Catheter maintenance bundles to help prevent vascular catheter infections

The improper placement or maintenance of central lines can lead to bloodstream infections. CLABSIs or Central-Line Associated Blood Stream Infections, an important type of healthcare-associated infection, are associated with mortality rates of 15-25%.¹ Besides, CLABSIs are also responsible for longer hospital stays and increased costs in many countries worldwide. ^{2, 3}

The International Nosocomial Infection Control Consortium (INICC) has used applied research and surveillance to study the challenges posed by CLABSIs. The study enabled them to compile a set of recommendations and practices to prevent or reduce the incidents of CLABSIs. This position paper by Lutwick, L et.al summarises the INICC recommendations.⁴

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Catheter maintenance bundles

A care bundle is defined as a set of interventions collectively designed to improve patient outcomes. The authors discuss the effective care bundles that have been reported in the literature. These include:

Insertion care bundles: The interventions specified in an insertion bundle are:

• The optimal site and catheter selection through the use of ultrasound guidance, a minimal number of lumen, minimised leakages through the use of compatible components, prudent use of Peripherally Inserted Central Catheter (PICC) lines and the use of midline catheters.
• Hand hygiene performed with alcohol-based rubs or antiseptic soap, before and after any interaction with the placement site.
• Skin preparation with 0.5-2.0% chlorhexidine/70% isopropanol.
• Barrier precautions using gloves and sterile gowns.

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Catheter maintenance bundles interventions include:

• Reviewing of the need and the replacement of the line.
• Hand hygiene before and after the intervention to maintain aseptic technique.
• Hub/access device disinfection.
• Changing the dressing at regular intervals, and the use of chlorhexidine-impregnated dressing.
• Daily chlorhexidine bathing, antibacterial catheters, and the use of prophylactic antimicrobials in areas with high CLABSI rates.

The use of appropriate intravenous infusion systems

Based on published data, the authors of the paper conclude that open systems (Eg. three-way stopcocks) pose a greater risk of contamination than closed ones (Eg. split septums + single-use prefilled flushing devices). In a randomised clinical trial comparing rates of CLABSI between patients using an open system and standard flushing, and those using a closed system, it was observed that the closed system had significantly lower rates of CLABSI.⁵

Catheter maintenance bundles and other suggested practices for managing CLABSIs

The most common organisms causing CLABSI are biofilm-producing Gram-positive cocci like S. aureus and coagulase-negative staphylococci (CNS). CLABSI symptoms may be mild or severe, depending on the causative organism. S. aureus and S.lugdunesis typically result in more severe symptomology.

The authors recommend the use of vancomycin as an empirical antimicrobial till culture results become available. Anti-staphylococcal beta-lactam antimicrobials are recommended in countries without high rates of MRSA. In cases of severe illness or immunocompromised patients, however, additional coverage for Gram-negative pathogens may be appropriate. Other agents may also be considered depending on anti-microbial resistance patterns.

The authors recommend that once the blood cultures are positive, all peripheral venous, arterial, midline and short-term non-tunnelled catheters be removed. Long-term catheters like PICC lines may be explanted. The approach towards the removal of any catheter should be individualised based on the patent, the causative organism and other clinical considerations.

The authors also advise clinicians that the length of antimicrobial therapy should depend on the pathogen and the degree of illness.  Some microbes can cause secondary metastatic infections, and this must also be taken into consideration when deciding the length of antimicrobial therapy.

CLABSIs in paediatrics

According to the authors, the incidences of CLABSIs in children and neonates are associated with specific challenges. Studies have shown that CLABSI rates are higher in children than in adults (1.6 to 44.6 cases in adult ICUs versus 2.6 to 60.0 cases in neonatal ICUs per 1000 central line days).⁶ Newborn infants are more susceptible to bloodstream infections due to poor skin integrity and undeveloped immune systems.

To reduce the incidences of CLABSIs in paediatric and neonatal units, the authors propose evidence-based interventions. These include administrative and policy measures, standard infection prevention techniques, skin prep for neonates, dwell time cutoffs for PICCs and appropriate site selection.

Conclusion

In this paper, the authors cite various studies from the literature to outline the challenges posed by CLABSIs and recommend ways and means to reduce them. These recommendations are intended to provide insights to healthcare professionals on the placement and maintenance of catheters to prevent infections. Besides, the authors also provide evidence-based advice on the diagnosis and treatment of CLABSIs. An important aspect of this paper is also the discussion on paediatric environments, and how CLABSIs can be reduced in them.

Lutwick L, Al-Maani AS, Mehtar S, et al . Managing and preventing vascular catheter infections: A position paper of the international society for infectious diseases. Int J Infect Dis. 2019 Jul;84:22-29. doi: 10.1016/j.ijid.2019.04.014

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