Reliable vascular access is one of the most essential features of modern medical care. Unfortunately, the intravascular devices (IVDs) needed to establish reliable access are associated with significant potential for producing bloodstream infection (BSI). More than 250 000 IVD-related BSIs occur in the United States each year, each associated with prolongation of hospital stay, a 12% to 25% attributable mortality, and an added cost to health care of $35 000.1 A recent meta-analysis has shown that rates of IVD-related BSI in children and in neonates with different types of IVDs are similar to those encountered in adults.2
Detailed evidence-based recommendations for prevention of IVD-related BSI were first published in 1973,3 then, for the first time by an expert panel convened by the Centers for Disease Control and Prevention’s (CDC’s) Hospital Infection Control Practices Advisory Committee (HICPAC) in 1981,4 and updated in 1996.5 With wide acceptance and consistent implementation of these guidelines, the incidence of central venous catheter (CVC)-associated BSI in US intensive care units (ICUs) has decreased 40% over the past decade.6 HICPAC aided by a panel of authorities has again updated the IVD Guideline,7 with specific recommendations—scored by the quality of the underlying scientific evidence, ranging from consensus theoretical rationale to well-designed, prospective, randomized clinical trials—that cover all aspects of IVD care in both adult and pediatric patients (Table 1).
CHLORHEXIDINE FOR CUTANEOUS ANTISEPSIS
There are 2 important changes in the new Guideline that apply both to pediatric and adult patients. First, given the evidence for the importance of skin microorganisms in the pathogenesis of IVD-related infection,1 measures to reduce cutaneous colonization of the insertion site would seem of highest priority, particularly the antiseptic used for disinfection of the site before insertion and in follow-up care. Recent meta-analyses have shown that chlorhexidine-containing solutions are superior to iodophors for preventing colonization of IVDs and, most importantly, IVD-related BSI.1,8 The Guideline now states that, at the present time, a 2% chlorhexidine solution should be considered the agent of first choice for vascular access; however, 10% povidone-iodine, alcoholic tinctures of iodine, or 70% alcohol alone are acceptable. Although 1 trial has evaluated a 0.5% chlorhexidine tincture, compared with povidone-iodine, for cutaneous antisepsis in neonates before peripheral intravenous (IV) catheter insertion, finding a 50% lower incidence of catheter colonization,9 no recommendations in the 2002 Guideline were made regarding the use of chlorhexidine in infants <2 years of age.
NOVEL TECHNOLOGIES FOR PREVENTION
The second major change in the 2002 Guideline involves the use of novel technologies, vis-à-vis, IVDs engineered to be implicitly resistant to infection: a novel chlorhexidine-impregnated sponge dressing, the use of antiinfective coatings on short-term noncuffed and nontunneled CVCs, and the use of antibiotic lock solutions with long-term IVDs, cuffed and tunneled CVCs, subcutaneous central ports, and peripherally inserted central catheters (PICCs).
To suppress the cutaneous flora about the catheter, a novel chlorhexidine-impregnated sponge dressing has been developed. In a large, prospective trial comparing the novel dressing with standard nonmedicated polyurethane dressings in adults with CVCs and arterial catheters in 2 university hospital ICUs, the chlorhexidine sponge dressing resulted in a 60% reduction in catheter-related BSI10; no adverse effects were seen and in vitro testing showed no evidence that the antiseptic dressing promoted resistance to chlorhexidine. The novel chlorhexidine dressing has also been studied in a multicenter trial that involved 6 neonatal ICUs; 75% of the catheters studied were PICCs.11 The study showed that the novel dressing replaced weekly yielded results comparable to disinfection with 10% povidone-iodine and semipermeable polyurethane dressings changed 3 times weekly, as regards catheter colonization and catheter-related BSI. Although well tolerated by term infants, use of the chlorhexidine dressing in low birth weight infants (<1000 g) was associated with a 15% incidence of dermotoxicity. The 2002 Guideline makes no recommendation regarding use of the chlorhexidine sponge dressing in pediatric patients, but recommends it not be used in neonates <7 days old, especially if the gestational age is <26 weeks.
The evidence is clear that coating catheters with silver sulfadiazine and chlorhexidine or with minocycline-rifampin reduces the risk of CVC-related BSI.1 Moreover, cost-benefit analyses suggests that the use of an antiseptic-impregnated CVC is cost-effective if the baseline incidence of CVC-related BSI is >0.4 BSI per 1000 CVC days12; it has been estimated that $59 000 will be saved, 7 cases of BSI avoided, and 1 death prevented for every 300 antiseptic-impregnated CVCs used. The major theoretical deterrents to coating catheter with antiinfectives, especially antibiotics, is the concern for promoting antibiotic resistance; however, this has not been detected in the studies to date. Although antiseptic-impregnated catheters are approved for use in children >3 kilograms, there have been no clinical trials to evaluate their efficacy and safety in pediatric or neonatal patients. The 2002 Guideline recommends for adult patients that if after implementing a comprehensive control strategy to reduce rates of CVC-related BSI—encompassing education, maximal sterile barriers at insertion, and use of 2% chlorhexidine for cutaneous antisepsis—the rate remains above the goal set by the institution based on benchmark rates and local factors, antiinfective CVCs should be considered for high-risk patients. No recommendations were made for the use of impregnated catheters in children, which is considered an unresolved issue.
Finally, the “antibiotic lock” is a novel technique of local prophylaxis in which an antibiotic solution is instilled in the catheter lumen and allowed to dwell for a defined period, usually several hours. There have been 7 prospective, randomized trials of antibiotic lock solutions for the prevention of BSIs with long-term IVDs; most had limitations, but most also showed benefit.1 The 3 best-controlled and largest trials, by Schwartz et al13 and by Henrickson et al14 in pediatric oncology patients with cuffed and tunneled CVCs, and a recent trial by Garland et al in neonates with PICCs,15 all showed an 80% reduction in catheter-related BSI, compared with the use of standard heparin lock solutions alone. Neither study found that use of an antibiotic-containing lock solution had any impact on nosocomial colonization or infection by vancomycin-resistant enterococci or staphylococci, or antibiotic-resistant Gram-negative bacilli. Because there is still concern that antibiotic lock solutions might contribute to resistance, the 2002 Guideline takes the conservative position that more data are needed before they can be recommended for routine use; however, in individual cases, where a patient requires indefinite vascular access—eg, for parenteral nutrition or hemodialysis—but continues to experience device-related BSIs despite stringent compliance with infection control guidelines, the use of an antibiotic lock solution to preserve vascular access is justifiable and an acceptable option.
OTHER NEW RECOMMENDATIONS FOR CHILDREN AND NEONATES
Peripheral IV Catheters
Peripheral IV catheter removal routinely within 96 hours is no longer recommended for children, as it yet is for adult patients. Peripheral IV catheters may be left in place until IV therapy is completed unless a complication—such as extravasation, phlebitis, or infection—occurs.
When optimal aseptic technique cannot be assured at the time of insertion, replace catheters inserted under emergency conditions as soon as possible, always within 48 hours.
Conduct surveillance for catheter-associated and, ideally, catheter-related BSIs in ICU and other patient populations to monitor trends and allow earliest detection of infection control problems. Express ICU rates as number of CVC-associated BSIs per 1000 catheter days and stratify by birth weight in neonatal ICUs to facilitate comparisons with national data.
Designate trained personnel with documented competence to insert CVCs and provide adequate supervision of trainees learning vascular access.
Use totally implantable subcutaneous IVDs for patients who require long-term access, but only infrequently and intermittently. Use cuffed and tunneled CVCs or PICCs for patients who require frequent or continuous access.
Use cuffed CVCs for acute renal failure if hemodialysis is anticipated to be required for >3 weeks. Use a fistula or graft, rather than a CVC, for patients with chronic renal failure, requiring indefinite access.
No recommendation can be made for the preferred site of central access in children to minimize the risk of infection. However, CVCs for hemodialysis should be placed in the internal jugular or femoral vein, rather than subclavian vein, to reduce the risk of venous stenosis.
Replace dressings on short-term CVCs every 2 days for gauze dressings and at least every 7 days for transparent dressings unless, in the case of pediatric patients, the risk of dislodging the catheter outweighs the benefit of changing the dressing. Replace dressings that become damp, loosened, or soiled, or when inspection of the site is necessary.
Replace dressings on tunneled CVCs or implanted central devices no more frequently than once per week until the insertion site is healed. The necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs is an unresolved issue.
No recommendation was made regarding the use of sutureless novel securement devices, which prevents catheter dislodgment and may reduce the risk of catheter-related BSI.1
Use a sterile sleeve for all pulmonary artery catheters.
Do not routinely replace CVCs or PICCs as a method to prevent catheter-related infection. CVCs do not necessarily need to be replaced in febrile or bacteremic patients if the source of infection is unlikely to be the catheter.
Do not routinely replace CVCs over a guidewire for prevention of infection, especially if catheter-related infection is suspected. However, remove short-term CVCs if there is evidence of exit site infection or if catheter-related BSI is strongly suspected, and if continued central access is needed, place the new CVC in a new site.
In general, umbilical or arterial catheters may be left in place up to 5 days and umbilical venous catheters up to 14 days. If there is suspicion of catheter-related infection, vascular insufficiency, or thrombosis, remove and do not replace the umbilical catheter.
Add low-dose heparin (0.25–1.0 unit/mL) to fluids infused through umbilical arterial catheters.
Although numerous studies have been performed on adults,1,3–8 there are many aspects of IVD care in neonatal or pediatric patients that have not been studied adequately,2 for which the Committee, because of insufficient data, could not make specific recommendations. Future research is needed to provide evidence to fill these voids. The safety and efficacy of chlorhexidine-based cutaneous antiseptics in children and neonates and the value of the chlorhexidine-impregnated sponge dressing on CVCs or arterial catheters in pediatric patients need to be evaluated. Antimicrobial-coated and antiseptic-impregnated CVCs need to be evaluated in children. Finally, additional trials are needed to document the efficacy and, especially, the ecologic safety of antiinfective lock solutions, both for neonatal and pediatric patients with long-term IVDs. Lock solutions should be sought that have rapid bactericidal and fungicidal activity but a low risk of inducing antimicrobial resistance.
Until adequately powered studies are done to better assess the safety and efficacy of those features of IVD care for which no pediatric or neonatal recommendations are available, consistent adherence to the “best practice” consensus Guideline developed by the CDC HICPAC will be most likely to provide maximal protection against IVD-related BSI in children.16
- Received August 20, 2002.
- Accepted August 20, 2002.
- Reprint requests to (J.S.G.) St Joseph Regional Medical Center, 5000 West Chambers St, Milwaukee, WI 53210. E-mail:
Dr Maki has received research grants from Arrow International, Becton Dickinson, Johnson & Johnson, Stuart-ICI, and 3M. He is also a consultant to the Centers for Disease Control and Prevention and was a co-author of the 2002 HICPAC IV Guideline.
- ↵Crnich CJ, Maki DG. The promise of novel technology for prevention of intravascular device-related bloodstream infection, Part 1: pathogenesis and short-term devices. Clin Infect Dis. 2002;34:1362–8; Part 2: long-term devices. Clin Infect Dis.2002;34 :1232– 1242
- ↵Kluger DM, Maki DG. The risk of intravascular device-related bloodstream infection in children and neonates. A meta-analysis of 88 published prospective studies. Proceedings and Abstracts of the 40th Annual Meeting of the Infectious Diseases Society of America; Chicago, IL; October 24–27, 2002. Abstract 623
- ↵Centers for Disease Control and Prevention Working Group. Guidelines for prevention of intravenous therapy-related infections. In: Guidelines for the Prevention and Control of Nosocomial Infections. USDHHS-PHS; 1981
- ↵O’Grady NP, Alexander M, Dellinger EP, et al. HICPAC guidelines for the prevention of intravascular catheter-related infections. MMWR Morb Mortal Wkly Rep.2002;55(RR-10) :1– 29
- ↵Maki DG, Mermel LA, Kluger DM, et al. The efficacy of a chlorhexidine-impregnated sponge (Biopatch7) for the prevention of intravascular catheter-related infection. A prospective, randomized, multicenter study. Proceedings and Abstracts of the 40th Interscience Conference on Antimicrobial Agent Chemotherapy; Toronto; September 16–20, 2000
- ↵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– 1436
- ↵Saint S, Veenstra DL, Lipsky BA. The clinical and economical consequences of nosocomial central venous catheter-related infection: are antimicrobial catheters useful? Infect Control Hosp Epidemiol.2002;21 :375– 380
- ↵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– 1597
- ↵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.2000;18 :1269– 1278
- ↵Garland JS, Henrickson KJ, Maki DG. A prospective randomized trial of vancomycin-heparin lock for prevention of catheter-related bloodstream infections in an NICU. Proceedings and Abstracts from the Society of Pediatr Res Annual Meeting; Baltimore, MD; May 5, 2002
- ↵Gross PA. Practice guidelines for infectious disease: rationale for a work in progress. Clin Infect Dis.1998;26 :1037– 1041
- Copyright © 2002 by the American Academy of Pediatrics