Guidelines for the Prevention of Intravascular
Naomi P. O'Grady, M.D.1 Mary Alexander2 E. Patchen Dellinger, M.D.3 Julie L. Gerberding, M.D., M.P.H.4 Stephen O. Heard, M.D.5 Dennis G. Maki, M.D.6 Henry Masur, M.D.1 Rita D. McCormick, M.D.7 Leonard A. Mermel, D.O.8 Michele L. Pearson, M.D.9 Issam I. Raad, M.D.10 Adrienne Randolph, M.D., M.Sc.11 Robert A. Weinstein, M.D.12 1National Institutes of Health, Bethesda, Maryland 2Infusion Nurses Society, Cambridge, Massachusetts 3University of Washington, Seattle, Washington 4Office of the Director, CDC, Atlanta, Georgia 5University of Massachusetts Medical School, Worcester, Massachusetts 6University of Wisconsin Medical School, Madison, Wisconsin 7University of Wisconsin Hospital and Clinics, Madison, Wisconsin 8Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode Island 9Division of Healthcare Quality Promotion, National Center for Infectious Diseases, CDC, Atlanta, Georgia 10MD Anderson Cancer Center, Houston, Texas 11The Children's Hospital, Boston, Massachusetts 12Cook County Hospital and Rush Medical College, Chicago, Illinois
The material in this report was prepared for publication by the National Center for Infectious Diseases, James M. Hughes, M.D., Director; Division of Healthcare
Quality Promotion, Steven L. Solomon, M.D., Acting Director.
These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance
and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working
group comprising members from professional organizations representing the disciplines of critical care medicine, infectious
diseases, health-care 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 Disease 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), Society of Cardiovascular and Interventional Radiology (SCVIR),
American Academy of Pediatrics (AAP), 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
Device-Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for
preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert
and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a
2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy
to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection
is high despite adherence to other strategies (i.e., education and training, maximal sterile barrier precautions, and
2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by
health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.
This report provides health-care practitioners with background information and specific recommendations to reduce
the incidence of intravascular catheter-related bloodstream infections (CRBSI). These guidelines replace the
Guideline for Prevention of Intravascular Device-Related
Infections, which was published in 1996
The Guidelines for the Prevention of Intravascular
Catheter-Related Infections have been developed for
practitioners who insert catheters and for persons who are responsible for surveillance and control of infections in hospital, outpatient, and
home health-care settings. This report was prepared by a working group composed of professionals representing the disciplines
of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional
radiology, pulmonary medicine, pediatrics, and nursing. The working group was led by the Society of Critical Care Medicine
(SCCM), in collaboration with Infectious Disease 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), Society of Cardiovascular and
Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices
Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC). The recommendations presented in
this report reflect consensus of HICPAC and other professional organizations.
Intravascular Catheter-Related Infections in Adult and Pediatric Patients:
Intravascular catheters are indispensable in modern-day medical practice, particularly in intensive care units
(ICUs). Although such catheters provide necessary vascular access, their use puts patients at risk for local and systemic
infectious complications, including local site infection, CRBSI, septic thrombophlebitis, endocarditis, and other metastatic
infections (e.g., lung abscess, brain abscess, osteomyelitis, and endophthalmitis).
Health-care institutions purchase millions of intravascular catheters each year. The incidence of CRBSI varies
considerably by type of catheter, frequency of catheter manipulation, and patient-related factors (e.g., underlying disease and acuity
of illness). Peripheral venous catheters are the devices most frequently used for vascular access. Although the incidence of local
or bloodstream infections (BSIs) associated with peripheral venous catheters is usually low, serious infectious
complications produce considerable annual morbidity because of the frequency with which such catheters are used. However, the majority
of serious catheter-related infections are associated with central venous catheters (CVCs), especially those that are placed
in patients in ICUs. In the ICU setting, the incidence of infection is often higher than in the less acute in-patient or
ambulatory setting. In the ICU, central venous access might be needed for extended periods of time; patients can be colonized
with hospital-acquired organisms; and the catheter can be manipulated multiple times per day for the administration of
fluids, drugs, and blood products. Moreover, some catheters can be inserted in urgent situations, during which optimal attention
to aseptic technique might not be feasible. Certain catheters (e.g., pulmonary artery catheters and peripheral arterial
catheters) can be accessed multiple times per day for hemodynamic measurements or to obtain samples for laboratory
analysis, augmenting the potential for contamination and subsequent clinical infection.
The magnitude of the potential for CVCs to cause morbidity and mortality resulting from infectious complications has
been estimated in several studies (2). In the United States, 15 million CVC days (i.e., the total number of days of exposure to
CVCs by all patients in the selected population during the selected time period) occur in ICUs each year
(2). If the average rate of CVC-associated BSIs is 5.3 per 1,000 catheter days in the ICU
(3), approximately 80,000 CVC-associated BSIs occur in
ICUs each year in the United States. The attributable mortality for these BSIs has ranged from no increase in mortality in
studies that controlled for severity of illness
(4--6), to 35% increase in mortality in prospective studies that did not use this
control (7,8). Thus, the attributable mortality remains unclear. The attributable cost per infection is an estimated
$34,508--$56,000 (5,9), and the annual cost of caring for patients with CVC-associated BSIs ranges from $296 million to $2.3 billion
A total of 250,000 cases of CVC-associated BSIs have been estimated to occur annually if entire hospitals are assessed
rather than ICUs exclusively (11). In this case, attributable mortality
is an estimated 12%--25% for each infection, and the
marginal cost to the health-care system is $25,000 per episode
Therefore, by several analyses, the cost of CVC-associated BSI is substantial, both in terms of morbidity and in terms
of financial resources expended. To improve patient outcome and reduce health-care costs, strategies should be implemented
to reduce the incidence of these infections. This effort should be multidisciplinary, involving health-care professionals who
insert and maintain intravascular catheters, health-care managers who allocate resources, and patients who are capable of assisting
in the care of their catheters. Although several individual strategies have been studied and shown to be effective in
reducing CRBSI, studies using multiple strategies have not
been conducted. Thus, it is not known whether implementing
multiple strategies will have an additive effect in reducing CRBSI, but it is logical to use multiple strategies concomitantly.
Terminology and Estimates of Risk
The terminology used to identify different types of catheters is confusing, because many clinicians and researchers
use different aspects of the catheter for informal reference. A catheter can be designated by the type of vessel it occupies
(e.g., peripheral venous, central venous, or arterial); its intended life span (e.g., temporary or short-term versus permanent or
long-term); its site of insertion (e.g., subclavian, femoral, internal jugular, peripheral, and peripherally inserted central
catheter [PICC]); its pathway from skin to vessel (e.g., tunneled versus nontunneled); its physical length (e.g., long versus short);
or some special characteristic of the catheter (e.g., presence or absence of a cuff, impregnation with heparin, antibiotics
or antiseptics, and the number of lumens). To accurately define a specific type of catheter, all of these aspects should be
described (Table 1).
The rate of all catheter-related infections (including local infections and systemic infections) is difficult to
determine. Although CRBSI is an ideal parameter because it represents the most serious form of catheter-related infection, the rate of
such infection depends on how CRBSI is defined.
Health-care professionals should recognize the difference between surveillance definitions and clinical definitions.
The surveillance definitions for catheter-associated BSI includes all BSIs that occur in patients with CVCs, when other sites
of infection have been excluded (Appendix A). That is, the surveillance definition overestimates the true incidence of
CRBSI because not all BSIs originate from a catheter. Some bacteremias are secondary BSIs from undocumented sources
(e.g., postoperative surgical sites, intra-abdominal infections, and
hospital-associated pneumonia or urinary tract infections).
Thus, surveillance definitions are really definitions for catheter-associated BSIs. A more rigorous definition might include only
those BSIs for which other sources were excluded by careful examination of the patient record, and where a culture of the
catheter tip demonstrated substantial colonies of an organism identical to those found in the bloodstream. Such a clinical
definition would focus on catheter-related BSIs. Therefore, to accurately compare a health-care facility's infection rate to published
data, comparable definitions also should be used.
CDC and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommend that the rate
of catheter-associated BSIs be expressed as the number of catheter associated BSIs per 1,000 CVC days
(12,13). This parameter is more useful than the rate expressed as the number of catheter-associated infections per 100 catheters (or percentage of
catheters studied), because it accounts for BSIs over time and therefore adjusts risk for the number of days the catheter is in use.
Epidemiology and Microbiology
Since 1970, CDC's National Nosocomial Infection Surveillance System (NNIS) has been collecting data on the
incidence and etiologies of hospital-acquired infections, including CVC-associated BSIs in a group of nearly 300 U.S. hospitals.
The majority of hospital-acquired BSIs are associated with the use of a CVC, with BSI rates being substantially higher
among patients with CVCs than among those without CVCs. Rates of CVC-associated BSI vary considerably by hospital
size, hospital service/unit, and type of CVC. During 1992--2001, NNIS hospitals reported ICU rates of CVC-associated
BSI ranging from 2.9 (in a cardiothoracic ICU) to 11.3 (in a neonatal nursery for infants weighing <1,000 g) BSIs per 1,000
CVC days (Table 2) (14).
The relative risk of catheter-associated BSI also has been assessed in a meta-analysis of 223 prospective studies of
adult patients (11). Relative risk of infection was best determined by analyzing rates of infection both by BSIs per 100 catheters
BSIs per 1,000 catheter days. These rates, and the NNIS-derived data, can be used as benchmarks by individual hospitals
to estimate how their rates compare with other institutions. Rates are influenced by patient-related parameters, such as severity
of illness and type of illness (e.g., third-degree burns versus postcardiac surgery), and by
catheter-related parameters, such as the condition under which the catheter was placed (e.g., elective versus urgent) and catheter type
(e.g., tunneled versus nontunneled or subclavian versus jugular).
Types of organisms that most commonly cause
hospital-acquired BSIs change over time. During 1986--1989,
coagulase-negative staphylococci, followed by Staphylococcus
aureus, were the most frequently reported causes of BSIs, accounting
for 27% and 16% of BSIs, respectively (Table 3)
(15). Pooled data from 1992 through 1999 indicate that
coagulase-negative staphylococci, followed by enterococci, are now the most frequently isolated causes of hospital-acquired BSIs
(12). Coagulase-negative staphylococci account for 37%
(12) and S. aureus account for 12.6% of reported hospital-acquired BSIs
(12). Also notable was the susceptibility pattern of
S. aureus isolates. In 1999, for the first time since NNIS has been
reporting susceptibilities, >50% of all S.
aureus isolates from ICUs were resistant to oxacillin
In 1999, enterococci accounted for 13.5% of BSIs, an increase from 8% reported to NNIS during 1986--1989.
The percentage of enterococcal ICU isolates resistant to vancomycin also is increasing, escalating from 0.5% in 1989 to 25.9%
in 1999 (12).
Candida spp. caused 8% of hospital-acquired BSIs reported to NNIS during 1986--1989
(15,16), and during 1992--1999
(12,17,18). Resistance of Candida spp. to commonly used antifungal agents is increasing. Although NNIS has not
reported the percentage of BSIs caused by nonalbicans species or fluconazole susceptibility data, other epidemiologic and clinical
data document that fluconazole resistance is an increasingly relevant consideration when designing empiric therapeutic regimens
for CRBSIs caused by yeast. Data from the Surveillance and Control of Pathogens of Epidemiologic Importance
(SCOPE) Program documented that 10% of C.
albicans bloodstream isolates from hospitalized patients were resistant to
fluconazole (17). Additionally, 48% of
Candida BSIs were caused by nonalbicans species, including
C. glabrata and C. krusei, which are more likely than
C. albicans to demonstrate resistance to fluconazole and itraconazole
Gram-negative bacilli accounted for 19% of catheter-associated BSIs during 1986--1989
(15) compared with 14% of catheter-associated BSIs during 1992--1999
(12). An increasing percentage of ICU-related isolates are caused
by Enterobacteriaceae that produce extended-spectrum ß-lactamases (ESBLs), particularly
Klebsiella pneumoniae (20). Such organisms not only are resistant to extended-spectrum cephalosporins, but also to frequently used, broad
spectrum antimicrobial agents.
Migration of skin organisms at the insertion site into the cutaneous catheter tract with colonization of the catheter tip is
the most common route of infection for peripherally inserted, short-term catheters
(21,22). Contamination of the catheter hub contributes substantially to intraluminal colonization of long-term catheters
(23--25). Occasionally, catheters might
become hematogenously seeded from another focus of infection. Rarely, infusate contamination leads to CRBSI
Important pathogenic determinants of catheter-related infection are 1) the material of which the device is made and 2)
the intrinsic virulence factors of the infecting organism. In vitro studies demonstrate that catheters made of polyvinyl chloride
or polyethylene are likely less resistant to the adherence of microorganisms than are catheters made of
Teflon®, silicone elastomer, or polyurethane
(27,28). Therefore, the majority of catheters sold in the United States are no longer made of
polyvinyl chloride or polyethylene. Some catheter materials also have surface irregularities that enhance the microbial adherence
of certain species (e.g., coagulase-negative staphylococci,
Acinetobacter calcoaceticus, and
(29--31); catheters made of these materials are especially vulnerable to microbial colonization and subsequent infection.
Additionally, certain catheter materials are more thrombogenic than others, a characteristic that also might predispose to
catheter colonization and catheter-related infection
(31,32). This association has led to emphasis on preventing
catheter-related thrombus as an additional mechanism for reducing CRBSI.
The adherence properties of a given microorganism also are important in the pathogenesis of catheter-related infection.
For example, S. aureus can adhere to host proteins (e.g., fibronectin) commonly present on catheters
(33,34). Also, coagulase-negative staphylococci adhere to polymer surfaces more readily than do other pathogens (e.g.,
Escherichia coli or S.aureus). Additionally, certain strains of coagulase-negative staphylococci produce an extracellular polysaccharide often referred to
"slime" (35,36). In the presence of catheters, this slime potentiates the pathogenicity of coagulase-negative staphylococci
by allowing them to withstand host defense mechanisms (e.g., acting as a barrier to engulfment and killing by
polymorphonuclear leukocytes) or by making them less susceptible to antimicrobial agents (e.g., forming a matrix that binds antimicrobials
before their contact with the organism cell wall)
(37). Certain Candida spp., in the presence of glucose-containing fluids,
might produce slime similar to that of their bacterial counterparts, potentially explaining the increased proportion of BSIs caused
by fungal pathogens among patients receiving parenteral nutrition fluids
Strategies for Prevention of Catheter-Related Infections in Adult
and Pediatric Patients
Quality Assurance and Continuing Education
Measures to minimize the risk for infection associated with intravascular therapy should strike a balance between
patient safety and cost effectiveness. As knowledge, technology, and health-care settings change, infection control and
prevention measures also should change. Well-organized programs that enable health-care providers to provide, monitor, and evaluate
care and to become educated are critical to the success of this effort. Reports spanning the past two decades have
consistently demonstrated that risk for infection declines following standardization of aseptic care
(39--43), and that insertion and maintenance of intravascular catheters by inexperienced staff might increase the risk for catheter colonization and
CRBSI (43,44). Specialized "IV teams" have shown unequivocal effectiveness in reducing the incidence of catheter-related
infections and associated complications and costs
(45--47). Additionally, infection risk increases with nursing staff reductions below
a critical level (48).
Site of Catheter Insertion
The site at which a catheter is placed influences the subsequent risk for catheter-related infection and phlebitis.
The influence of site on the risk for catheter infections is related in
part to the risk for thrombophlebitis and density of local skin flora.
Phlebitis has long been recognized as a risk for infection. For adults, lower extremity insertion sites are associated with
a higher risk for infection than are upper extremity sites
(49--51). In addition, hand veins have a lower risk for phlebitis than
do veins on the wrist or upper arm (52).
The density of skin flora at the catheter insertion site is a major risk factor for CRBSI. Authorities recommend that CVCs
be placed in a subclavian site instead of a jugular or femoral site to reduce the risk for infection. No randomized trial
satisfactorily has compared infection rates for catheters placed in jugular, subclavian, and femoral sites. Catheters inserted into an
internal jugular vein have been associated with higher risk for infection than those inserted into a subclavian or femoral
Femoral catheters have been demonstrated to have relatively high colonization rates when used in adults
(55). Femoral catheters should be avoided, when possible, because they are associated with a higher risk for deep venous thrombosis than
are internal jugular or subclavian catheters
(56--60) and because of a presumption that such catheters are more likely to
become infected. However, studies in pediatric patients have demonstrated that femoral catheters have a low incidence of
mechanical complications and might have an equivalent infection rate to that of nonfemoral catheters
(61--63). Thus, in adult patients, a subclavian site is preferred for infection control purposes, although other factors (e.g., the potential for
mechanical complications, risk for subclavian vein stenosis, and catheter-operator skill) should be considered when deciding where
to place the catheter. In a meta-analysis of eight studies, the use of bedside ultrasound for the placement of CVCs
substantially reduced mechanical complications compared with the standard landmark placement technique (relative risk [RR] = 0.22;
95% confidence interval [CI] = 0.10--0.45)
(64). Consideration of comfort, security, and maintenance of asepsis as well as
patient-specific factors (e.g., preexisting catheters, anatomic deformity, and bleeding diathesis), relative risk of
mechanical complications (e.g., bleeding and pneumothorax), the availability of bedside ultrasound, and the risk for infection
should guide site selection.
Type of Catheter Material
Teflon® or polyurethane catheters have been associated with
fewer infectious complications than catheters made of
polyvinyl chloride or polyethylene
(27,65,66). Steel needles used as an alternative to catheters for peripheral venous access have the
same rate of infectious complications as do
Teflon® catheters (67,68). However, the use of steel needles frequently is complicated
by infiltration of intravenous (IV) fluids into the subcutaneous tissues, a potentially serious complication if the infused fluid is
a vesicant (68).
Hand Hygiene and Aseptic Technique
For short peripheral catheters, good hand hygiene before catheter insertion or maintenance, combined with proper
aseptic technique during catheter manipulation, provides protection against infection. Good hand hygiene can be achieved
through the use of either a waterless, alcohol-based product
(69) or an antibacterial soap and water with adequate rinsing
(70). Appropriate aseptic technique does not necessarily require sterile gloves; a new pair of disposable nonsterile gloves can be
used in conjunction with a "no-touch" technique for the insertion of peripheral venous catheters. However, gloves are required
by the Occupational Safety and Health Administration as standard precautions for the prevention of bloodborne
Compared with peripheral venous catheters, CVCs carry a substantially greater risk for infection; therefore, the level
of barrier precautions needed to prevent infection during insertion of CVCs should be more stringent. Maximal sterile
barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape) during the insertion of CVCs
substantially reduces the incidence of CRBSI compared with standard precautions (e.g., sterile gloves and small drapes)
(22,71). Although the efficacy of such precautions for insertion of PICCs and midline catheters has not been studied, the use of maximal
barrier precautions also is probably applicable to PICCs.
In the United States, povidone iodine has been the most widely used antiseptic for cleansing arterial catheter and
CVC- insertion sites (72). However, in one study, preparation of central venous and arterial sites with a 2% aqueous
chlorhexidine gluconate lowered BSI rates compared with site preparation with 10% povidone-iodine or 70% alcohol
(73). Commercially available products containing chlorhexidine have not been available until recently; in July 2000, the U.S. Food and
Drug Administration (FDA) approved a 2% tincture of chlorhexidine preparation for skin antisepsis. Other preparations
of chlorhexidine might not be as effective. Tincture of chlorhexidine gluconate 0.5% is no more effective in preventing CRBSI
or CVC colonization than 10% povidone iodine, as demonstrated by a prospective, randomized study of adults
(74). However, in a study involving neonates, 0.5% chlorhexidine reduced peripheral IV colonization compared with povidone iodine
(20/418 versus 38/408 catheters; p = 0.01)
(75). This study, which did not include CVCs, had an insufficient number
of participants to assess differences in BSI rates. A 1% tincture of chlorhexidine preparation is available in Canada and
Australia, but not yet in the United States. No published trials have compared a 1% chlorhexidine preparation to povidone-iodine.
Catheter Site Dressing Regimens
Transparent, semipermeable polyurethane dressings have become a popular means of dressing catheter insertion
sites. Transparent dressings reliably secure the device, permit continuous visual inspection of the catheter site, permit patients
to bathe and shower without saturating the dressing, and require less frequent changes than do standard gauze and tape
dressings; the use of these dressings saves personnel time.
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
(65). 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 either the incidences of 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
A meta-analysis has assessed studies that compared the risk for catheter-related BSIs for groups using transparent
dressings versus groups using gauze dressing
(76). 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 might be preferred.
In a multi-center study, a chlorhexidine-impregnated sponge
(Biopatch) placed over the site of short-term arterial
and CVCs reduced the risk for catheter colonization and CRBSI
(77). No adverse systemic effects resulted from use of this device.
Catheter Securement Devices
Sutureless securement devices can be advantageous over suture in preventing catheter-related BSIs. One study,
which involved only a limited number of patients and was underpowered, compared a sutureless device with suture for
the securement of PICCS; in this study, CRBSI was reduced in the group of patients that received the sutureless device
In-line filters reduce the incidence of infusion-related phlebitis
(79,80). No data support their efficacy in
preventing infections associated with intravascular catheters and infusion systems. Proponents of filters cite several potential benefits
to using these filters, including 1) reducing the risk for infection from contaminated infusate or proximal contamination
(i.e., introduced proximal to the filter); 2) reducing the risk for phlebitis in patients who require high doses of medication or
in those in whom infusion-related phlebitis already has occurred; 3) removing particulate matter that might contaminate
IV fluids (81); and 4) filtering endotoxin produced by gram-negative organisms in contaminated infusate
(82). These theoretical advantages should be tempered by the knowledge that infusate-related BSI is rare and that filtration of medications or
infusates in the pharmacy is a more practical and less costly way to remove the majority of particulates. Furthermore, in-line
filters might become blocked, especially with certain solutions (e.g., dextran, lipids, and mannitol), thereby increasing the number
of line manipulations and decreasing the availability of administered drugs
(83). Thus, for reducing the risk for CRBSI, no
strong recommendation can be made in favor of using in-line filters.
Antimicrobial/Antiseptic Impregnated Catheters and Cuffs
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
(84). All of the studies involving antimicrobial/antiseptic impregnated
catheters have been conducted using triple-lumen, noncuffed catheters in adult patients whose catheters remained in place <30
days. Although all of the studies have been conducted in adults, these catheters have been approved by FDA for use in
patients weighing >3 kg. No antiseptic or antimicrobial impregnated catheters currently are available for use in weighing <3 kg.
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
(2,85) demonstrated that such catheters reduced
the risk for CRBSI compared with standard noncoated catheters. The mean duration of catheter placement in one
meta-analysis ranged from 5.1 to 11.2 days
(86). The half-life of antimicrobial activity against
S. epidermidis is 3 days in vitro for
catheters coated with chlorhexidine/silver sulfadiazine; this antimicrobial activity decreases over time
(87). The benefit for the patients who receive these catheters will be realized within the first 14 days
(86). A second-generation catheter is now available
with chlorhexidine coating both the internal and external luminal surfaces. 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. The
external surface coating of chlorhexidine is combined with silver-sulfadiazine, and the internal surface is coated with
chlorhexidine alone. Preliminary studies indicate that prolonged anti-infective activity provides improved efficacy in preventing
infections (88). Although rare, anaphylaxis has been reported with the use of these chlorhexidine/silver sulfadiazine catheters in
Japan (89). Whether patients will become colonized or infected with organisms resistant to chlorhexidine/silver sulfadiazine has
not been determined (86).
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
(90) in settings in which the risk for CRBSI is high despite adherence to other preventive strategies (e.g., maximal barrier
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
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
(91). The beneficial effect began after day 6 of catheterization. None of the
catheters were evaluated beyond 30 days. No minocycline/rifampin-resistant organisms were reported. However, in vitro data
indicate that these impregnated catheters could increase the incidence of minocycline and rifampin resistance among
pathogens, especially staphylococci. The half-life of antimicrobial activity against
S. epidermidis is 25 days with catheters coated
with minocycline/rifampin, compared with 3 days for the first-generation catheters coated with chlorhexidine/silver sulfadiazine
in vitro (87). In vivo, the duration of antimicrobial activity of the minocycline/rifampin catheter is longer than that of the
first-generation chlorhexidine/silver sulfadiazine catheter
(91). No comparative studies have been published using the
second-generation chlorhexidine/ silver sulfadiazine catheter. Studies are needed to evaluated whether the improved performance
of the minocyline/rifampin catheters results from the antimicrobial agents used or from the coating of both the internal
and external surfaces. As with chlorhexidine/silver sulfadiazine catheters, some clinicians have recommended that the
minocycline/rifampin catheters be considered in patient populations when the rate of CRBSI exceeds 3.3 per 1,000 catheter days
(86). Others suggest that reducing all rates of CRBSI should be the goal
(92). The decision to use chlorhexidine/silver
sulfadiazine or minocycline/rifampin impregnated catheters should be based on the need to enhance prevention of CRBSI after
standard procedures have been implemented (e.g., educating personnel, using maximal sterile barrier precautions, and using
2% chlorhexidine skin antisepsis) and then balanced against the concern for
emergence of resistant pathogens and the cost of implementing
Platinum/Silver. Ionic metals have broad antimicrobial
activityand are being used in catheters and cuffs to prevent
CRBSI. A combination platinum/silver impregnated catheter is available in Europe and has recently been approved by FDA for use
in the United States. Although these catheters are being marketed for their antimicrobial properties, no published
studies have been presented to support an antimicrobial effect.
Silver cuffs. Ionic silver has been used in subcutaneous collagen cuffs attached to CVCs
(93). The ionic silver provides antimicrobial activity and the cuff provides a mechanical barrier to the migration of microorganisms along the external
surface of the catheter. In studies of catheters left in place
>20 days, the cuff failed to reduce the incidence of CRBSI
(94,95). Two other studies of short-term catheters could not demonstrate efficacy because of the minimal number of CRBSIs
Systemic Antibiotic Prophylaxis
No studies have demonstrated that oral or parenteral antibacterial or antifungal drugs might reduce the incidence of
CRBSI among adults (97--99). However, among low birth weight infants, two studies have assessed vancomycin prophylaxis;
both demonstrated a reduction in CRBSI but no reduction in mortality
(100,101). Because the prophylactic use of vancomycin
is an independent risk factor for the acquisition of vancomycin-resistant enterococcus (VRE)
(102), the risk for acquiring VRE likely outweighs the benefit of using prophylactic vancomycin.
Povidone-iodine ointment applied at the insertion site of hemodialysis catheters has been studied as a
prophylactic intervention to reduce the incidence of catheter-related infections. One randomized study of 129 hemodialysis
catheters demonstrated a reduction in the incidence of exit-site infections, catheter-tip colonization, and BSIs with the routine use
of povidone-iodine ointment at the catheter insertion site compared with no ointment at the insertion site
Several studies have evaluated the effectiveness of mupirocin ointment applied at the insertion sites of CVCs as a means
to prevent CRBSI (104--106). Although mupirocin reduced the risk for CRBSI
(106), mupirocin ointment also has been associated
with mupirocin resistance (107,108), and might adversely affect the integrity of polyurethane catheters
Nasal carriers of S. aureus have a higher risk for acquiring CRBSI than do noncarriers
(103,111). Mupirocin ointment has been used intranasally to decrease nasal carriage of
S. aureus and lessen the risk for CRBSI. However, resistance to
mupirocin develops in both S. aureus and coagulase-negative staphylococci soon after routine use of mupirocin is instituted
Other antibiotic ointments applied to the catheter insertion site also have been studied and have yielded conflicting
results (112--114). In addition, rates of catheter colonization with
Candida spp. might be increased with the use of
antibiotic ointments that have no fungicidal activity
(112,114). To avoid compromising the integrity of the catheter, any ointment that
is applied to the catheter insertion site should be checked against the catheter and ointment manufacturers'
recommendations regarding compatibility.
Antibiotic Lock Prophylaxis
To prevent CRBSI, antibiotic lock prophylaxis has been attempted by flushing and filling the lumen of the catheter with
an antibiotic solution and leaving the solution to dwell in the lumen of the catheter. Three studies have demonstrated
the usefulness of such prophylaxis in neutropenic patients with long-term catheters
(115--117). In two of the studies, patients received either heparin alone (10 U/ml) or heparin plus 25 micrograms/ml of vancomycin. The third study
compared vancomycin/ciprofloxacin/heparin (VCH) to vancomycin/heparin (VH)and then to heparin alone. The rate of CRBSI
with vancomycin-susceptible organisms was significantly lower (VCH p = 0.022; VH p = 0.028) and the time to the first episode
of bacteremia with vancomycin-susceptible organisms was substantially longer (VCH p = 0.036; VH p = 0.011) in
patients receiving either vancomycin/ciprofloxacin/heparin or vancomycin/heparin compared with heparin alone
(115--117). One study involving a limited number of children revealed no difference in rates of CRBSI between children receiving a
heparin flush compared with those receiving heparin and vancomycin
(118). However, because the use of vancomycin is
an independent risk factor for the acquisition of VRE
(102), this practice is not recommended routinely.
An anticoagulant/antimicrobial combination comprising minocycline and ethylenediaminetetraraacetic acid (EDTA)
has been proposed as a lock solution because it has antibiofilm and antimicrobial activity against gram-positive,
gram-negative, and Candida organisms
(119), as well as anticoagulant properties. However, no controlled or randomized trials
have demonstrated its efficacy.
Anticoagulant flush solutions are used widely to prevent catheter thrombosis. Because thrombi and fibrin deposits
on catheters might serve as a nidus for microbial colonization of intravascular catheters
(120,121), the use of anticoagulants might have a role in the prevention of CRBSI.
In a meta-analysis evaluating the benefit of heparin prophylaxis (3 U/ml in TPN, 5,000 U every 6 or 12 hours flush,
or 2,500 U low molecular weight heparin subcutaneously) in patients with short-term CVCs, the risk for catheter-related
central venous thrombosis was reduced with the use of prophylactic heparin
(122). However, no substantial difference in the rate
for CRBSI was observed. Because the majority of heparin solutions contain preservatives with antimicrobial activity, whether
any decrease in the rate of CRBSI is a result of the reduced thrombus formation, the preservative, or both is unclear.
The majority of pulmonary artery, umbilical, and central venous catheters are available with a heparin-bonded coating.
The majority are heparin-bonded with benzalkonium chloride, which provides the catheters with antimicrobial activity
(123) and provides an anti-thrombotic effect
Warfarin also has been evaluated as a means for reducing CRBSI by reducing thrombus formation on catheters
(125,126). In patients with long-term CVCs, low-dose warfarin (i.e., 1 mg/day) reduced the incidence of catheter thrombus. No
data demonstrate that warfarin reduces the incidence of CRBSI.
Replacement of Catheters
Peripheral Venous Catheters
Scheduled replacement of intravascular catheters has been proposed as a method to prevent phlebitis and
catheter-related infections. Studies of short peripheral venous catheters indicate that the incidence of thrombophlebitis and
bacterial colonization of catheters increases when catheters are left in place >72 hours
(66,67,127). However, rates of phlebitis are
not substantially different in peripheral catheters left in place 72 hours compared with 96 hours
(128). Because phlebitis and catheter colonization have been associated with an increased risk for catheter-related infection, short peripheral catheter
commonly are rotated at 72--96-hour intervals to reduce both the risk for infection and patient discomfort associated
Midline catheters have been associated with lower rates of phlebitis than short peripheral catheters and with lower rates
of infection than CVCs (129--131). In one prospective study of 140 midline catheters, their use was associated with a BSI rate
of 0.8 per 1,000 catheter-days (131). No specific risk factors, including duration of catheterization, were associated
with infection. Midline catheters were in place a median of 7 days, but for as long as 49 days. Although the findings of this
study suggested that midline catheters can be changed only when there is a specific indication, no prospective, randomized
studies have assessed the benefit of routine replacement as a strategy to prevent CRBSI associated with midline catheters.
CVCs, Including PICCs and Hemodialysis Catheters
Catheter replacement at scheduled time intervals as a method to reduce CRBSI has not lowered rates. Two trials
have assessed a strategy of changing the catheter every 7 days compared with a strategy of changing catheters as needed
(132,133). One of these studies involved 112 surgical ICU patients needing CVCs, pulmonary artery catheters, or peripheral
arterial catheters (132), whereas the other study involved only subclavian hemodialysis catheters
(133). In both studies, no difference in CRBSI was observed in patients undergoing scheduled catheter replacement every 7 days compared with patients
whose catheters were replaced as needed.
Scheduled guidewire exchanges of CVCs is another proposed strategy for preventing CRBSI. The results of a
meta-analysis of 12 randomized controlled trials assessing CVC management failed to prove any reduction of CRBSI rates through
routine replacement of CVCs by guidewire exchange compared with catheter replacement on an as-needed basis
(134). Thus, routine replacement of CVCs is not necessary for catheters that are functioning and have no evidence of causing local or
Catheter replacement over a guidewire has become an accepted technique for replacing a malfunctioning catheter
or exchanging a pulmonary artery catheter for a CVC when invasive monitoring no longer is needed. Catheter insertion over
a guidewire is associated with less discomfort and a significantly lower rate of mechanical complications than are
those percutaneously inserted at a new site
(135); in addition, this technique provides a means of preserving limited venous access
in some patients. Replacement of temporary catheters over a guidewire in the presence of bacteremia is not an
acceptable replacement strategy, because the source of infection is usually colonization of the skin tract from the insertion site to the
vein (22,135). However, in selected patients with tunneled hemodialysis catheters and bacteremia, catheter exchange over
a guidewire, in combination with antibiotic therapy, might be an alternative as a salvage strategy in patients with limited
venous access (136--139).
The use of catheters for hemodialysis is the most common factor contributing to bacteremia in dialysis patients
(140,141). The relative risk for bacteremia in patients with dialysis catheters is sevenfold the risk for patients with primary
arteriovenous fistulas (142). Despite the National Kidney Foundation's effort to reduce the number of hemodialysis patients maintained
with catheter access, catheter use increased from 12.7% in 1995 to 22.2% in 1999
(143). Rates for bacteremia per 100 patient months were 0.2 for arteriovenous fistulas, 0.5 for grafts, 5.0 for cuffed catheters, and 8.5 for noncuffed catheters
(CDC, unpublished data, 1999).
To reduce the rate of infection, hemodialysis catheters should be avoided in favor of arteriovenous fistulas and grafts.
If temporary access is needed for dialysis, a cuffed catheter is preferable to a noncuffed catheter, even in the ICU setting, if
the catheter is expected to stay in place for >3 weeks
Pulmonary Artery Catheters
Pulmonary artery catheters are inserted through a
Teflon® introducer and typically remain in place an average of 3 days.
The majority of pulmonary artery catheters are heparin bonded, which reduces not only catheter thrombosis but also
microbial adherence to the catheter (145). Meta-analysis indicates that standard nonheparin-bonded pulmonary artery catheter rates
CRBSI are 5.5 per 1,000 catheter days; for heparin-bonded pulmonary artery catheters, this rate is 2.6 per 1,000 catheter
days (11). Because the majority of pulmonary artery catheters are heparin-bonded, the relative risk of infection with these
catheters is similar to that of CVC (2.6 versus 2.3 per 1,000 catheter days)
A prospective study of 442 pulmonary artery catheters demonstrated an increased risk for CRBSI after 5 days (0/442
CRBSI before 5 days versus 5/442 CSBSI after 5 days; p < 0.001)
(146). A prospective observational study of 71 pulmonary
artery catheters demonstrated higher infection rates in catheters left in place longer than 7 days (2% before 7 days versus 16% after
7 days; p = 0.056) (147). However, no studies indicate that catheter replacement at scheduled time intervals is an
effective method to reduce CRBSI (132,135). In patients who continue to require hemodynamic monitoring, pulmonary
artery catheters do not need to be changed more frequently than every 7 days. No specific recommendation can be made
regarding routine replacement of catheters that need to be in place for >7 days.
Pulmonary artery catheters are usually packaged with a thin plastic sleeve that prevents touch contamination when
placed over the catheter. In a study of 166 catheters, patients who were randomly assigned to have their catheters
self-contained within this sleeve had a reduced risk for CRBSI compared with those who had a pulmonary artery catheter placed without
the sleeve (p = 0.002) (148).
Peripheral Arterial Catheters
Peripheral arterial catheters are usually inserted into the radial or femoral artery and permit continuous blood
pressure monitoring and blood gas measurements. The rate of CRBSI is comparable to that of temporary CVCs (2.9 versus 2.3
per 1,000 catheter days) (11). One study of peripheral arterial catheters demonstrated no difference in infection rates
between changing catheters at scheduled times and changing arterial catheters on an as-needed basis
(132). One observational study of 71 arterial catheters revealed that 10 local infections and four CRBSIs occurred in patients who had peripheral
arterial catheters in place for >4 days compared with one local infection and no CRBSIs in patients whose catheters were in place
<4 days (p < 0.05) (147). Because the risk for CRBSI is likely similar to that of short-term CVCs, arterial catheters can
be approached in a similar way. No specific recommendation can be made regarding replacement of catheters that need to be
in place for >5 days.
Replacement of Administration Sets
The optimal interval for routine replacement of IV administration sets has been examined in three well-controlled
studies. Data from each of these studies reveal that replacing administration sets no more frequently than 72 hours after initiation
of use is safe and cost-effective (149--151). Data from a more recent study demonstrated that rates of phlebitis were
not substantially different if administration sets were left in place 96 hours compared with 72 hours
(128). When a fluid that enhances microbial growth is infused (e.g., lipid emulsions and blood products), more frequent changes of administration
sets are indicated, because these products have been identified as independent risk factors for CRBSI
Stopcocks (used for injection of medications, administration of IV infusions, and collection of blood samples) represent
a potential portal of entry for microorganisms into vascular access catheters and IV fluids. Stopcock contamination is
common, occurring in 45% and 50% in the majority of series. Whether such contamination is a substantial entry point of CRBSI
has been difficult to prove.
"Piggyback" systems are used as an alternative to stopcocks. However, they also pose a risk for contamination of
the intravascular fluid if the device entering the rubber membrane of an injection port is exposed to air or comes into
direct contact with nonsterile tape used to fix the needle to the port. Modified piggyback systems have the potential to
prevent contamination at these sites (159).
Needleless Intravascular Catheter Systems
Attempts to reduce the incidence of sharp injuries and the resultant risk for transmission of bloodborne infections to
health-care workers have led to the design and introduction of needleless infusion systems. When the devices are used according
to manufacturers' recommendations, they do not substantially affect the incidence of CRBSI
Multidose Parenteral Medication Vials
Parenteral medications commonly are dispensed in multidose, parenteral medication vials that might be used for
prolonged periods for one or more patients. Although the overall risk for extrinsic contamination of multidose vials is likely
minimal (168), the consequences of contamination might result in life-threatening infection
(169,170). Single-use vials are frequently preservative-free and might pose a risk for contamination if they are punctured several times.
Special Considerations for Intravascular Catheter-Related Infections
in Pediatric Patients
Prevention of CRBSI in children requires additional considerations, although only certain studies have been
performed specifically in children. Pediatric data have been derived largely from studies in neonatal or pediatric ICUs and
pediatric oncology patients.
As in adults, the majority of BSIs in children are associated with the use of an intravascular catheter. From 1995
through 2000, the pooled mean catheter-associated BSI rate for all pediatric ICUs reporting data to NNIS was 7.7 per 1,000
catheter days (171,172). Umbilical catheter and CVC-associated BSI rates for neonatal ICUs ranged from 11.3 per 1,000 catheter
days in children with birth weight <1,000 g to 4.0 per 1,000 catheter days in children whose birth weight was >2,500 g
(171). Catheter utilization rates were comparable in adult and pediatric ICUs
As in adults, the majority of CRBSIs in children are caused by coagulase-negative staphylococci. During 1992--1999,
these bacteria accounted for 37.7% of BSIs in pediatric ICUs reporting to NNIS
(12). Exposure to lipids has been identified as
an independent risk factor for development of coagulase-negative staphylococcal bacteremia in very low birth weight infants
(i.e., those weighing <1,000 g) (odds ratio [OR] = 9.4; 95% CI = 1.2--74.2)
(155), as well as candidemia in the neonatal ICU
(OR = 5.33; 95% CI = 1.23--48.4) (154). Gram-negative bacteria accounted for 25% of BSIs reported in pediatric ICUs
(172), whereas enterococci and
Candida spp. accounted for 10% and 9%, respectively
Peripheral Venous Catheters
As in adults, the use of peripheral venous catheters in pediatric patients might be complicated by phlebitis,
infusion extravasation, and catheter infection
(174). Catheter location, infusion of parenteral nutritional fluids with continuous
IV lipid emulsions, and length of ICU stay before catheter insertion have all increased pediatric patients' risk for
phlebitis. However, contrary to the risk in adults, the risk for phlebitis in children has not increased with the duration of
Peripheral Arterial Catheters
In a prospective study of 340 peripheral arterial catheters in children, the following two risk factors for
catheter-related infection were identified: 1) use of an arterial system that permitted backflow of blood into the pressure tubing and
2) duration of catheterization (176). Although a correlation was found between duration of arterial catheterization and risk
for catheter colonization, the risk remained constant for 2--20 days at 6.2%
Although the umbilical stump becomes heavily colonized soon after birth, umbilical-vessel catheterization often is used
for vascular access in newborn infants. Umbilical vessels can be cannulated easily and permit both collection of blood samples
and measurement of hemodynamic status. The incidences of catheter colonization and BSI are similar for umbilical vein
catheters and umbilical artery catheters. In several studies, an estimated 40%--55% of umbilical artery catheters were colonized and
5% resulted in CRBSI; umbilical vein catheters were associated with colonization in 22%--59% of cases
(177--179) and with
CRBSI in 3%--8% of cases (178). Although CRBSI rates are similar for umbilical catheters in the high position (i.e., above
the diaphragm) compared with the low position (i.e., below the diaphragm and above the aortic bifurcation), catheters placed
in the high position result in a lower incidence of vascular complications without an increase in adverse sequelae
Risk factors for infection differ for umbilical artery and umbilical vein catheters. In one study, neonates with very low
birth weight who also received antibiotics for
>10 days were at increased risk for umbilical artery CRBSIs
(178). In comparison, those with higher birth weight and receipt of parenteral nutrition fluids were at increased risk for umbilical vein
CRBSI. Duration of catheterization was not an independent risk factor for infection of either type of umbilical catheter.
Because of the limited vascular sites in children, attention should be given to the frequency with which catheters are
replaced in these patients. In a study in which survival analysis techniques were used to examine the relation between the duration
of central venous catheterization and complications in pediatric ICU patients, all of the patients studied (n = 397)
remained uninfected for a median of 23.7 days
(180). In addition, no relation was found between duration of catheterization and
the daily probability of infection (r = 0.21; p > 0.1), suggesting that routine replacement of CVCs likely does not reduce
the incidence of catheter-related infection
Catheter Site Care
Although data regarding the use of the chlorhexidine-impregnated sponge
(Biopatch) in children are limited,
one randomized, controlled study involving 705 neonates reported a substantial decrease in colonized catheter tips in infants in
the Biopatch group compared with the group that had standard dressings (15% versus 24%; RR = 0.6; 95% CI = 0.5--0.9),
but no difference in the rates of CRBSI or BSI without a source.
Biopatch was associated with localized contact dermatitis
in infants of very low birth weight. Of 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 < 0.0001). 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
Performance indicators for reducing CRBSI are 1) implementation of educational programs that include didactic
and interactive components for those who insert and maintain catheters; 2) use of maximal sterile barrier precautions
during catheter placement; 3) use of chlorhexidine for skin antisepsis; and 4) rates of catheter discontinuation when the catheter is
no longer essential for medical management. The impact these recommendations will have on individual institutions should
be evaluated using specific performance indicators.
Recommendations for Placement
of Intravascular Catheters in Adults and Children
These recommendations are designed to reduce the infectious complications associated with intravascular catheter
use. Recommendations should be considered in the context of the institution's experience with catheter-related
infections, experience with other adverse catheter-related complications (e.g., thrombosis, hemorrhage, and pneumothorax),
and availability of personnel skilled in the placement of intravascular devices. Recommendations are provided for 1)
intravascular-catheter use in general; 2) specific devices; and 3) special circumstances (i.e., intravascular-device use in pediatric patients
and CVC use for parenteral nutrition and hemodialysis access). Recommendations regarding the frequency of replacing
catheters, dressings, administration sets, and fluids also are provided (Appendix B).
As in previous guidelines issued by CDC and HICPAC, each recommendation is categorized on the basis of
existing scientific data, theoretical rationale, applicability, and economic impact. The CDC/HICPAC system for
categorizing recommendations is as follows:
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.
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
Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.
I. Health-care worker education and training
A. Educate health-care workers 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
(39,43,45--47,182--187). Category IA B. Assess knowledge of and adherence to guidelines periodically for all persons who insert and manage
intravascular catheters (39,43,46,182,188).
Category IA C. Ensure appropriate nursing staff levels in ICUs to minimize the incidence of CRBSIs
(48,189,190). Category IB
A. Monitor the catheter sites visually or by palpation through the intact dressing on a regular basis, depending on
the clinical situation of individual patients. If patients have tenderness at the insertion site, fever without obvious
source, or other manifestations suggesting local or BSI, the dressing should be removed to allow thorough examination
of the site (1,191--193). Category IB B. Encourage patients to report to their health-care provider any changes in their catheter site or any new
discomfort. Category II|
C. Record the operator, date, and time of catheter insertion and removal, and dressing changes on a standardized
form. Category II D. Do not routinely culture catheter tips
(8,194,195). Category IA
III. Hand hygiene
A. Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic-containing soap
and water or with waterless alcohol-based gels or foams. Observe hand hygiene 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
(43,70,196--200). Category IA B. Use of gloves does not obviate the need for hand hygiene
(43,198,199). Category IA
IV. Aseptic technique during catheter insertion and care
A. Maintain aseptic technique for the insertion and care of intravascular catheters
(22,71,201,202). Category IA B. Wear clean or sterile gloves when inserting an intravascular catheter as required by the Occupational Safety
and Health Administration Bloodborne Pathogens Standard.
Category IC. Wearing clean gloves rather than sterile gloves
is acceptable for the insertion of peripheral intravascular
catheters if the access site is not touched after the application
of skin antiseptics. Sterile gloves should be worn for the insertion of arterial and central catheters
(201,203). Category IA C. Wear clean or sterile gloves when changing the dressing on intravascular catheters.
V. Catheter insertion
Do not routinely use arterial or venous cutdown procedures as a method to insert catheters
(204--206). Category IA
VI. Catheter site care
A. Cutaneous antisepsis
1. Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing
changes. Although a 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor, or 70%
alcohol can be used (73,75,207,208). Category IA 2. No recommendation can be made for the use of chlorhexidine in infants aged <2 months.
Unresolved issue 3. Allow the antiseptic to remain on the insertion site and to air dry before catheter insertion. Allow
povidone iodine to remain on the skin for at least 2 minutes, or longer if it is not yet dry before insertion
(73,75,207,208). Category IB 4. Do not apply organic solvents (e.g., acetone and ether) to the skin before insertion of catheters or
during dressing changes (209). Category IA
VII. Catheter-site dressing regimens
A. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site
(146,210--212). Category IA B. Tunneled CVC sites that are well healed might not require dressings.
Category II C. If the patient is diaphoretic, or if the site is bleeding or oozing, a gauze dressing is preferable to a transparent,
semi-permeable dressing (146,210--212). Category II D. Replace catheter-site dressing if the dressing becomes damp, loosened, or visibly soiled
(146,210). Category IB E. Change dressings at least weekly for adult and adolescent patients depending on the circumstances of the
individual patient (211). Category II F. Do not use topical antibiotic ointment or creams on insertion sites (except when using dialysis catheters) because
of their potential to promote fungal infections and antimicrobial resistance
(107,213). Category IA (See Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters, in Adult and
Pediatric Patients, Section II.I.)
G. Do not submerge the catheter under 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
(214,215). Category II
VIII. Selection and replacement of intravascular catheters
A. Select the catheter, insertion technique, and insertion site with the lowest risk for complications (infectious
and noninfectious) for the anticipated type and duration of IV therapy
(22,55,59, 216--218). Category IA B. Promptly remove any intravascular catheter that is no longer essential
(219,220). Category IA C. Do not routinely replace central venous or arterial catheters solely for the purposes of reducing the incidence
of infection (134,135,221). Category IB D. Replace peripheral venous catheters at least every 72--96 hours in adults to prevent phlebitis
(128). Leave peripheral venous catheters in place in children until IV therapy is completed, unless complications (e.g., phlebitis
and infiltration) occur (174,175,222,223). Category IB E. When adherence to aseptic technique cannot be ensured (i.e., when catheters are inserted during a
medical emergency), replace all catheters as soon as possible and after no longer than
48hours (22,71,201,202). Category II F. Use clinical judgment to determine when to replace a catheter that could be a source of infection (e.g., do
not routinely replace catheters in patients whose only indication of infection is fever). Do not routinely replace
venous catheters in patients who are bacteremic or fungemic if the source of infection is unlikely to be the catheter
(224). Category II G. Replace any short-term CVC if purulence is observed at the insertion site, which indicates infection
(224,225). Category IB H. Replace all CVCs if the patient is hemodynamically unstable and CRBSI is suspected
(224,225). Category II I. Do not use guidewire techniques to replace catheters in patients suspected of having catheter-related
infection (134,135). Category IB
IX. Replacement of administration sets*, needleless systems, and parenteral fluids
A. Administration sets
1. Replace administration sets, including secondary sets and add-on devices, no more frequently than at
72-hour intervals, unless catheter-related infection is suspected or documented
(23, 149--151). Category IA 2. Replace tubing used to administer blood, blood products, or lipid emulsions (those combined with amino
acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion
229). Category IB. If the solution contains only dextrose and amino acids, the administration set does not
need to be replaced more frequently than every 72 hours
(226). Category II 3. Replace tubing used to administer propofol infusions every 6 or 12 hours, depending on its use, per
the manufacturer's recommendation (230). Category IA
B. Needleless intravascular devices
1. Change the needleless components at least as
frequently as the administration set (160--162,
164--167). Category II 2. Change caps no more frequently than every 72 hours or according to manufacturers'
recommendations (160,162,165,166). Category II 3. Ensure that all components of the system are compatible to minimize leaks and breaks in the system
(163). Category II 4. Minimize contamination risk by wiping the access port with an appropriate antiseptic and accessing the
port only with sterile devices (162,163,165).
C. Parenteral fluids
1. Complete the infusion of lipid-containing solutions (e.g., 3-in-1 solutions) within 24 hours of hanging
the solution (156--158,226,229). Category IB 2. Complete the infusion of lipid emulsions alone within 12 hours of hanging the emulsion. If
volume considerations require more time, the infusion should be completed within 24 hours
(156--158). Category IB 3. Complete infusions of blood or other blood products within 4 hours of hanging the blood
(231--234). Category II 4. No recommendation can be made for the hang time of other parenteral fluids.
X. IV-injection ports
A. Clean injection ports with 70% alcohol or an iodophor before accessing the system
(164,235,236). Category IA B. Cap all stopcocks when not in use
(235). Category IB
XI. Preparation and quality control of IV admixtures
A. Admix all routine parenteral fluids in the pharmacy in a laminar-flow hood using aseptic technique
(237,238). Category IB B. Do not use any container of parenteral fluid that has visible turbidity, leaks, cracks, or particulate matter or if
the manufacturer's expiration date has passed
(237). Category IB C. Use single-dose vials for parenteral additives or medications when possible
(237,239). Category II D. Do not combine the leftover content of single-use vials for later use
(237,239). Category IA E. If multidose vials are used
1. Refrigerate multidose vials after they are opened if recommended by the manufacturer.
Category II 2. Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial
(236). Category IA 3. Use a sterile device to access a multidose vial and avoid touch contamination of the device before penetrating
the access diaphragm (235,240). Category IA 4. Discard multidose vial if sterility is compromised
(235,240). Category IA
XII. In-line filters
Do not use filters routinely for infection-control purposes
(80,241). Category IA
XIII. IV-therapy personnel
Designate trained personnel for the insertion and maintenance of intravascular catheters
(46,47,210,242). Category IA
XIV. Prophylactic antimicrobials
Do not administer intranasal or systemic antimicrobial prophylaxis routinely before insertion or during use of
an intravascular catheter to prevent catheter colonization or BSI
(97,98,108,243). Category IA
Peripheral Venous Catheters, Including Midline Catheters, in Adult and
I. Selection of peripheral catheter
A. Select catheters on the basis of the intended purpose and duration of use, known complications (e.g., phlebitis
and infiltration), and experience of individual catheter operators
(67,68,244). Category IB B. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis
if extravasation occurs (67,68). Category IA C. Use a midline catheter or PICC when the duration of IV therapy will likely exceed 6 days
(244). Category IB
II. Selection of peripheral-catheter insertion site
A. In adults, use an upper- instead of a lower-extremity site for catheter insertion. Replace a catheter inserted in a
lower-extremity site to an upper-extremity site as soon as possible
(67,245). Category IA B. In pediatric patients, the hand, the dorsum of the foot, or the scalp can be used as the catheter insertion site.
Category II C. Replacement of catheter
1. 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 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 2. Remove peripheral venous catheters if the patient develops signs of phlebitis (e.g., warmth, tenderness,
erythema, and palpable venous cord), infection, or a malfunctioning catheter
(66). Category IB 3. In adults, replace short, peripheral venous catheters at least 72--96 hours to reduce the risk for phlebitis. If
sites for venous access are limited and no evidence of phlebitis or infection is present, peripheral venous catheters
can be left in place for longer periods, although the patient and the insertion sites should be closely
monitored (66,128,246). Category IB 4. Do not routinely replace midline catheters to reduce the risk for infection
(131). Category IB 5. In pediatric patients, leave peripheral venous catheters in place until IV therapy is completed, unless
a complication (e.g., phlebitis and infiltration) occurs
(174,175,222,223). Category IB
III. Catheter and catheter-site care
Do not routinely apply prophylactic topical
antimicrobial or antiseptic ointment or cream to the insertion site
of peripheral venous catheters (107,213). Category IA
Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary
Artery Catheters, in Adult and Pediatric Patients
A. Conduct surveillance in ICUs and other patient populations to determine CRBSI rates, monitor trends in
those rates, and assist in identifying lapses in infection-control practices
(3,12,16,247--250). Category IA B. Express ICU data as the number of catheter-associated
BSIs per 1,000 catheter-days for both adults and children
and stratify by birth weight categories for neonatal ICUs to facilitate comparisons with national data in
comparable patient populations and health-care settings
(3,12,16,247--250). Category IB C. Investigate events leading to unexpected life-threatening
or fatal outcomes. This includes any process variation for which
a recurrence would likely present an adverse outcome
(13). Category IC
II. General principles
A. Use a CVC with the minimum number of ports or lumens essential for the management of the patient
(251--254). Category IB B. Use an antimicrobial or antiseptic-impregnated CVC in adults whose catheter is expected to remain in place >5
days if, after implementing a comprehensive strategy to reduce rates of CRBSI, the CRBSI rate remains above the goal
set by the individual institution based on benchmark rates (Table 2) and local factors. The comprehensive strategy
should include the following three components: educating persons who insert and maintain catheters, use of maximal
barrier precautions, and a 2% chlorhexidine preparation for skin antisepsis during CVC insertion
(84--86,90,91,255). Category IB C. No recommendation can be made for the use of impregnated catheters in children.
Unresolved issue D. Designate personnel who have been trained and exhibit competency in the insertion of catheters to supervise
trainees who perform catheter insertion
(39,43,46,182,187,188). Category IA E. Use totally implantable access devices for patients who require long-term, intermittent vascular access. For
patients requiring frequent or continuous access, a PICC or tunneled CVC is preferable
(256,257). Category II F. Use a cuffed CVC for dialysis if the period of temporary access is anticipated to be prolonged (e.g., >3
weeks) (144,258). Category IB G. Use a fistula or graft instead of a CVC for permanent access for dialysis
(142). Category IB H. Do not use hemodialysis catheters for blood drawing or applications other than hemodialysis except during dialysis
or under emergency circumstances. Category II I. Use povidone-iodine antiseptic 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
(103,114,144). Category II
III. Selection of catheter insertion site
A. Weigh the risk and benefits of placing a 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
(22,55,59,218). Category IA B. Use a subclavian site (rather than a jugular or a femoral site) in adult patients to minimize infection risk
for nontunneled CVC placement (22,55,59,60).
Category IA C. No recommendation can be made for a preferred site of insertion to minimize infection risk for a nontunneled
CVC (61--63). Unresolved issue D. Place catheters used for hemodialysis and pheresis in a jugular or femoral vein rather than a subclavian vein to
avoid venous stenosis if catheter access is needed
(259--263). Category IA
IV. Maximal sterile barrier precautions during catheter insertion
A. Use aseptic technique including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet,
for the insertion of CVCs (including PICCS) or guidewire exchange
(22,71). Category IA B. Use a sterile sleeve to protect pulmonary artery catheters during insertion
(148). Category IB
V. Replacement of catheter
A. Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent
catheter-related infections (132,134,135). Category IB B. 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
(224,264). Category II C. Guidewire exchange
1. Do not use guidewire exchanges routinely for nontunneled catheters to prevent infection
(135,265). Category IB 2. Use a guidewire exchange to replace a malfunctioning nontunneled catheter if no evidence of infection is
present (135,265). Category IB 3. Use a new set of sterile gloves before handling the new catheter when guidewire exchanges are performed
(22,71). Category II
VI. Catheter and catheter-site care
A. General measures
Designate one port exclusively for hyperalimen-tation if a multilumen catheter is used to administer
parenteral nutrition (266). Category II
B. Antibiotic lock solutions
Do not routinely use antibiotic lock solutions to prevent CRBSI. Use prophylactic antibiotic lock solution only
in special circumstances (e.g., in treating a patient with a long-term cuffed or tunneled catheter or port who has a
history of multiple CRBSIs despite optimal maximal adherence to aseptic technique)
(115,116,267,268). Category II
C. Catheter-site dressing regimens
1. Replace the catheter-site dressing when it becomes damp, loosened, or soiled or when inspection of the site
is necessary (65,146,211). Category IA 2. Replace dressings used on short-term CVC sites every 2 days for gauze dressings and at least every 7 days
for transparent dressings, except in those pediatric patients in which the risk for dis-lodging the catheter
outweighs the benefit of changing the dressing
(211). Category IB 3. Replace dressings used on tunneled or implanted CVC sites no more than once per week,
until the insertion site has healed (211). Category IB 4. 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
D. No recommendation can be made for the use of chlorhexidine sponge dressings to reduce the incidence of
infection. Unresolved issue E. Do not use chlorhexidine sponge dressings in neonates aged <7 days or of gestational age <26 weeks
(181). Category II F. No recommendation can be made for the use of sutureless securement devices.
Unresolved issue G. Ensure that catheter-site care is compatible with the catheter material
(109,110). Category IB H. Use a sterile sleeve for all pulmonary artery catheters
(148). Category IB
Additional Recommendations for Peripheral Arterial Catheters and
Pressure Monitoring Devices for Adult and Pediatric Patients
I. Selection of pressure monitoring system
Use disposable, rather than reusable, transducer assemblies when possible
(269--273). Category IB
II. Replacement of catheter and pressure monitoring system
A. Do not routinely replace peripheral arterial catheters to prevent catheter-related infections
(132,147, 221,274). Category II B. 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
(22,270). Category IB
III. Care of pressure monitoring systems
A. General measures
1. Keep all components of the pressure monitoring system (including calibration devices and flush solution)
sterile (269,275--277). Category IA 2. 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
(272,278). Category II 3. When the pressure monitoring system is accessed through a diaphragm rather than a stopcock, wipe
the diaphragm with an appropriate antiseptic before accessing the system
(272). Category IA 4. Do not administer dextrose-containing solutions
or parenteral nutrition fluids through the pressure
monitoring circuit (272,279,280). Category IA
B. Sterilization or disinfection of pressure monitoring systems
1. Use disposable transducers
(272,279--282). Category IB 2. Sterilize reusable transducers according to the manufacturers' instructions if the use of disposable transducers
is not feasible (272,279--282). Category IA
Recommendations for Umbilical Catheters
I. Replacement of catheters
A. Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency, or thrombosis
are present (283). Category II B. Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present
(283). Category II C. No recommendation can be made for treating through an umbilical venous catheter suspected of being
infected. Unresolved issue D. Replace umbilical venous catheters only if the catheter malfunctions.
II. Catheter-site care
A. 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 (75,177,178,284,285). Category IB B. Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential
to promote fungal infections and antimicrobial resistance
(107,213). Category IA C. Add low doses of heparin (0.25--1.0 F/ml) to the fluid infused through umbilical arterial catheters
(286--288). Category IB D. 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
(283,289). Category II E. 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 (290,291). Category II
* Administration sets include the area from the spike of tubing entering the fluid container to the hub of the vascular access device. However, a short extension tube
might be connected to the catheter and might be considered a portion of the catheter to facilitate aseptic technique when changing administration sets.
Pearson ML. Guideline for prevention of intravascular device-related infections. Part I. Intravascular device-related infections: an overview.
The Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996;24:262--77.
Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132:391--402.
CDC. National Nosocomial Infections Surveillance (NNIS) System report, data summary from October 1986--April 1998, issued June 1998. Am
J Infect Control 1998;26:522--33.
Digiovine B, Chenoweth C, Watts C, Higgins M. The attributable mortality and costs of primary nosocomial bloodstream infections in the
intensive care unit. Am J Respir Crit Care Med 1999;160:976--81.
Rello J, Ochagavia A, Sabanes E, et al. Evaluation of outcome of intravenous catheter-related infections in critically ill patients. Am J Respir Crit
Care Med 2000;162:1027--30.
Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically
ill patients: a matched, risk-adjusted, cohort study. Infect Control Hosp Epidemiol 1999;20:396--401.
Collignon PJ. Intravascular catheter associated sepsis: a common problem. The Australian Study on Intravascular Catheter Associated Sepsis. Med
J Aust 1994;161:374--8.
Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable
mortality. JAMA 1994;271:1598--601.
Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-related
bloodstream infection in the surgical intensive care unit. Arch Surg 2001;136:229--34.
Mermel LA. Correction: catheter related bloodstream-infections. Ann Intern Med 2000;133:395.
Kluger DM, Maki DG. The relative risk of intravascular device related bloodstream infections in adults [Abstract]. In: Abstracts of the
39th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco, CA: American Society for Microbiology, 1999:514.
CDC. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1990--May 1999, issued June 1999. Am
J Infect Control 1999;27:520--32.
Joint Commission on the Accreditation of Healthcare Organizations. Accreditation manual for hospitals. In: Joint Commission on the
Accreditation of Healthcare Organizations, ed. Chicago, IL: Joint Commission on the Accreditation of Healthcare Organizations, 1994:121--40.
CDC. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1992--June 2001, issued August 2001. Am
J Infect Control 2001;6:404--21.
Schaberg DR, Culver DH, Gaynes RP. Major trends in the microbial etiology of nosocomial infection. Am J Med 1991;91(suppl):S72--S75.
Banerjee SN, Emori TG, Culver DH, et al. Secular trends in nosocomial primary bloodstream infections in the United States, 1980--1989.
National Nosocomial Infections Surveillance System. Am J Med 1991;91(suppl):S86--S89.
Pfaller MA, Jones RN, Messer SA, Edmond MB, Wenzel RP. National surveillance of nosocomial blood stream infection due to
Candida albicans: frequency of occurrence and antifungal susceptibility in the SCOPE Program. Diagn Microbiol Infect Dis 1998;31:327--32.
Pfaller MA, Jones RN, Messer SA, Edmond MB, Wenzel RP. National surveillance of nosocomial blood stream infection due to species of
Candida other than Candida albicans: frequency of occurrence and antifungal susceptibility in the SCOPE Program. Diagn Microbiol Infect Dis
Nguyen MH, Peacock JE Jr., Morris AJ, et al. The changing face of candidemia: emergence of
non-Candida albicans species and antifungal
resistance. Am J Med 1996;100:617--23.
Fridkin SK, Gaynes RP. Antimicrobial resistance in intensive care units. Clin Chest Med 1999;20:303--16.
Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J
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;91(suppl):S197--S205.
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. Parenter Enteral Nutr 1985;9:322--5.
Linares J, Sitges-Serra A, Garau J, Perez JL, Martin R. Pathogenesis of catheter sepsis: a prospective study with quantitative and
semiquantitative cultures of catheter hub and segments. J Clin Microbiol 1985;21:357--60.
Raad II, Costerton W, Sabharwal U, Sacilowski M, Anaissie E, Bodey GP. Ultrastructural analysis of indwelling vascular catheters: a
quantitative relationship between luminal colonization and duration of placement. J Infect Dis 1993;168:400--7.
Maki DG. Infections associated with intravascular lines. In: Remington JS, ed. Current Clinical Topics in Infectious Diseases. New York:
Sheth NK, Franson TR, Rose HD, Buckmire FL, Cooper JA, Sohnle PG. Colonization of bacteria on polyvinyl chloride and Teflon
intravascular catheters in hospitalized patients. J Clin Microbiol 1983;18:1061--3.
Ashkenazi S, Weiss E, Drucker MM, Bodey GP. Bacterial adherence to intravenous catheters and needles and its influence by cannula type
and bacterial surface hydrophobicity. J Lab Clin Med 1986;107:136--40.
Locci R, Peters G, Pulverer G. Microbial colonization of prosthetic
devices. IV. Scanning electron microscopy of intravenous catheters invaded by
yeasts. Zentralbl Bakteriol Mikrobiol Hyg [B] 1981;173:419--24.
Locci R, Peters G, Pulverer G. Microbial colonization of prosthetic devices. I. Microtopographical characteristics of intravenous catheters as
detected by scanning electron microscopy. Zentralbl Bakteriol Mikrobiol Hyg [B] 1981;173:285--92.
Nachnani GH, Lessin LS, Motomiya T, Jensen WN, Bodey GP. Scanning electron microscopy of thrombogenesis on vascular catheter surfaces.
N Engl J Med 1972;286:139--40.
Stillman RM, Soliman F, Garcia L, Sawyer PN. Etiology of catheter-associated sepsis. Correlation with thrombogenicity. Arch Surg
Herrmann M, Lai QJ, Albrecht RM, Mosher DF, Proctor RA. Adhesion of
Staphylococcus aureus to surface-bound platelets: role of
fibrinogen/fibrin and platelet integrins. J Infect Dis 1993;167:312--22.
Herrmann M, Suchard SJ, Boxer LA, Waldvogel FA, Lew PD. Thrombospondin binds to
Staphylococcus aureus and promotes
staphylococcal adherence to surfaces. Infect Immun 1991;59:279--88.
Ludwicka A, Uhlenbruck G, Peters G, et al. Investigation on extracellular slime substance produced by
Staphylococcus epidermidis. Zentralbl
Bakteriol Mikrobiol Hyg 1984;258:256--67.
Gray ED, Peters G, Verstegen M, Regelmann WE. Effect of extracellular slime substance from
Staphylococcus epidermidis on the human
cellular immune response. Lancet 1984;1:365--7.
Branchini ML, Pfaller MA, Rhine-Chalberg J, Frempong T, Isenberg HD. Genotypic variation and slime production among blood and
catheter isolates of Candida parapsilosis. J Clin Microbiol 1994;32:452--6.
Sherertz RJ, Ely EW, Westbrook DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern
Ryan JA Jr., Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition: a prospective study of 200 consecutive patients.
N Engl J Med 1974;290:757--61.
Sanders RA, Sheldon GF. Septic complications of total parenteral nutrition: a five year experience. Am J Surg 1976;132:214--20.
Murphy LM, Lipman TO. Central venous catheter care in parenteral nutrition: a review. Parenter Enteral Nutr 1987;11:190--201.
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;355:1864--8.
Armstrong CW, Mayhall CG, Miller KB, et al. Prospective study of catheter replacement and other risk factors for infection of
hyperalimentation catheters. J Infect Dis 1986;154:808--16.
Nehme AE. Nutritional support of the hospitalized patient: the team concept. JAMA 1980;243:1906--8.
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;158:473--7.
Tomford JW, Hershey CO. The IV therapy team: impact on patient care and costs of hospitalization. NITA 1985;8:387--9.
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;17:150--8.
Bansmer G, Keith D, Tesluk H. Complications following use of indwelling catheters of inferior vena cava. JAMA 1958;167:1606--11.
Crane C. Venous interruption of septic thrombophlebitis. N Engl J Med 1960;262:947--51.
Indar R. The dangers of indwelling polyethelene cannulae in deep veins. Lancet 1959;1:284--6.
Heard SO, Wagle M, Vijayakumar E, et al. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on
the incidence of catheter-related bacteremia. Arch Intern Med 1998;158:81--7.
Richet H, Hubert B, Nitemberg G, 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;28:2520--5.
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;19:842--5.
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;117:178--83.
Mian NZ, Bayly R, Schreck DM, Besserman EB, Richmand D. Incidence of deep venous thrombosis associated with femoral venous
catheterization. Acad Emerg Med 1997;4:1118--21.
Durbec O, Viviand X, Potie F, Vialet R, Albanese J, Martin C. A prospective evaluation of the use of femoral venous catheters in critically ill
adults. Crit Care Med 1997;25:1986--9.
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;23:52--9.
Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a
randomized controlled trial. JAMA 2001;286:700--7.
Venkataraman ST, Thompson AE, Orr RA. Femoral vascular
catheterization in critically ill infants and children. Clin Pediatr 1997;36:311--9.
Stenzel JP, Green TP, Fuhrman BP, Carlson PE, Marchessault RP. Percutaneous femoral venous catheterizations: a prospective study of
complications. J Pediatr 1989;114:411--5.
Goldstein AM, Weber JM, Sheridan RL. Femoral venous access is safe in burned children: an analysis of 224 catheters. J Pediatr 1997;130:442--6.
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;24:2053--8.
Maki DG, Ringer M. Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters: gauze, a
transparent polyurethane dressing, and an iodophor-transparent dressing. JAMA 1987;258:2396--403.
Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters: a randomized controlled trial. Ann Intern
Band JD, Maki DG. Steel needles used for intravenous therapy: morbidity in patients with hematologic malignancy. Arch Intern Med
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;70:702--6.
Pittet D, Hugonnet S, Harbath S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
Larson EL, Rackoff WR, Weiman M, et al. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect
Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions
during insertion. Infect Control Hosp Epidemiol 1994;15:231--8.
Clemence MA, Walker D, Farr BM. Central venous catheter practices: results of a survey. Am J Infect Control 1995;23:5--12.
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;338:339--43.
Humar A, Ostromecki A, Direnfeld J, et al. Prospective randomized trial of 10% povidone-iodine versus 0.5% tincture of chlorhexidine as
cutaneous antisepsis for prevention of central venous catheter infection. Clin Infect Dis 2000;31:1001--7.
Garland JS, Buck RK, Maloney P, et al. Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of
peripheral intravenous catheter colonization in neonates: a prospective trial. Pediatr Infect Dis J 1995;14:510--6.
Hoffmann KK, Weber DJ, Samsa GP, Rutala WA. Transparent polyurethane film as an intravenous catheter dressing: a meta-analysis of the
infection risks. JAMA 1992;267:2072--6.
Maki DG, Mermel LA, Klugar D, et al. The efficacy of a chlorhexidine impregnated sponge (Biopatch) for the prevention of intravascular
catheter-related infection- a prospective randomized controlled multicenter study [Abstract]. Presented at the Interscience Conference on Antimicrobial
Agents and Chemotherapy. Toronto, Ontario, Canada: American Society for Microbiology, 2000.
Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters.
J Vasc Interv Radiol 2001 (in press).
Rusho WJ, Bair JN. Effect of filtration on complications of postoperative intravenous therapy. Am J Hosp Pharm 1979;36:1355--6.
Maddox RR, John JF Jr., Brown LL, Smith CE. Effect of inline filtration on postinfusion phlebitis. Clin Pharm 1983;2:58--61.
Turco SJ, Davis NM. Particulate matter in intravenous infusion fluids---phase 3. Am J Hosp Pharm 1973;30:611--3.
Baumgartner TG, Schmidt GL, Thakker KM, et al. Bacterial endotoxin retention by inline intravenous filters. Am J Hosp Pharm 1986;43:681--4.
Butler DL, Munson JM, DeLuca PP. Effect of inline filtration on the potency of low-dose drugs. Am J Hosp Pharm 1980;37:935--41.
Raad II, Darouiche R, Dupuis J, et al. 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
Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy of antiseptic-impregnated central venous catheters in preventing
catheter-related bloodstream infection: a meta-analysis. JAMA 1999;281:261--7.
Maki DG, Stolz SM, Wheeler S, Mermel LA. Prevention of central venous catheter-related bloodstream infection by use of an
antiseptic-impregnated catheter: a randomized, controlled trial. Ann Intern Med 1997;127:257--66.
Raad II, Darouiche R, Hachem R, Mansouri M, Bodey GP. The broad-spectrum activity and efficacy of catheters coated with minocycline
and rifampin. J Infect Dis 1996;173:418--24.
Bassetti S, Hu J, D'Agostino RB Jr., Sherertz RJ. Prolonged antimicrobial activity of a catheter containing chlorhexidine-silver sulfadiazine
extends protection against catheter infections in vivo. Antimicrob Agents Chemother 2001;45:1535--8.
Oda T, Hamasaki J, Kanda N, Mikami K. Anaphylactic shock induced by an antiseptic-coated central venous catheter. Anesthesiology
Veenstra DL, Saint S, Sullivan SD. Cost-effectiveness of antiseptic-impregnated central venous catheters for the prevention of
catheter-related bloodstream infection. JAMA 1999;282:554--60.
Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl
J Med 1999;340:1--8.
Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
Maki DG, Cobb L, Garman JK, Shapiro JM, Ringer M, Helgerson RB. An attachable silver-impregnated cuff for prevention of infection with
central venous catheters: a prospective randomized multicenter trial. Am J Med 1988;85:307--14.
Dahlberg PJ, Agger WA, Singer JR, et al. Subclavian hemodialysis catheter infections: a prospective, randomized trial of an attachable
silver-impregnated cuff for prevention of catheter-related infections. Infect Control Hosp Epidemiol 1995;16:506--11.
Groeger JS, Lucas AB, Coit D, et al. A prospective, randomized evaluation of the effect of silver impregnated subcutaneous cuffs for
preventing tunneled chronic venous access catheter infections in cancer patients. Ann Surg 1993;218:206--10.
Bonawitz SC, Hammell EJ, Kirkpatrick JR. Prevention of central venous
catheter sepsis: a prospective randomized trial. Am Surg 1991;57:618--23.
McKee R, Dunsmuir R, Whitby M, Garden OJ. Does antibiotic prophylaxis at the time of catheter insertion reduce the incidence of
catheter-related sepsis in intravenous nutrition? J Hosp Infect 1985;6:419--25.
Ranson MR, Oppenheim BA, Jackson A, Kamthan AG, Scarffe JH. Double-blind placebo controlled study of vancomycin prophylaxis for
central venous catheter insertion in cancer patients. J Hosp Infect 1990;15:95--102.
Ljungman P, Hagglund H, Bjorkstrand B, Lonnqvist B, Ringden O. Peroperative teicoplanin for prevention of gram-positive infections in
neutropenic patients with indwelling central venous catheters: a randomized, controlled study. Support Care Cancer 1997;5:485--8.
Kacica MA, Horgan MJ, Ochoa L, Sandler R, Lepow ML, Venezia RA. Prevention of gram-positive sepsis in neonates weighing less than 1500 g.
J Pediatr 1994;125:253--8.
Spafford PS, Sinkin RA, Cox C, Reubens L, Powell KR. Prevention of central venous catheter-related coagulase-negative staphylococcal sepsis
in neonates. J Pediatr 1994;125:259--63.
Levin A, Mason AJ, Jindal KK, Fong IW, Goldstein MB. Prevention of hemodialysis subclavian vein catheter infections by topical
povidone-iodine. Kidney Int 1991;40:934--8.
Casewell MW. The nose: an underestimated source of
Staphylococcus aureus causing wound infection. J Hosp Infect 1998;40(suppl):S3--S11.
Hill RL, Fisher AP, Ware RJ, Wilson S, Casewell MW. Mupirocin for the reduction of colonization of internal jugular cannulae---a
randomized controlled trial. J Hosp Infect 1990;15:311--21.
Sesso R, Barbosa D, Leme IL, et al.
Staphylococcus aureus prophylaxis in hemodialysis patients using central venous catheter: effect of
mupirocin ointment. J Am Soc Nephrol 1998;9:1085--92.
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;31:189--93.
Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant
Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol 1996;17:811--3.
Rao SP, Oreopoulos DG. Unusual complications of a polyurethane PD catheter. Perit Dial Int 1997;17:410--2.
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;13:1870--1.
von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of
Staphylococcus aureus bacteremia. N Engl J Med 2001;344:11--6.
Zinner SH, Denny-Brown BC, Braun P, Burke JP, Toala P, Kass EH. Risk of infection with intravenous indwelling catheters: effect of application
of antibiotic ointment. J Infect Dis 1969;120:616--9.
Norden CW. Application of antibiotic ointment to the site of venous catheterization---a controlled trial. J Infect Dis 1969;120:611--5.
Maki DG, Band JD. A comparative study of polyantibiotic and iodophor ointments in prevention of vascular catheter-related infection. Am J
Henrickson KJ, Axtell RA, Hoover SM, et al. 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
Carratala J, Niubo J, Fernandez-Sevilla A, et al. 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;43:2200--4.
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;8:1591--7.
Rackoff WR, Weiman M, Jakobowski D, et al. A randomized, controlled trial of the efficacy of a heparin and vancomycin solution in
preventing central venous catheter infections in children. J Pediatr 1995;127:147--51.
Raad II, Buzaid A, Rhyne J, et al. Minocycline and ethylene-diaminetetraacetate for the prevention of recurrent vascular catheter infections.
Clin Infect Dis 1997;25:149--51.
Raad II, Luna M, Khalil SA, Costerton JW, Lam C, Bodey GP. The relationship between the thrombotic and infectious complications of
central venous catheters. JAMA 1994;271:1014--6.
Timsit JF, Farkas JC, Boyer JM, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risk factors, and relationship
with catheter-related sepsis. Chest 1998;114:207--13.
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;113:165--71.
Mermel LA, Stolz SM, Maki DG. Surface antimicrobial activity of heparin-bonded and antiseptic-impregnated vascular catheters. J Infect
Pierce CM, Wade A, Mok Q. Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children.
Intensive Care Med 2000;26:967--72.
Bern MM, Lokich JJ, Wallach SR, et al. Very low doses of warfarin can prevent thrombosis in central venous catheters: a randomized prospective
trial. Ann Intern Med 1990;112:423--8.
Boraks P, Seale J, Price J, et al. Prevention of central venous catheter associated thrombosis using minidose warfarin in patients with
haematological malignancies. Br J Haematol 1998;101:483--6.
Collin J, Collin C. Infusion thrombophlebitis. Lancet 1975;2:458.
Lai KK. Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours. Am J Infect Control 1998;26:66--70.
Fontaine PJ. Performance of a new softening expanding midline
catheter in home intravenous therapy patients. J Intraven Nurs 1991;14:91--9.
Harwood IR, Greene LM, Kozakowski-Koch JA, Rasor JS. New peripherally inserted midline catheter: a better alternative for intravenous
antibiotic therapy in patients with cystic fibrosis. Pediatr Pulmonol 1992;12:233--9.
Mermel LA, Parenteau S, Tow SM. The risk of midline catheterization in hospitalized patients. A prospective study. Ann Intern Med
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;18:1073--9.
Uldall PR, Merchant N, Woods F, Yarworski U, Vas S. Changing subclavian haemodialysis cannulas to reduce infection. Lancet 1981;1:1373.
Cook D, Randolph A, Kernerman P, et al. Central venous catheter replacement strategies: a systematic review of the literature. Crit Care
Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J
Robinson D, Suhocki P, Schwab SJ. Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange. Kidney
Beathard GA. Management of bacteremia associated with tunneled-cuffed hemodialysis catheters. J Am Soc Nephrol 1999;10:1045--9.
Saad TF. Bacteremia associated with tunneled, cuffed hemodialysis catheters. Am J Kidney Dis 1999;34:1114--24.
Duszak R Jr., Haskal ZJ, Thomas-Hawkins C, et al. Replacement of failing tunneled hemodialysis catheters through pre-existing
subcutaneous tunnels: a comparison of catheter function and infection rates for de novo placements and over-the-wire exchanges. J Vasc Interv Radiol
Jaar BG, Hermann JA, Furth SL, Briggs W, Powe NR. Septicemia in diabetic hemodialysis patients: comparison of incidence, risk factors,
and mortality with nondiabetic hemodialysis patients. Am J Kidney Dis 2000;35:282--92.
Powe NR, Jaar B, Furth SL, Hermann J, Briggs W. Septicemia in dialysis patients: incidence, risk factors, and prognosis. Kidney Int
Hoen B, Paul-Dauphin A, Hestin D, Kessler M. EPIBACDIAL: a multicenter prospective study of risk factors for bacteremia in chronic
hemodialysis patients. J Am Soc Nephrol 1998;9:869--76.
Tokars JI, Miller ER, Alter MJ, et al. National surveillance of
dialysis-associated diseases in the United States, 1997. Semin Dial 2000;13:75--85.
Foundation NK. III. NKF-K/DOQI Clinical practice guidelines for
vascular access: update 2000. Am J Kidney Dis 2001;37(suppl):S137--S81.
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;22:1729--37.
Raad II, 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;23:17--26.
Cohen Y, Fosse JP, Karoubi P, et al. 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;157:284--7.
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;6:367--70.
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;258:1777--81.
Snydman DR, Donnelly-Reidy M, Perry LK, Martin WJ. Intravenous tubing containing burettes can be safely changed at 72 hour intervals.
Infect Control 1987;8:113--6.
Hanna HA, Raad II. Blood products: a significant risk factor for long-term catheter-related bloodstream infections in cancer patients. Infect
Control Hosp Epidemiol 2001;22:165--6.
Raad II, Hanna HA, Awad A, et al. Optimal frequency of changing intravenous administration sets: is it safe to prolong use beyond 72 hours?
Infect Control Hosp Epidemiol 2001;22:136--9.
Saiman L, Ludington E, Dawson JD, et al. Risk factors for
Candida species colonization of neonatal intensive care unit patients. Pediatr Infect Dis
Avila-Figueroa C, Goldmann DA, Richardson DK, Gray JE, Ferrari A, Freeman J. Intravenous lipid emulsions are the major determinant
of coagulase-negative staphylococcal bacteremia in very low birth weight newborns. Pediatr Infect Dis J 1998;17:10--7.
Crocker KS, Noga R, Filibeck DJ, Krey SH, Markovic M, Steffee WP. Microbial growth comparisons of five commercial parenteral lipid emulsions.
J Parenter Enteral Nutr 1984;8:391--5.
Jarvis WR, Highsmith AK. Bacterial growth and endotoxin production in lipid emulsion. J Clin Microbiol 1984;19:17--20.
Melly MA, Meng HC, Schaffner W. Microbiol growth in lipid emulsions used in parenteral nutrition. Arch Surg 1975;110:1479--81.
Inoue Y, Nezu R, Matsuda H, et al. Prevention of catheter-related sepsis during parenteral nutrition: effect of a new connection device. J
Parenter Enteral Nutr 1992;16:581--5.
Arduino MJ, Bland LA, Danzig LE, McAllister SK, Aguero SM. Microbiologic evaluation of needleless and needle-access devices. Am J
Infect Control 1997;25:377--80.
Brown JD, Moss HA, Elliott TS. The potential for catheter microbial
contamination from a needleless connector. J Hosp Infect 1997;36:181--9.
Cookson ST, Ihrig M, O'Mara EM, et al. 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;19:23--7.
Do AN, Ray BJ, Banerjee SN, et al. Bloodstream infection associated with needleless device use and the importance of infection-control
practices in the home health care setting. J Infect Dis 1999;179:442--8.
Luebke MA, Arduino MJ, Duda DL, et al. Comparison of the microbial barrier properties of a needleless and a conventional
needle-based intravenous access system. Am J Infect Control 1998;26:437--41.
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;19:772--7.
Mendelson MH, Short LJ, Schechter CB, et al. Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of
staff, patient, and institutional outcomes. Infect Control Hosp Epidemiol 1998;19:401--6.
Seymour VM, Dhallu TS, Moss HA, Tebbs SE, Elliot TS. A prospective clinical study to investigate the microbial contamination of a
needleless connector. J Hosp Infect 2000;45:165--8.
Longfield RN, Smith LP, Longfield JN, Coberly J, Cruess D. Multiple-dose vials: persistence of bacterial contaminants and infection
control implications. Infect Control 1985;6:194--9.
Henry B, Plante-Jenkins C, Ostrowska K. An outbreak of Serratia marcescens associated with the anesthetic agent propofol. Am J Infect
Grohskopf LA, Roth VR, Feikin DR, et al. Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center.
N Engl J Med 2001;344:1491--7.
CDC. National Nosocomial Infections Surveillance (NNIS) System report, data summary from April 1995--April 2000, issued June 2000. Am
J Infect Control 2000;28:429--35.
Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in pediatric intensive care units in the United States: National
Nosocomial Infections Surveillance System. Pediatrics 1999;103:103--9.
Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States: National
Nosocomial Infections Surveillance System. Crit Care Med 1999;27:887--92.
Garland JS, Dunne WM Jr., Havens P, et al. Peripheral intravenous catheter complications in critically ill children: a prospective study.
Garland JS, Nelson DB, Cheah TE, Hennes HH, Johnson TM. Infectious complications during peripheral intravenous therapy with Teflon
catheters: a prospective study. Pediatr Infect Dis J 1987;6:918--21.
Furfaro S, Gauthier M, Lacroix J, Nadeau D, Lafleur L, Mathews S. Arterial catheter-related infections in children: a 1-year cohort analysis. Am J
Dis Child 1991;145:1037--43.
Krauss AN, Albert RF, Kannan MM. Contamination of umbilical catheters in the newborn infant. J Pediatr 1970;77:965--9.
Landers S, Moise AA, Fraley JK, Smith EO, Baker CJ. Factors associated with umbilical catheter-related sepsis in neonates. Am J Dis
Balagtas RC, Bell CE, Edwards LD, Levin S. Risk of local and systemic infections associated with umbilical vein catheterization: a prospective
study in 86 newborn patients. Pediatrics 1971;48:359--67.
Stenzel JP, Green TP, Fuhrman BP, Carlson PE, Marchessault RP. Percutaneous central venous catheterization in a pediatric intensive care
unit: a survival analysis of complications. Crit Care Med 1989;17:984--8.
Garland JS, Alex CP, Mueller CD, et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing
for prevention of central venous catheter infections in neonates. Pediatrics 2001;107:1431--6.
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
Conly JM, Hill S, Ross J, Lertzman J, Louie TJ. Handwashing practices in an intensive care unit: the effects of an educational program
and its relationship to infection rates. Am J Infect Control 1989;17:330--9.
East SA. Planning, implementation, and evaluation of a successful hospital-based peripherally inserted central catheter program. J Intraven
Kyle KS, Myers JS. Peripherally inserted central catheters. Development of a hospital-based program. J Intraven Nurs 1990;13:287--90.
BeVier PA, Rice CE. Initiating a pediatric peripherally inserted central
catheter and midline catheter program. J Intraven Nurs 1994;17:201--5.
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;144:1191--4.
Wenzel RP, Wentzel RP. The development of academic programs for quality assessment. Arch Intern Med 1991;151:653--4.
Robert J, Fridkin SK, Blumberg HM, et al. 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;21:12--7.
Vicca AF. Nursing staff workload as a determinant of methicillin-resistant
Staphylococcus aureus spread in an adult intensive therapy unit. J
Hosp Infect 1999;43:109--13.
White MC, Ragland KE. Surveillance of intravenous catheter-related
infections among home care clients. Am J Infect Control 1994;22:231--5.
Lorenzen AN, Itkin DJ. Surveillance of infection in home care. Am J Infect Control 1992;20:326--9.
White MC. Infections and infection risks in home care settings. Infect Control Hosp Epidemiol 1992;13:535--9.
Raad II, Baba M, Bodey GP. Diagnosis of catheter-related infections: the role of surveillance and targeted quantitative skin cultures. Clin Infect
Widmer AF, Nettleman M, Flint K, Wenzel RP. The clinical impact of culturing central venous catheters: a prospective study. Arch Intern
Boyce JM, Farr BM, Jarvis WR, et al. Guideline for hand hygiene in the healthcare setting. Am J Infect Control 2002 (in press).
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;160:1017--21.
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;159:821--6.
Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of handwashing in prevention of endemic intensive care unit infections.
Infect Control Hosp Epidemiol 1990;11:589--94.
Boyce JM, Kelliher S, Vallande N. Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus
hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol 2000;21:442--8.
Capdevila JA. Catheter-related infection: an update on diagnosis, treatment, and prevention. Int J Infect Dis 1998;2:230--6.
Abi-Said D, Raad II, 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;20:101--5.
Povoski SP. A prospective analysis of the cephalic vein cutdown approach for chronic indwelling central venous access in 100 consecutive
cancer patients. Ann Surg Oncol 2000;7:496--502.
Arrighi DA, Farnell MB, Mucha P Jr., Iistrup DM, Anderson DL. Prospective, randomized trial of rapid venous access for patients in
hypovolemic shock. Ann Emerg Med 1989;18:927--30.
Ahmed Z, Mohyuddin Z. Complications associated with different insertion techniques for Hickman catheters. Postgrad Med J 1998;74:104--7.
Little JR, Murray PR, Traynor PS, Spitznagel E. A randomized trial of povidone-iodine compared with iodine tincture for venipuncture
site disinfection: effects on rates of blood culture contamination. Am J Med 1999;107:119--25.
Mimoz O, Pieroni L, Lawrence C, et al. 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;24:1818--23.
Maki DG, McCormack KN. Defatting catheter insertion sites in total parenteral nutrition is of no value as an infection control measure.
Controlled clinical trial. Am J Med 1987;83:833--40.
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;20:618--20.
Rasero L, Degl'Innocenti M, Mocali M, et al. Comparison of two different time interval protocols for central venous catheter dressing in
bone marrow transplant patients: results of a randomized, multicenter study. Haematologica 2000;85:275--9.
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
Flowers RH, 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;261:878--83.
Robbins J, Cromwell P, Korones DN. Swimming and central venous catheter-related infections in the child with cancer. J Pediatr Oncol
Howell PB, Walters PE, Donowitz GR, Farr BM. Risk factors for infection of adult patients with cancer who have tunneled central venous
catheters. Cancer 1995;75:1367--75.
Goetz AM, Miller J, Wagener MM, Muder RR. Complications related to intravenous midline catheter usage: a 2-year study. J Intraven
Martin C, Viviand X, Saux P, Gouin F. Upper-extremity deep vein thrombosis after central venous catheterization via the axillary vein. Crit Care
Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD. Perforation of the great vessels during central venous line placement. Arch Intern
Lederle FA, Parenti CM, Berskow LC, Ellingson KJ. The idle intravenous catheter. Ann Intern Med 1992;116:737--8.
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;154:1829--32.
Thomas F, Burke JP, Parker J, et al. The risk of infection related to radial vs femoral sites for arterial catheterization. Crit Care Med 1983;11:807--12.
Nelson DB, Garland JS. The natural history of Teflon catheter-associated phlebitis in children. Am J Dis Child 1987;141:1090--2.
Shimandle RB, Johnson D, Baker M, Stotland N, Karrison T, Arnow PM. Safety of peripheral intravenous catheters in children. Infect Control
Hosp Epidemiol 1999;20:736--40.
O'Grady NP, Barie PS, Bartlett J, et al. Practice parameters for evaluating new fever in critically ill adult patients. Task Force of the American
College of Critical Care Medicine of the Society of Critical Care Medicine in collaboration with the Infectious Disease Society of America. Crit Care
Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis
Mershon J, Nogami W, Williams JM, Yoder C, Eitzen HE, Lemons JA. Bacterial/fungal growth in a combined parenteral nutrition solution.
J Parenter Enteral Nutr 1986;10:498--502.
Gilbert M, Gallagher SC, Eads M, Elmore MF. Microbial growth patterns in a total parenteral nutrition formulation containing lipid emulsion.
J Parenter Enteral Nutr 1986;10:494--7.
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;131:267--72.
Didier ME, Fischer S, Maki DG. Total nutrient admixtures appear safer than lipid emulsion alone as regards microbial contamination:
growth properties of microbial pathogens at room temperature. J Parenter Enteral Nutr 1998;22:291--6.
Bennett SN, McNeil MM, Bland LA, et al. Postoperative infections traced to contamination of an intravenous anesthetic, propofol. N Engl J
Roth VR, Arduino MJ, Nobiletti J, et al. Transfusion-related sepsis due to Serratia liquefaciens in the United States. Transfusion 2000;40:931--5.
Blajchman MA. Reducing the risk of bacterial contamination of cellular blood components. Dev Biol Stand 2000;102:183--93.
Barrett BB, Andersen JW, Anderson KC. Strategies for the avoidance of bacterial contamination of blood components. Transfusion 1993;33:228--33.
Plott RT, Wagner RF Jr., Tyring SK. Iatrogenic contamination of multidose vials in simulated use. A reassessment of current patient
injection technique. Arch Dermatol 1990;126:1441--4.
Salzman MB, Isenberg HD, Rubin LG. Use of disinfectants to reduce microbial contamination of hubs of vascular catheters. J Clin
ASPH Council on Professional Affairs. ASHP guidelines on quality assurance for pharmacy-prepared sterile products. Am J Health Syst
Herruzo-Cabrera R, Garcia-Caballero J, Vera-Cortes ML, Vazquez-Encinar A, Garcia-Caballero F, Rey-Calero J, Garcia de Lorenzo A. Growth
of microorganisms in parenteral nutrient solutions. Am J Hosp Pharm 1984;41:1178--80.
Green KA, Shouldachi B, Schoer K, Moro D, Blend R, McGeer A. Gadolinium-based MR contrast media: potential for growth of
microbial contaminants when single vials are used for multiple patients. Am J Roentgenol 1995;165:669--71.
Arrington ME, Gabbert KC, Mazgaj PW, Wolf MT. Multidose vial contamination in anesthesia. Aana J 1990;58:462--6.
Falchuk KH, Peterson L, McNeil BJ. Microparticulate-induced
phlebitis: its prevention by in-line filtration. N Engl J Med 1985;312:78--82.
Cohran J, Larson E, Roach H, Blane C, Pierce P. Effect of intravascular surveillance and education program on rates of nosocomial
bloodstream infections. Heart Lung 1996;25:161--4.
Netto dos Santos KR, de Souza Fonseca L, Gontijo Filho PP. Emergence of high-level mupirocin resistance in methicillin-resistant
Staphylococcus aureus isolated from Brazilian university hospitals. Infect Control Hosp Epidemiol 1996;17:813--6.
Ryder MA. Peripheral access options. Surg Oncol Clin N Am 1995;4:395--427.
Maki DG, Goldman DA, Rhame FS. Infection control in intravenous therapy. Ann Intern Med 1973;79:867--87.
Tager IB, Ginsberg MB, Ellis SE, et al. An epidemiologic study of the risks associated with peripheral intravenous catheters. Am J
Horan TC, Emori TG. Definitions of key terms used in the NNIS System. Am J Infect Control 1997;25:112--6.
Khuri-Bulos NA, Shennak M, Agabi S, et al. Nosocomial infections in the intensive care units at a university hospital in a developing
country: comparison with National Nosocomial Infections Surveillance intensive care unit rates. Am J Infect Control 1999;27:547--52.
Pittet D, Wenzel RP. Nosocomial bloodstream infections. Secular trends in rates, mortality, and contribution to total hospital deaths. Arch
Intern Med 1995;155:1177--84.
Clark-Christoff N, Watters VA, Sparks W, Snyder P, Grant JP. Use of triple-lumen subclavian catheters for administration of total parenteral
nutrition. J Parenter Enteral Nutr 1992;16:403--7.
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;83:34--6.
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;84:667--72.
Yeung C, May J, Hughes R. Infection rate for single lumen v triple lumen subclavian catheters. Infect Control Hosp Epidemiol 1988;9:154--8.
Collin GR. Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: a continuous quality improvement project.
Groeger JS, Lucas AB, Thaler HT, et al. Infectious morbidity associated with long-term use of venous access devices in patients with cancer.
Ann Intern Med 1993;119:1168--74.
Pegues D, Axelrod P, McClarren C, et al. Comparison of infections in Hickman and implanted port catheters in adult solid tumor patients. J
Surg Oncol 1992;49:156--62.
Moss AH, Vasilakis C, Holley JL, Foulks CJ, Pillai K, McDowell DE. Use of a silicone dual-lumen catheter with a Dacron cuff as a
long-term vascular access for hemodialysis patients. Am J Kidney Dis 1990;16:211--5.
Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterization vein stenosis in haemodialysis: comparative angiographic study of
50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991;6:722--4.
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;54:154--61.
Barrett N, Spencer S, McIvor J, Brown EA. Subclavian stenosis: a major complication of subclavian dialysis catheters. Nephrol Dial
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;217:89--93.
Macdonald S, Watt AJ, McNally D, Edwards RD, Moss JG. Comparison of technical success and outcome of tunneled catheters inserted via
the jugular and subclavian approaches. J Vasc Interv Radiol 2000;11:225--31.
Widmer AF. Management of catheter-related bacteremia and fungemia
in patients on total parenteral nutrition. Nutrition 1997;13(suppl):S18--S25.
Powell C, Kudsk KA, Kulich PA, Mandelbaum JA, Fabri PJ. Effect of frequent guidewire changes on triple-lumen catheter sepsis. J Parenter
Enteral Nutr 1988;12:462--4.
Snydman DR, Murray SA, Kornfeld SJ, Majka JA, Ellis CA. Total parenteral nutrition-related infections: prospective epidemiologic study
using semiquantitative methods. Am J Med 1982;73:695--9.
Easom A. Prophylactic antibiotic lock therapy for hemodialysis catheters. Nephrol Nurs J 2000;27:75.
Vercaigne LM, Sitar DS, Penner SB, Bernstein K, Wang GQ, Burczynski FJ. Antibiotic-heparin lock: in vitro antibiotic stability combined
with heparin in a central venous catheter. Pharmacotherapy 2000;20:394--9.
Luskin RL, Weinstein RA, Nathan C, Chamberlin WH, Kabins SA. Extended use of disposable pressure transducers: a bacteriologic
evaluation. JAMA 1986;255:916--20.
Maki DG, Hassemer CA. Endemic rate of fluid contamination and related septicemia in arterial pressure monitoring. Am J Med 1981;70:733--8.
Mermel LA, Maki DG. Epidemic bloodstream infections from hemodynamic pressure monitoring: signs of the times. Infect Control Hosp
Tenold R, Priano L, Kim K, Rourke B, Marrone T. Infection potential of nondisposable pressure transducers prepared prior to use. Crit Care
Leroy O, Billiau V, Beuscart C, et al. Nosocomial infections associated with long-term radial artery cannulation. Intensive Care Med 1989;15:241--6.
Fisher MC, Long SS, Roberts EM, Dunn JM, Balsara RK.
Pseudomonas maltophilia bacteremia in children undergoing open heart surgery.
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;292:1099--102.
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;69:338--44.
Shinozaki T, Deane RS, Mazuzan JE Jr., Hamel AJ, Hazelton D. Bacterial contamination of arterial lines: a prospective study. JAMA
Solomon SL, Alexander H, Eley JW, et al. Nosocomial fungemia in neonates associated with intravascular pressure-monitoring devices. Pediatr
Infect Dis 1986;5:680--5.
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;25:1029--32.
Beck-Sague CM, Jarvis WR, Brook JH, et al. Epidemic bacteremia due to Acinetobacter baumannii in five intensive care units. Am J
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;27:2433--6.
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;35:460--5.
Cronin WA, Germanson TP, Donowitz LG. Intravascular catheter colonization and related bloodstream infection in critically ill neonates.
Infect Control Hosp Epidemiol 1990;11:301--8.
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;56:911--4.
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;10:229--32.
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;111:774--8.
David RJ, Merten DF, Anderson JC, Gross S. Prevention of umbilical artery catheter clots with heparinized infusates. Dev Pharmacol
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;11:94--9.
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;11:67--70.
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;16:461--6.
Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128--40.
Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Erratum. Am J Infect
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