I, Simchen E, Faich GA. An epidemiologic study of the risks associated with peripheral intravenous catheters. Am J Epidemiol. 1983 Dec;118(6):839-51. PubMed External Web Site Policy

Tenold R, Priano L, Kim K, Rourke B, Marrone T. Infection potential of nondisposable pressure transducers prepared prior to use. Crit Care Med. 1987 Jun;15(6):582-3. PubMed External Web Site Policy

Thomas F, Burke JP, Parker J, Orme JF Jr, Gardner RM, Clemmer TP, Hill GA, MacFarlane P. The risk of infection related to radial vs femoral sites for arterial catheterization. Crit Care Med. 1983 Oct;11(10):807-12. PubMed External Web Site Policy

Timsit JF, Schwebel C, Bouadma L, Geffroy A, Garrouste-Orgeas M, Pease S, Herault MC, Haouache H, Calvino-Gunther S, Gestin B, Armand-Lefevre L, Leflon V, Chaplain C, Benali A, Francais A, Adrie C, Zahar JR, Thuong M, Arrault X, Croize J, Lucet JC, Dressing Study Group. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA. 2009 Mar 25;301(12):1231-41. PubMed External Web Site Policy

Tomford JW, Hershey CO, McLaren CE, Porter DK, Cohen DI. Intravenous therapy team and peripheral venous catheter-associated complications. A prospective controlled study. Arch Intern Med. 1984 Jun;144(6):1191-4. PubMed External Web Site Policy

Tomford JW, Hershey CO. The i.v. therapy team: impact on patient care and costs of hospitalization. NITA. 1985 Sep-Oct;8(5):387-9. PubMed External Web Site Policy

Traore O, Liotier J, Souweine B. Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units. Crit Care Med. 2005 Jun;33(6):1276-80. PubMed External Web Site Policy

Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology. 2000 Oct;217(1):89-93. PubMed External Web Site Policy

Trottier SJ, Veremakis C, O'Brien J, Auer AI. Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial. Crit Care Med. 1995 Jan;23(1):52-9. PubMed External Web Site Policy

Tully JL, Friedland GH, Baldini LM, Goldmann DA. Complications of intravenous therapy with steel needles and Teflon catheters. A comparative study. Am J Med. 1981 Mar;70(3):702-6. PubMed External Web Site Policy

van de Wetering MD, van Woensel JB. Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in oncology patients. Cochrane Database Syst Rev. 2007;(1):CD003295. [38 references] PubMed External Web Site Policy

Van Donk P, Rickard CM, McGrail MR, Doolan G. Routine replacement versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: A randomized controlled trial. Infect Control Hosp Epidemiol. 2009 Sep;30(9):915-7. PubMed External Web Site Policy

Villarino ME, Jarvis WR, O'Hara C, Bresnahan J, Clark N. Epidemic of Serratia marcescens bacteremia in a cardiac intensive care unit. J Clin Microbiol. 1989 Nov;27(11):2433-6. PubMed External Web Site Policy

Warren DK, Cosgrove SE, Diekema DJ, Zuccotti G, Climo MW, Bolon MK, Tokars JI, Noskin GA, Wong ES, Sepkowitz KA, Herwaldt LA, Perl TM, Solomon SL, Fraser VJ, Prevention Epicenter Program. A multicenter intervention to prevent catheter-associated bloodstream infections. Infect Control Hosp Epidemiol. 2006 Jul;27(7):662-9. PubMed External Web Site Policy

Warren DK, Zack JE, Cox MJ, Cohen MM, Fraser VJ. An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center. Crit Care Med. 2003 Jul;31(7):1959-63. PubMed External Web Site Policy

Warren DK, Zack JE, Mayfield JL, Chen A, Prentice D, Fraser VJ, Kollef MH. The effect of an education program on the incidence of central venous catheter-associated bloodstream infection in a medical ICU. Chest. 2004 Nov;126(5):1612-8. PubMed External Web Site Policy

Webster J, Clarke S, Paterson D, Hutton A, van Dyk S, Gale C, Hopkins T. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ. 2008;337:a339. PubMed External Web Site Policy

Webster J, Osborne S, Rickard C, Hall J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2010;(3):CD007798. [31 references] PubMed External Web Site Policy

Weems JJ Jr, Chamberland ME, Ward J, Willy M, Padhye AA, Solomon SL. Candida parapsilosis fungemia associated with parenteral nutrition and contaminated blood pressure transducers. J Clin Microbiol. 1987 Jun;25(6):1029-32. PubMed External Web Site Policy

Weijmer MC, van den Dorpel MA, Van de Ven PJ, ter Wee PM, van Geelen JA, Groeneveld JO, van Jaarsveld BC, Koopmans MG, le Poole CY, Schrander-Van der Meer AM, Siegert CE, Stas KJ, CITRATE Study Group. Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol. 2005 Sep;16(9):2769-77. PubMed External Web Site Policy

Weinstein RA, Emori TG, Anderson RL, Stamm WE. Pressure transducers as a source of bacteremia after open heart surgery. Report of an outbreak and guidelines for prevention. Chest. 1976 Mar;69(3):338-44. PubMed External Web Site Policy

White MC, Ragland KE. Surveillance of intravenous catheter-related infections among home care clients. Am J Infect Control. 1994 Aug;22(4):231-5. PubMed External Web Site Policy

White MC. Infections and infection risks in home care settings. Infect Control Hosp Epidemiol. 1992 Sep;13(9):535-9. PubMed External Web Site Policy

Yamamoto AJ, Solomon JA, Soulen MC, Tang J, Parkinson K, Lin R, Schears GJ. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol. 2002 Jan;13(1):77-81. PubMed External Web Site Policy

Yeung C, May J, Hughes R. Infection rate for single lumen v triple lumen subclavian catheters. Infect Control Hosp Epidemiol. 1988 Apr;9(4):154-8. PubMed External Web Site Policy

Yoo S, Ha M, Choi D, Pai H. Effectiveness of surveillance of central catheter-related bloodstream infection in an ICU in Korea. Infect Control Hosp Epidemiol. 2001 Jul;22(7):433-6. PubMed External Web Site Policy

Zakrzewska-Bode A, Muytjens HL, Liem KD, Hoogkamp-Korstanje JA. Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters. J Hosp Infect. 1995 Nov;31(3):189-93. PubMed External Web Site Policy

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

As in previous guidelines issued by the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC), each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact.

Potential Benefits

Improved patient outcomes and decreased health-care costs by reducing the infectious complications associated with intravascular catheter use

Potential Harms

Although most studies indicate a beneficial effect of the antimicrobial flush or lock solution in terms of prevention of catheter-related infection, this must be balanced by the potential for side effects, toxicity, allergic reactions, or emergence of resistance associated with the antimicrobial agent.

Qualifying Statements

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Safety

Bibliographic Source(s)

O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph A, Rupp ME, Saint S, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections, 2011. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2011. 83 p. [370 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

1996 (revised 2011)

Guideline Developer(s)

American Academy of Pediatrics - Medical Specialty Society

American College of Chest Physicians - Medical Specialty Society

American Society for Parenteral and Enteral Nutrition - Professional Association

American Society of Critical Care Anesthesiologists - Professional Association

American Thoracic Society - Medical Specialty Society

Association for Professionals in Infection Control and Epidemiology, Inc. - Professional Association

Centers for Disease Control and Prevention - Federal Government Agency [U.S.]

Infectious Diseases Society of America - Medical Specialty Society

Infusion Nurses Society - Professional Association

Oncology Nursing Society - Professional Association

Pediatric Infectious Diseases Society - Medical Specialty Society

Society for Healthcare Epidemiology of America - Professional Association

Society of Critical Care Medicine - Professional Association

Society of Interventional Radiology - Medical Specialty Society

Surgical Infection Society - Professional Association

Guideline Developer Comment

This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, healthcare infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Diseases Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), American Society for Parenteral and Enteral Nutrition (ASPEN), Society of Interventional Radiology (SIR), American Academy of Pediatrics (AAP), Pediatric Infectious Diseases Society (PIDS), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC).

Source(s) of Funding

United States Government

Guideline Committee

Healthcare Infection Control Practices Advisory Committee

Composition of Group That Authored the Guideline

Report Prepared by: Naomi P. O'Grady, MD, National Institutes of Health, Bethesda, Maryland; Mary Alexander, RN, Infusion Nurses Society, Norwood, Massachusetts; Lillian A. Burns, MT, MPH, CIC, Greenwich Hospital, Greenwich, Connecticut; E. Patchen Dellinger, MD, University of Washington, Seattle, Washington; Jeffery Garland, MD, SM, Wheaton Franciscan Healthcare-St. Joseph, Milwaukee, Wisconsin; Stephen O. Heard, MD, University of Massachusetts Medical School, Worcester, Massachusetts; Pamela A. Lipsett, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland; Henry Masur, MD, National Institutes of Health, Bethesda, Maryland; Leonard A. Mermel, DO, ScM, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island; Michele L. Pearson, MD, Office of Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia; Issam I. Raad, MD, MD Anderson Cancer Center, Houston, Texas; Adrienne Randolph, MD, MSc, The Children's Hospital, Boston, Massachusetts; Mark E. Rupp, MD, University of Nebraska Medical Center, Omaha, Nebraska; Sanjay Saint, MD, MPH, Ann Arbor VA Medical Center and University of Michigan, Ann Arbor, Michigan

Healthcare Infection Control Practices Advisory Committee Members: Patrick J. Brennan, MD (Chairman), Chief Medical Officer, Division of Infectious Diseases, University of Pennsylvania Health System; Michael R. Bell, MD (Executive Secretary), Deputy Director, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention; Dale Bratzler, DO, MPH, President and CEO, Oklahoma Foundation for Medical Quality; Lillian A. Burns, MT, MPH, Infection Control Coordinator, Greenwich Hospital, Infectious Diseases Department; Alexis Elward, MD, Assistant Professor, Pediatrics Infectious Diseases, Washington University School of Medicine, Department of Pediatrics, Division of Infectious Diseases; Susan Huang, MD, MPH, Assistant Professor, Medical Director, Epidemiology and Infection Prevention, Division of Infectious Diseases, UC Irvine School of Medicine; Tammy Lundstrom, MD, JD, Chief Medical Officer, Providence Hospital; Yvette S. McCarter, PhD, Director, Clinical Microbiology Laboratory, Department of Pathology, University of Florida Health Science Center; Denise M. Murphy, RN, MPH, CIC, Vice President, Quality and Patient Safety, Main Line Health System; Stephen Ostroff, MD, Director, Bureau of Epidemiology, Pennsylvania Department of Health; Russell N. Olmsted, MPH, CIC, Epidemiologist, Infection Control Services, St. Joseph Mercy Health System; David Alexander Pegues, MD, Professor of Medicine, Hospital Epidemiologist, David Geffen School of Medicine at UCLA; Peter J. Pronovost, MD, PhD, FCCM, Director, Johns Hopkins Quality and Safety Research Group; Barbara M. Soule, RN, MPA, CIC, Practice Leader, Infection Prevention and Control Services; Joint Commission Resources/Joint Commission International; William, P. Schecter, MD, Professor of Surgery, Department of Surgery, San Francisco General Hospital

Financial Disclosures/Conflicts of Interest

N.P.O.'G. served as a board member for the ABIM Subspecialty Board for Critical Care Medicine. M.A. is an employee of the Infusion Nurses Society, honoraria from 3M, Becton Dickinson, Smiths Medical. L.A.B. is a consultant for Institute of Healthcare Improvement; board membership for Theradoc, Medline; honoraria from APIC, Clorox. E.P.D. consulting from Merck, Baxter, Ortho-McNeil, Targanta, Schering-Plough, Optimer, Cadence, Cardinal, BDGeneOhm, WebEx, Cerebrio, and Tyco; grant support through the NIH; payment for lecture from Merck; payment for development of educational presentation from Medscape; travel and meeting expenses paid for by ASHP, IDSA, ASM, American College of Surgeons, NQF, SHEA/CDC, HHS, Trauma Shock Inflammation and Sepsis Meeting (Munich), University of Minnesota. J.G. honoraria from Ethicon. S.O.H. provides research support from Angiotech; honoraria from Angiotech, Merck. L.A.M provides research support from Astellas, Theravance, Pfizer; consulting for Ash Access, Cadence, CorMedix, Catheter Connections, Carefusion, Sage, Bard, Teleflex; payment for manuscript preparation from Catheter Connections. I.I.R. provides research support from Cubist, Enzon, and Basilea; consulting for Clorox; stock equity or options in Great Lakes Pharmaceuticals and Inventive Protocol; Speakers Bureau for Cook, Inc.; royalty income (patents owned by MD Anderson on which Dr. Raad is an inventor: American Medical Systems, Cook, Inc., Cook urological, Teleflex, TyRx, Medtronic, Biomet, Great Lakes Pharmaceuticals. A.R. consulting income from Eisai Pharmaceuticals, Discovery Laboratories. M.E.R. provides research support from Molnlycke, Cardinal Healthcare Foundation, Sanofi-Pasteur, 3M, and Cubist; consulting from Semprus; honorarium for lectures from 3M, Carefusion, Baxter and Becton Dickinson; previously served on Board of Directors for Society for Healthcare Epidemiology of America. All other authors: no conflicts.

Guideline Status

This is the current release of the guideline.

This guideline updates a previously released version: O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections [published erratum appears in MMWR Weekly 2002 Aug 16;51(32):71]. MMWR Recomm Rep 2002 Aug 9;51(RR-10):1-29.

Guideline Availability

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) Web site External Web Site Policy.

Print copies: Available from the Centers for Disease Control and Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on March 17, 2003. This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This NGC summary was updated by ECRI Institute on October 25, 2011. This summary was updated by ECRI Institute on March 6, 2014 following the U.S. Food and Drug Administration advisory on Over-the-Counter Topical Antiseptic Products.

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