Skip directly to search Skip directly to A to Z list Skip directly to navigation Skip directly to site content Skip directly to page options
CDC Home

2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections

Download the complete 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections [PDF - 1.05 MB]

Maximal Sterile Barrier Precautions

Recommendations

  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 [14, 75, 76, 80]. Category IB
  2. Use a sterile sleeve to protect pulmonary artery catheters during insertion [81]. Category IB

Background

Maximum sterile barrier (MSB) precautions are defined as wearing a sterile gown, sterile gloves, and cap and using a full body drape (similar to the drapes used in the operating room) during the placement of CVC. Maximal sterile barrier precautions during insertion of CVC were compared with sterile gloves and a small drape in a randomized controlled trial. The MSB group had fewer episodes of both catheter colonization (RR = .32, 95% CI, .10–.96, P = .04) and CR-BSI (RR = .16, 95% CI, .02–1.30, P = .06). In addition, the group using MSB precautions had infections that occurred much later and contained gram negative, rather than gram positive, organisms [76]. A study of pulmonary artery catheters also secondarily demonstrated that use of MSB precautions lowered risk of infection [37]. Another study evaluated an educational program directed at improving infection control practices, especially MSB precautions. In this study, MSB precautions use increased and CRBSI decreased [14]. A small trial demonstrated a reduced risk of skin colonization at the insertion site when MSB precautions were used [OR 3.40, 95%CI 1.32 to 3.67] [80].

Top

Skin Preparation

Recommendations

  1. Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, an iodophor or chlorhexidine gluconate) before peripheral venous catheter insertion [82]. 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 [82, 83]. 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 [82, 83]. Category IB

Background

Two well-designed studies evaluating the chlorhexidine-containing cutaneous antiseptic regimen in comparison with either povidone iodine or alcohol for the care of an intravascular catheter insertion site have shown lower rates of catheter colonization or CRBSI associated with the chlorhexidine preparation [82, 83]. (The comparison of chlorhexidine gluconate alcohol to povidone iodine alcohol has not been done.) When 0.5% tincture of chlorhexidine was compared with 10% povidone iodine, no differences were seen in central venous catheter (CVC) colonization or in CRBSI [256]. In a three-armed study (2% aqueous chlorhexidine gluconate vs 10% povidone-iodine vs 70% alcohol), 2% aqueous chlorhexidine gluconate tended to decrease CRBSI compared with 10% povidone iodine or 70% alcohol [82]. A meta-analysis of 4,143 catheters suggested that chlorhexidine preparation reduced the risk of catheter related infection by 49% (95% CI .28 to .88) relative to povidone iodine [257]. An economic decision analysis based on available evidence suggested that the use of chlorhexidine, rather than povidone iodine, for CVC care would result in a 1.6% decrease in the incidence of CRBSI, a 0.23% decrease in the incidence of death, and a savings of $113 per catheter used [258]. While chlorhexidine has become a standard antiseptic for skin preparation for the insertion of both central and peripheral venous catheters, 5% povidone iodine solution in 70% ethanol was associated with a substantial reduction of CVC-related colonization and infection compared with 10% aqueous povidone iodine [259].

Top

Catheter Site Dressing Regimens

Recommendations

  1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site [84–87]. Category IA
  2. If the patient is diaphoretic or if the site is bleeding or oozing, use gauze dressing until this is resolved [84–87]. Category II
  3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled [84, 85]. 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 [88, 89]. 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) [90–92]. 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 [87, 93]. 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 [94, 95]. Category IB
  11. Use a sterile sleeve for all pulmonary artery catheters [80]. Category IB
  12. Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, and MSB [93, 96–98]. 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 [99–101]. Category IB
  15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category II

Background

Transparent, semi-permeable polyurethane dressings permit continuous visual inspection of the catheter site and require less frequent changes than do standard gauze and tape dressings. In the largest controlled trial of dressing regimens on peripheral catheters, the infectious morbidity associated with the use of transparent dressings on approximately 2,000 peripheral catheters was examined [254]. Data from this study suggest that the rate of colonization among catheters dressed with transparent dressings (5.7%) is comparable to that of those dressed with gauze (4.6%) and that no clinically substantial differences exist in the incidence of either catheter site colonization or phlebitis. Furthermore, these data suggest that transparent dressings can be safely left on peripheral venous catheters for the duration of catheter insertion without increasing the risk for thrombophlebitis [254].

A meta-analysis has assessed studies that compared the risk for CRBSIs using transparent dressings versus using gauze dressing [260]. The risk for CRBSIs did not differ between the groups. The choice of dressing can be a matter of preference. If blood is oozing from the catheter insertion site, gauze dressing is preferred. Another systemic review of randomized controlled trials comparing gauze and tape to transparent dressings found no significant differences between dressing types in CRBSIs, catheter tip colonization, or skin colonization [261].

Chlorhexidine impregnated dressings have been used to reduce the risk of CRBSI. In the largest multicenter randomized controlled trial published to date comparing chlorhexidine impregnated sponge dressings vs standard dressings in ICU patients, rates of CRBSIs were reduced even when background rates of infection were low. In this study, 1636 patients (3778 catheters, 28 931 catheter-days) were evaluated. The chlorhexidine- impregnated sponge dressings decreased the rates of major CRBSIs (10/1953 [0.5%], 0.6 per 1000 catheter-days vs 19/1825 [1.1%], 1.4 per 1000 catheter-days; hazard ratio [HR], 0.39 [95% confidence interval {CI}, .17–.93]; P = .03) and CRBSIs (6/1953 catheters, 0.40 per 1000 catheter-days vs 17/1825 catheters, 1.3 per 1000 catheter-days; HR, 0.24 [95% CI, .09–.65]) [93]. A randomized controlled study of polyurethane or a chlorhexidine impregnated sponge dressing in 140 children showed no statistical difference in BSIs; however, the chlorhexidine group had lower rates of CVC colonization [98]. In 601 cancer patients receiving chemotherapy, the incidence of CRBSI was reduced in patients receiving the chlorhexidine impregnated sponge dressing compared with standard dressings (P = .016, relative risk 0.54; confidence interval 0.31–.94) [262]. A meta-analysis that included eight randomized controlled trials demonstrated that chlorhexidine impregnated sponge dressings are associated with a reduction of vascular and epidural catheter exit site colonization but no significant reduction in CRBSI (2.2% versus 3.8%, OR 0.58, 95% CI: .29–1.14, p= .11) [97].

Although data regarding the use of a chlorhexidine impregnated sponge dressing in children are limited, one randomized, controlled study involving 705 neonates reported a substantial decrease in colonized catheters in infants in the chlorhexidine impregnated sponge dressing group compared with the group that had standard dressings (15% versus 24%; RR = .6; 95% CI 5 0.5–.9), but no difference in the rates of CRBSI or BSI without a source. Chlorhexidine impregnated sponge dressings were associated with localized contact dermatitis in infants of very low birth weight. In 98 neonates with very low birth weight, 15 (15%) developed localized contact dermatitis; four (1.5%) of 237 neonates weighing >1,000 g developed this reaction (P < .0001). Infants with gestational age <26 weeks who had CVCs placed at age <8 days were at increased risk for having localized contact dermatitis, whereas no infants in the control group developed this local reaction [96].

Top

Patient Cleansing

Recommendation

Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI [102–104]. Category II

Background

Daily cleansing of ICU patients with a 2% chlorhexidine impregnated washcloth may be a simple, effective strategy to decrease the rate of primary BSIs. In a single center study of 836 ICU patients, patients receiving the chlorhexidine intervention were significantly less likely to acquire a primary BSI (4.1 vs 10.4 infections per 1000 patient days; incidence difference, 6.3 [95% confidence interval, 1.2–11.0) than those bathed with soap and water [102].

Top

Catheter Securement Devices

Recommendation

Use a sutureless securement device to reduce the risk of infection for intravascular catheters [105]. Category II

Background

Catheter stabilization is recognized as an intervention to decrease the risk for phlebitis, catheter migration and dislodgement, and may be advantageous in preventing CRBSIs. Pathogenesis of CRBSI occurs via migration of skin flora through the percutaneous entry site. Sutureless securement devices avoid disruption around the catheter entry site and may decrease the degree of bacterial colonization. [105]. Using a sutureless securement device also mitigates the risk of sharps injury to the healthcare provider from inadvertent needlestick injury.

Top

Antimicrobial/Antiseptic Impregnated Catheters and Cuffs

Recommendation

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 [106–113]. Category IA

Background

Certain catheters and cuffs that are coated or impregnated with antimicrobial or antiseptic agents can decrease the risk for CRBSI and potentially decrease hospital costs associated with treating CRBSIs, despite the additional acquisition cost of an antimicrobial/antiseptic impregnated catheter [110]. Nearly all of the studies involving antimicrobial/antiseptic-impregnated catheters have been conducted using triple-lumen, uncuffed catheters in adult patients whose catheters remained in place <30 days. While most of the studies have been conducted in adults, these catheters have been approved by FDA for use in patients weighing >3 kg. Two non-randomized studies [112, 113] in pediatric ICU patients suggest that these catheters might reduce risk of catheter-associated infection. No antiseptic or antimicrobial impregnated catheters currently are available for use in infants weighing <3kg.

Chlorhexidine/Silver Sulfadiazine Catheters coated with chlorhexidine/silver sulfadiazine only on the external luminal surface have been studied as a means to reduce CRBSI. Two meta-analyses of first-generation catheters [1, 263] demonstrated that such catheters reduced the risk for CRBSI compared with standard non-coated catheters. The duration of catheter placement in one study ranged from 5.1 to 11.2 days [264]. A second-generation catheter is now available with chlorhexidine coating the internal surface extending into the extension set and hubs while the external luminal surface is coated with chlorhexidine and silver sulfadiazine. The external surface has three times the amount of chlorhexidine and extended release of the surface bound antiseptics than that in the first generation catheters. All three prospective, randomized studies of second-generation catheters demonstrated a significant reduction in catheter colonization, but they were underpowered to show a difference in CRBSI [106–108]. Prolonged anti-infective activity provides improved efficacy in preventing infections [265]. Although rare, anaphylaxis with the use of these chlorhexidine/silver sulfadiazine catheters has been observed [266–270].

Chlorhexidine/silver sulfadiazine catheters are more expensive than standard catheters. However, one analysis has suggested that the use of chlorhexidine/silver sulfadiazine catheters should lead to a cost savings of $68 to $391 per catheter [271] in settings in which the risk for CRBSI is high, despite adherence to other preventive strategies (e.g., maximal barrier precautions and aseptic techniques). Use of these catheters might be cost effective in ICU patients, burn patients, neutropenic patients, and other patient populations in which the rate of infection exceeds 3.3 per 1,000 catheter days [264].

Minocycline/Rifampin In a multicenter randomized trial, CVCs impregnated on both the external and internal surfaces with minocycline/rifampin were associated with lower rates of CRBSI when compared with the first generation chlorhexidine/ silver sulfadiazine impregnated catheters [109]. The beneficial effect began after day 6 of catheterization. Silicone minocycline/ rifampin impregnated CVCs with an average dwell time of over 60 days have been shown to be effective in reducing CRBSI [111]. No minocycline/rifampin-resistant organisms were reported in these studies. Two trials demonstrated that use of these catheters significantly reduced CRBSI compared with uncoated catheters [110, 111]. No comparative studies have been published using the second-generation chlorhexidine/silver sulfadiazine catheter. Although there have been concerns related to the potential for development of resistance, several prospective clinical studies have shown that the risk is low [272, 273]. Further, no resistance to minocyline or rifampin related to the use of the catheter has been documented in the clinical setting. Two studies using decision model analysis revealed these catheters were associated with superior cost savings compared with first generation chlorhexidine/ silver sulfadiazine catheters [274, 275]. Such analysis needs to be done compared with the second-generation catheters. However, as baseline rates of infection decrease and the cost of catheters decrease, the cost-benefit ratio will likely change.

The decision to use chlorhexidine/silver sulfadiazine or minocycline/rifampin impregnated catheters should be based on the need to enhance prevention of CRBSI after bundled standard procedures have been implemented (e.g., educating personnel, using maximal sterile barrier precautions, and using >0.5% chlorhexidine preparation with alcohol for skin antisepsis) and then balanced against the concern for emergence of resistant pathogens and the cost of implementing this strategy.

Platinum/Silver A combination platinum/silver impregnated catheter (i.e, a silver iontophoretic catheter) is available for use in the United States. Several prospective, randomized studies have been published comparing these catheters to uncoated catheters [276–279]. One study showed a reduction in the incidence density of catheter colonization and CRBSI [278], but the other studies found no difference in catheter colonization or CRBSI between the impregnated catheter and a non-impregnated catheter [39, 276, 277]. In light of this, a firm recommendation for or against the use of these catheters cannot be made.

Top

Systemic Antibiotic Prophylaxis

Recommendation

Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI [114]. Category IB

Background

Several studies have examined the role of systemic antibiotic prophylaxis in prevention of catheter-related infection. A recent meta-analysis reviewed these studies in oncology patients [114]. Four studies used a prophylactic glycopeptide prior to catheter insertion. However, heterogeneity in these studies precludes making any conclusion regarding efficacy.

In a study examining the effect of ongoing oral prophylaxis with rifampin and novobiocin on catheter-related infection in cancer patients treated with interleukin-2 [280], a reduction in CRBSI was observed, even though 9 of 26 subjects (35%) discontinued the prophylactic antibiotics due to side effects or toxicity. In non-oncology patients, no benefit was associated with vancomycin administration prior to catheter insertion in 55 patients undergoing catheterization for parenteral nutrition [281]. Similarly, extending perioperative prophylactic antibiotics in cardiovascular surgery patients did not reduce central venous catheter colonization [282]. A recent Cochrane review of prophylactic antibiotics in neonates with umbilical venous catheters concluded that there is insufficient evidence from randomized trials to support or refute the use of prophylactic antibiotics [283].

Late onset neonatal sepsis is often due to coagulase negative staphylococci and is thought to frequently stem from infected central venous catheters. Five trials involved a total of 371 neonates comparing vancomycin by continuous infusion via parenteral nutrition or intermittent dosing, and placebo. The infants treated with vancomycin experienced less sepsis (RR .11; 95% CI .05-.24) and less sepsis due to coagulase negative staphylococci (RR .33; 95% CI .19–.59) [284]. However, mortality and length of stay were not significantly different between the two groups. There were insufficient data to evaluate the risk of selection for vancomycin resistant organisms.

Top

Antibiotic/Antiseptic Ointments

Recommendation

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 [59, 115–119]. Category IB

Background

A variety of topical antibiotic or antiseptic ointments have been utilized in attempts to lower the antimicrobial burden at the catheter insertion site and thus prevent infection. A number of older studies, examining primarily peripheral venous catheters, yielded varying conclusions [82, 285, 286]. In addition, the use of antibiotic ointments that have limited antifungal activity may serve to increase colonization and/or infection due to Candida species [89].

More recent studies have examined this approach in high-risk patients, particularly those undergoing hemodialysis [116–119]. Three randomized, controlled trials have evaluated the use of 10% povidone iodine [117–119]. A significant decrease in colonization, exit-site infection, or bloodstream infection was observed. The beneficial effect was most prominent in subjects with nasal colonization by Staphylococcus aureus [117–119].

Nasal carriers of S. aureus are more likely to experience a CRBSI than non-colonized persons [287–289]. This has prompted investigators to assess the utility of topical mupirocin, a potent anti-staphylococcal agent. Several studies have demonstrated a reduced risk of CRBSI when mupirocin ointment was applied at the catheter insertion site [117, 290–292]. Others have shown similar benefits when mupirocin was applied nasally [288, 289, 293]. However, enthusiasm for this measure has been dampened by the rapid emergence of mupirocin resistance observed at some centers [88, 294, 295], and the potential degrading effect that mupirocin has on polyurethane catheters [94, 95].

In the only study demonstrating a significant effect on mortality, the application of bacitracin/gramicidin/polymyxin B ointment at the catheter insertion site was compared with placebo in 169 hemodialysis patients [296]. Infections were observed in more patients in the placebo group than in the bacitracin/gramicidin/polymyxin B group (34 versus 12%; relative risk, 0.35; 95% CI, .18 to .68). The number of infections per 1,000 catheter days (4.10 versus 1.02; P < .0001) and the number of bacteremias per 1,000 catheter days (2.48 versus .63; P = .0004) were also greater in the placebo group. Within the 6-month study period, there were 13 deaths in the placebo group as compared with three deaths in the bacitracin/gramicidin/ polymyxin B group (P = .004). Thus, there is evidence from one study in hemodialysis patients that bacitracin/gramicidin/ polymyxin B ointment can improve outcome, but no similar data exist for use in other patient populations [296]. It should be noted that the gramicidin-containing ointment is not currently available in the United States.

Top

 

 
Contact Us:
  • Centers for Disease Control and Prevention
    1600 Clifton Rd
    Atlanta, GA 30333
  • 800-CDC-INFO
    (800-232-4636)
    TTY: (888) 232-6348
  • Contact CDC–INFO
CDC Safe Healthcare Blog See this discussed on CDCs Safe Healthcare Blog
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Rd. Atlanta, GA 30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO
A-Z Index
  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z
  27. #