**Berenholtz SM, Pronovost PJ, Lipsett PA, et al. (2004) Eliminating
Catheter-Related Bloodstream Infections in the Intensive Care Unit.
*Critical Care Medicine*, 32:2014-2020.**

**Abstract:** OBJECTIVE: To determine whether a multifaceted systems
intervention would eliminate catheter-related bloodstream infections
(CR-BSIs). DESIGN: Prospective cohort study in a surgical intensive care
unit (ICU) with a concurrent control ICU. SETTING: The Johns Hopkins
Hospital. PATIENTS: All patients with a central venous catheter in the
ICU. INTERVENTION: To eliminate CR-BSIs, a quality improvement team
implemented five interventions: educating the staff; creating a catheter
insertion cart; asking providers daily whether catheters could be
removed; implementing a checklist to ensure adherence to evidence-based
guidelines for preventing CR-BSIs; and empowering nurses to stop the
catheter insertion procedure if a violation of the guidelines was
observed. MEASUREMENT: The primary outcome variable was the rate of
CR-BSIs per 1,000 catheter days from January 1, 1998, through December
31, 2002. Secondary outcome variables included adherence to
evidence-based infection control guidelines during catheter insertion.
MAIN RESULTS: Before the intervention, we found that physicians followed
infection control guidelines during 62% of the procedures. During the
intervention time period, the CR-BSI rate in the study ICU decreased
from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000
catheter days in the fourth quarter of 2002. The CR-BSI rate in the
control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and
1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We
estimate that these interventions may have prevented 43 CR-BSIs, eight
deaths, and 1,945,922 dollars in additional costs per year in the study
ICU. CONCLUSIONS: Multifaceted interventions that helped to ensure
adherence with evidence-based infection control guidelines nearly
eliminated CR-BSIs in our surgical ICU.

**Calvert N, Hind D, McWilliams R et al (2004) Ultrasound for Central
Venous Cannulation: Economic Evaluation of Cost-Effectiveness.
*Anaesthesia* (59) 1116-1120.**

**Abstract:** We compared the economics of using two-dimensional
ultrasound locating devices and more traditional landmark methods for
central venous cannulation in the National Health Service (NHS). The
evaluation consisted of a systematic review of randomised controlled
trials and an economic evaluation using decision analytic
cost-effectiveness modeling. Incremental costs per complication avoided
associated with landmark and ultrasound central venous cannulation were
modeled for patients scheduled for central venous cannulation. The
marginal economic cost of using ultrasound for central venous
cannulation was less than 10 pounds sterling per procedure, assuming
that a machine is used for 15 procedures each week. The base case
scenario implied that 2000 pounds sterling worth of resource savings
result for every 1000 procedures undertaken and 90 avoided
complications. Sensitivity analysis indicated that the results of
modeling appear robust to the central assumptions used. Ultrasound
guidance used in central venous cannulation procedures saves NHS
resources even with conservative modeling assumptions.

**Centers for Disease Control and Prevention: Guidelines for the
Prevention of Intravascular Catheter-Related Infections (2002). *MMWR
,*51(No. RR 10), 1-36*.***

**Abstract:** 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.

**Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. (2002)
Chlorhexidine Compared with Povidone-Iodine Solution for Vascular
Catheter-Site Care: A Meta-Analysis. *Annals of Internal Medicine,*
136(11), 792-801**

**Abstract:** PURPOSE: Bloodstream infections related to use of
catheters, particularly central-line catheters, are an important cause
of patient morbidity, mortality, and increased health care costs. This
study evaluated the efficacy of skin disinfection with chlorhexidine
gluconate compared with povidone-iodine solution in preventing
catheter-related bloodstream infection. DATA SOURCES: Multiple
computerized databases (1966 to 2001), reference lists of identified
articles, and queries of principal investigators and antiseptic
manufacturers. STUDY SELECTION: Randomized, controlled trials comparing
chlorhexidine gluconate with povidone-iodine solutions for catheter-site
care. DATA EXTRACTION: Using a standardized form, two reviewers
abstracted data on study design, patient population, intervention, and
incidence of catheter-related bloodstream infection from all included
studies. DATA SYNTHESIS: Eight studies involving a total of 4143
catheters met the inclusion criteria. All studies were conducted in a
hospital setting, and various catheter types were used. The summary risk
ratio for catheter-related bloodstream infection was 0.49 (95% CI, 0.28
to 0.88) in patients whose catheter sites were disinfected with
chlorhexidine gluconate instead of povidone-iodine. Among patients with
a central vascular catheter, chlorhexidine gluconate reduced the risk
for catheter-related bloodstream infection by 49% (risk ratio, 0.51
\[CI, 0.27 to 0.97\]). CONCLUSIONS: These results suggest that incidence
of bloodstream infections is significantly reduced in patients with
central vascular lines who receive chlorhexidine gluconate versus
povidone-iodine for insertion-site skin disinfection. Use of
chlorhexidine gluconate is a simple and effective means of reducing
vascular catheter-related infections.

**Harbarth S, Sax H, Gastmeier P. (2003) The Preventable Proportion of
Nosocomial Infections: An Overview of Published Reports*. J Hosp
Infect,* 54(4), 258-66.**

**Abstract:** The proportion of nosocomial infections potentially
preventable under routine working conditions remains unclear. We
performed a systematic review to describe multi-modal intervention
studies, as well as studies assessing exogenous cross-infection
published during the last decade, in order to give a crude estimate of
the proportion of potentially preventable nosocomial infections. The
evaluation of 30 reports suggests that great potential exists to
decrease nosocomial infection rates, from a minimum reduction effect of
10% to a maximum effect of 70%, depending on the setting, study design,
baseline infection rates and type of infection. The most important
reduction effect was identified for catheter-related bacteremia, whereas
a smaller, but still substantial potential for prevention seems to exist
for other types of infections. Based on these estimates, we consider at
least 20% of all nosocomial infections as probably preventable, and hope
that this overview will stimulate further research on feasible and
cost-effective prevention of nosocomial infections for daily practice.

**Hind D, Calvert N, McWilliams R, et al (2003) Ultrasonic Location
Devices for Central Venous Cannulation: Meta-Analysis *BMJ* (327) 361**

**Abstract:** OBJECTIVES: To assess the evidence for the clinical
effectiveness of ultrasound guided central venous cannulation. DATA
SOURCES: 15 electronic bibliographic databases, covering biomedical,
science, social science, health economics, and grey literature. DESIGN:
Systematic review and meta-analysis of randomised controlled trials.
Populations Patients scheduled for central venous access. INTERVENTION
REVIEWED: Guidance using real time two dimensional ultrasonography or
Doppler needles and probes compared with the anatomical landmark method
of cannulation. DATA EXTRACTION: Risk of failed catheter placement
(primary outcome), risk of complications from placement, risk of failure
on first attempt at placement, number of attempts to successful
catheterisation, and time (seconds) to successful catheterisation. DATA
SYNTHESIS: 18 trials (1646 participants) were identified. Compared with
the landmark method, real time two dimensional ultrasound guidance for
cannulating the internal jugular vein in adults was associated with a
significantly lower failure rate both overall (relative risk 0.14, 95%
confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39
to 0.88). Limited evidence favoured two dimensional ultrasound guidance
for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to
0.57 and 0.29, 0.07 to 1.21, respectively). Three studies in infants
confirmed a higher success rate with two dimensional ultrasonography for
internal jugular procedures (0.15, 0.03 to 0.64). Doppler guided
cannulation of the internal jugular vein in adults was more successful
than the landmark method (0.39, 0.17 to 0.92), but the landmark method
was more successful for subclavian vein procedures (1.48, 1.03 to 2.14).
No significant difference was found between these techniques for
cannulation of the internal jugular vein in infants. An indirect
comparison of relative risks suggested that two dimensional
ultrasonography would be more successful than Doppler guidance for
subclavian vein procedures in adults (0.09, 0.02 to 0.38). CONCLUSIONS:
Evidence supports the use of two dimensional ultrasonography for central
venous cannulation.

**Hirschhorn L, (2000) Campaigning for Change. *Harvard Business
Review*, May/June, 2-7.**

**Abstract:** Most organizations must change if they\'re to stay alive.
Change is tough to accomplish, but it\'s not impossible and can be
systematized. The author, who has been involved in change initiatives at
scores of companies, believes that the success of such programs has more
to do with execution than with conceptualization. The successful change
programs he observed had one thing in common: They employed three
distinct but linked campaigns\--political, marketing, and military. The
author cites examples from such companies as Hewlett-Packard,
Bristol-Myers Squibb, and Saturn to illustrate how effective such
campaigns can be. A political campaign creates a coalition strong enough
to support and guide the initiative. Sometimes, coalitions arise from
changes to a company\'s formal structure. But they may come out of the
informal structure, or they could stem from a temporary
counterstructure. A marketing campaign must go beyond simply publicizing
the initiative\'s benefits. It focuses on listening to ideas that bubble
up from the field as well as on working with lead customers to design
the initiative. A clearly articulated theme for the transformation
program must also be developed. A military campaign deploys executives\'
scarce resources of attention and time. Successful executives secure
their supply lines by, for instance, piggybacking onto initiatives that
have already captured people\'s interests or already exist as bootleg
projects. These managers also set up pilot projects that turn into
beachheads because the projects expose them to the difficult dynamics
they will ultimately face. Successful executives launch all three
campaigns simultaneously. The three always feed on one another, and if
any one campaign is not properly implemented, the change initiative is
bound to fail.

**Hu KK, Lipsky BA, Veenstra DL, Saint S. (2004) Using Maximal Sterile
Barriers to Prevent Central Venous Catheter-Related Infection: A
Systematic Evidence-Based Review. A*m J Infect Control,* 32(3), 142-6.**

**Abstract:** BACKGROUND: Catheter-related infections cause increased
morbidity, mortality, and health care costs. Infection control experts
advocate using maximal sterile barriers to reduce the incidence of these
infections. Low compliance rates suggest that clinicians are not
convinced or are not aware that available data support adopting this
more cumbersome, time-consuming, and relatively more expensive
technique. Accordingly, we conducted a systematic, evidence-based review
of the medical literature to determine the value of maximal sterile
barriers. DATA SOURCES: We used multiple computerized databases,
reference lists of identified articles, and queries of prominent
investigators. STUDY SELECTION: We selected studies comparing infectious
outcomes using maximal sterile barriers versus using less stringent
sterile barrier techniques during central venous catheter insertion.
DATA SYNTHESIS: We found only 3 primary research studies. Although each
study suggests maximal sterile barriers may reduce infectious
complications, the evidence supporting this conclusion is incomplete.
The only randomized controlled trial limited enrollment to ambulatory
oncology patients. These 3 studies differed notably in their patient
populations, research designs, and health care settings. CONCLUSION: The
medical literature suggests maximal sterile barriers are advantageous in
at least one setting and may be useful in others. While we believe the
available evidence does support the use of maximal sterile barriers
during routine insertion of central venous catheters, prospective
studies and economic analyses would better clarify its value.

**[Hu
KK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hu+KK"%5BAuthor%5D),
[Veenstra
DL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Veenstra+DL"%5BAuthor%5D),
[Lipsky
BA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lipsky+BA"%5BAuthor%5D),
[Saint
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Saint+S"%5BAuthor%5D).
Use of Maximal Sterile Barriers During Central Venous Catheter
Insertion: Clinical and Economic Outcomes, [*Clin Infect
Dis.*](javascript:AL_get(this, 'jour', 'Clin Infect Dis.');) 2004 Nov
15;39(10):1441-5.**

**Abstract:** BACKGROUND: We performed a cost-effectiveness analysis to
determine the effect of maximal sterile barriers (MSBs) on reducing
central venous catheter (CVC)\--related infections. Use of MSBs when
placing CVCs may reduce the risk of infections but is more cumbersome,
time-consuming, and expensive than other techniques. METHODS: We
developed a decision analytic model in which a patient could have a CVC
placed with either an MSB or a less stringent technique. We calculated
total direct medical costs and the incidences of catheter-related
bloodstream infections, catheter colonization, and death. RESULTS: Use
of MSBs lowered costs (from 621 dollars to 369 dollars per catheter
insertion) and decreased the incidences of catheter-related bloodstream
infections (from 5.3% to 2.8%), catheter colonization with local
infection (from 5.5% to 2.9%) and death (from 0.8% to 0.4%). MSBs
improved patient safety throughout all sensitivity analyses.
CONCLUSIONS: Use of MSBs during CVC insertion likely lowers medical
costs and decreases the incidences of catheter colonization,
catheter-related bloodstream infections, and death. Cost savings were
found over a wide range of clinical and economic assumptions, suggesting
that MSBs should be routinely used when CVCs are inserted.

# Loughran SC, Borzatta M (1996) Peripherally Inserted Central Catheters: A report of 2506 Catheter days. *Journal of Parental and Enteral Nutrition,* 19(2), 133-136.

**Abstract:** BACKGROUND: The establishment of reliable central venous
access is essential in the management of patients with major
complications, including pneumothorax and hemopneumothorax. Although
peripherally inserted central catheters (PICCs) offer advantages over
traditional central venous approaches, PICC lines are associated with a
number of insertion and maintenance problems, including clotting and
catheter fracture. These complications often result in catheter removal
before completion of prescribed therapy. METHODS: We conducted a
retrospective descriptive study in a convenience sample of 322
consecutively placed PICC lines. Study variables included size of
catheter, tip placement, infused solutions, patient diagnosis, and unit
of line placement. The rationale for line discontinuance as well as for
complication rates is described. RESULTS: Complication rates for
infection and central venous thrombosis were less than 1%. Phlebitis
occurred in 9.7% of patients, and catheter fracture occurred in 9.7% of
patients. Two distinct clusters of phlebitis, early and late
development, were observed. Early phlebitis is attributable to the
mechanics of insertion, and late phlebitis is attributable to chemical
and patient-specific causes. Catheter fractures were primarily related
to tearing of the catheter during insertion or traction on the
catheter-hub junction (51.6%). CONCLUSIONS: The majority of published
data about PICC lines is in the area of chemotherapy or antibiotic
infusion. Our study supports the use of PICC lines in patients receiving
a variety of solutions, primarily parenteral nutrition. With an
experienced, team approach to catheter placement and maintenance, PICC
lines provide reliable, cost-effective venous access and reduce many of
the complications of central venous access in a variety of clinical
settings

**Maki DG, Ringer M, Alvarado CJ. (1991) Prospective Randomized Trial of
Povidone-Iodine, Alcohol, and Chlorhexidine for Prevention of Infection
Associated with Central Venous and Arterial Catheters. *Lancet.* 338,
339--343*.***

**Abstract:** More than 90% of all intravascular device-related
septicaemias are due to central venous or arterial catheters. To assess
the efficacy of cutaneous antisepsis to prevent catheter-associated
infection, we prospectively studied three antiseptics for disinfection
of patients\' central venous and arterial catheter insertion sites in a
surgical intensive care unit. 668 catheters were randomised to 10%
povidone-iodine, 70% alcohol, or 2% aqueous chlorhexidine disinfection
of the site before insertion and for site care every other day
thereafter. Chlorhexidine was associated with the lowest incidence of
local catheter-related infection (2.3 per 100 catheters vs 7.1 and 9.3
for alcohol and povidone-iodine, respectively, p = 0.02) and
catheter-related bacteraemia (0.5 vs 2.3 and 2.6). Of the 14
infusion-related bacteraemias (4 due to contaminated infusate or
catheter hub, 10 due to infected catheters), 1 was in the chlorhexidine
group and 13 were in the other two groups (odds ratio 0.16, p = 0.04).
We conclude that use of 2% chlorhexidine, rather than 10%
povidone-iodine or 70% alcohol, for cutaneous disinfection before
insertion of an intravascular device and for post-insertion site care
can substantially reduce the incidence of device-related infection.

**Maki DG, Stolz SM, Wheeler S, Mermel LA, (1997) Prevention of Central
Venous Catheter-Related Bloodstream Infection by Use of an
Antiseptic-Impregnated Catheter. *Annals of Internal Medicine*, 127,
257-266.**

**Abstract:** BACKGROUND: Bloodstream infection related to short-term
use of noncuffed central venous catheters is a common and serious
problem. Technologic innovations to reduce the risk for these infections
are needed. OBJECTIVE: To determine 1) the efficacy of a novel
antiseptic catheter in preventing central venous catheter-related
infection, 2) patient tolerance of this catheter, and 3) the sources of
bloodstream infection originating from noncuffed, multilumen central
venous catheters. DESIGN: Randomized, controlled clinical trial.
SETTING: Medical-surgical intensive care unit of a 450-bed university
hospital. PARTICIPANTS: 158 adults scheduled to receive a central venous
catheter; 403 catheters were studied. INTERVENTION: Participants
received either a standard triple-lumen polyurethane catheter or a
catheter that was indistinguishable from the standard catheter and was
impregnated with chlorhexidine and silver sulfadiazine. MEASUREMENTS:
Catheters were studied for colonization and catheter-related bloodstream
infection at removal; local and systemic effects of catheters were
assessed. The origin of each catheter-associated bloodstream infection
was sought by culturing all potential sources (skin, catheter segments,
hubs, and infusate) and confirmed by restriction-fragment DNA subtyping.
RESULTS: Antiseptic catheters were less likely to be colonized at
removal than control catheters (13.5 compared with 24.1 colonized
catheters per 100 catheters; relative risk, 0.56 \[95% CI, 0.36 to
0.89\]; P = 0.005) and were nearly fivefold less likely to produce
bloodstream infection (1.0 compared with 4.7 infections per 100
catheters; 1.6 compared with 7.6 infections per 1000 catheter-days;
relative risk, 0.21 \[CI, 0.03 to 0.95\]; P = 0.03). In the control
group, 8 catheter-related bloodstream infections were caused by
Staphylococcus aureus, gram-negative bacilli, enterococci, or Candida
species; no infections with these organisms occurred in the antiseptic
catheter group (P = 0.003). No adverse effects from the antiseptic
catheter were seen, and none of the 122 isolates obtained from infected
catheters in either group showed in vitro resistance to
chlorhexidine-silver sulfadiazine. Cost-benefit analysis indicated that
the antiseptic catheter should prove cost-beneficial if an
institution\'s rate of catheter-related bacteremia with noncuffed
central venous catheters is at least 3 infections per 1000
catheter-days). CONCLUSIONS: The chlorhexidine-silver sulfadiazine
catheter is well tolerated, reduces the incidence of catheter-related
infection, extends the time that noncuffed central venous catheters can
be safely left in place for the short term, and should allow cost
savings.

**Mermel LA (2000) Prevention of Intravascular Catheter-Related
Infections. *Annals of Internal Medicine*, 132, 391-402.**

**Abstract:** PURPOSE: To review the literature on prevention of
intravascular catheter-related infections. DATA SOURCES: The MEDLINE
database, conference proceedings, and bibliographies of review articles
and book chapters were searched for relevant articles. Primary authors
were contacted directly if data were incomplete. STUDY SELECTION:
Studies met the following criteria unless otherwise stated: Trials were
prospective and randomized; catheters were inserted into new sites, not
into old sites over guidewires; catheter cultures were done by using
semi-quantitative or quantitative methods; and, for prospective studies,
catheter-related bloodstream infection was confirmed by microbial growth
from percutaneously drawn blood cultures that matched catheter cultures.
DATA EXTRACTION: Data on population, methods, preventive strategy, and
outcome (measured as catheter-related bloodstream infections) were
gathered. The quality of the data was graded by using preestablished
criteria. DATA SYNTHESIS: The recommended preventive strategies with the
strongest supportive evidence are full barrier precautions during
central venous catheter insertion; subcutaneous tunneling short-term
catheters inserted in the internal jugular or femoral veins when
catheters are not used for drawing blood; contamination shields for
pulmonary artery catheters; povidone-iodine ointment applied to
insertion sites of hemodialysis catheters; specialized nursing teams
caring for patients with short-term peripheral venous catheters,
especially at institutions with a high incidence of catheter-related
infection; no routine replacement of central venous catheters;
antiseptic chamber filled hub or hub-protective antiseptic sponge for
central venous catheters; and use of chlorhexidine-silver
sulfadiazine-impregnated or minocycline-rifampin-impregnated short-term
central venous catheters if the rate of infection is high despite
adherence to other strategies that do not incorporate antimicrobial
agents (for example, maximal barrier precautions). CONCLUSIONS: Simple
interventions can reduce the risk for serious catheter-related
infection. Adequately powered randomized trials are needed.

**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(3B):197S-205S.**

**Abstract:** To delineate the pathogenesis and epidemiology of
catheter-related infection with Swan-Ganz pulmonary artery (PA)
catheters, a prospective clinical study of hospitalized adult medical
and surgical patients was done. Role of catheter material was assessed
by randomizing insertions to heparin-bonded PA catheters made of
polyvinylchloride or polyurethane. Sources of infection and pathogenesis
were studied by culturing skin, the introducer, the PA catheter tip, all
hubs, infusate from each lumen, and the extravascular portion of the PA
catheter beneath the external protective plastic sleeve. Concordance
between isolates from sources and infected catheters was determined by
speciation, antibiogram, and for coagulase-negative staphylococci,
plasmid profile analysis. Risk factors for infection were determined by
stepwise logistic regression. Overall, 65 (22%) of 297 Swan-Ganz
catheters showed local infection of the introducer (58 catheters) or the
intravascular portion of the PA catheter (20 catheters); only two
catheters (0.7%) caused bacteremia. Eighty percent of infected Swan-Ganz
catheters (the introducer or PA catheter) showed concordance with
organisms cultured from skin of the insertion site, 17% with a
contaminated hub and 18% with organisms contaminating the extravascular
portion of the PA catheter beneath the sleeve. Isolates from infected PA
catheters were most likely to show concordance with concomitantly
infected introducers (71%). Cutaneous colonization of the insertion site
with greater than 10(2) cfu/10 cm2 (relative risk \[RR\] 5.5; p less
than 0.001), insertion into an internal jugular vein (RR 4.3; p less
than 0.01), catheterization greater than 3 days (RR 3.1; p less than
0.01), and insertion in the operating room using less stringent barrier
precautions (RR 2.1; p = 0.03) were each associated with a significantly
increased risk of catheter-related infection. The risk of bacteremic
infection with Swan-Ganz catheters is now low, in the range of 1%, with
reasonable care. Swan-Ganz catheters are vulnerable to contamination
from multiple sources, but the patient\'s skin is the single most
important source of organisms causing invasive infection, which in most
cases involves the introducer rather than the PA catheter. Heavy
colonization of the insertion site, percutaneous insertion in the
internal jugular vein rather than subclavian vein, catheterization
longer than 3 days, and insertion with less stringent barrier
precautions significantly increase the risk of catheter-related
infection. These findings hold promise for application to management of
Swan-Ganz catheters and research in catheter design to reduce the risk
of catheter-related infection.

**Merrer J, De Jonghe B, Golliot F, et al (2001) Complications of
Femoral and Subclavian venous Catheterization in Critically Ill
patients: A Randomized Controlled Trial. *JAMA,* 286(6), 700-7.**

**Abstract:** CONTEXT: Whether venous catheterization at the femoral
site is associated with an increased risk of complications compared with
that at the subclavian site is debated. OBJECTIVE: To compare
mechanical, infectious, and thrombotic complications of femoral and
subclavian venous catheterization. DESIGN AND SETTING: Concealed,
randomized controlled clinical trial conducted between December 1997 and
July 2000 at 8 intensive care units (ICUs) in France. PATIENTS: Two
hundred eighty-nine adult patients receiving a first central venous
catheter. INTERVENTIONS: Patients were randomly assigned to undergo
central venous catheterization at the femoral site (n = 145) or
subclavian site (n = 144). MAIN OUTCOME MEASURES: Rate and severity of
mechanical, infectious, and thrombotic complications, compared by
catheterization site in 289, 270, and 223 patients, respectively.
RESULTS: Femoral catheterization was associated with a higher incidence
rate of overall infectious complications (19.8% vs 4.5%; P\<.001;
incidence density of 20 vs 3.7 per 1000 catheter-days) and of major
infectious complications (clinical sepsis with or without bloodstream
infection, 4.4% vs 1.5%; P =.07; incidence density of 4.5 vs 1.2 per
1000 catheter-days), as well as of overall thrombotic complications
(21.5% vs 1.9%; P\<.001) and complete thrombosis of the vessel (6% vs
0%; P =.01); rates of overall and major mechanical complications were
similar between the 2 groups (17.3% vs 18.8 %; P =.74 and 1.4% vs 2.8%;
P =.44, respectively). Risk factors for mechanical complications were
duration of insertion (odds ratio \[OR\], 1.05; 95% confidence interval
\[CI\], 1.03-1.08 per additional minute; P\<.001); insertion in 2 of the
centers (OR, 4.52; 95% CI, 1.81-11.23; P =.001); and insertion during
the night (OR, 2.06; 95% CI, 1.04-4.08; P =.03). The only factor
associated with infectious complications was femoral catheterization
(hazard ratio \[HR\], 4.83; 95% CI, 1.96-11.93; P\<.001); antibiotic
administration via the catheter decreased risk of infectious
complications (HR, 0.41; 95% CI, 0.18-0.93; P =.03). Femoral
catheterization was the only risk factor for thrombotic complications
(OR, 14.42; 95% CI, 3.33-62.57; P\<.001). CONCLUSION: Femoral venous
catheterization is associated with a greater risk of infectious and
thrombotic complications than subclavian catheterization in ICU
patients.

**Mimoz O, Pieroni L, Lawrence C et al. (1996) Prospective, Randomized
Trial of Two Antiseptic Solutions for Prevention of Central Venous or
Arterial Catheter Colonization and Infection in Intensive Care Unit
Patients. *Critical Care Medicine,* 24(11),1818-1823.**

**Abstract:** OBJECTIVES: To compare the efficacy of a newly available
antiseptic solution (composed of 0.25% chlorhexidine gluconate, 0.025%
benzalkonium chloride, and 4% benzyl alcohol), with 10% povidone iodine,
on the prevention of central venous or arterial catheter colonization
and infection. DESIGN: Prospective, randomized clinical trial. SETTING:
Surgical-trauma intensive care unit (ICU) in a university hospital.
PATIENTS: All patients admitted to the ICU and requiring the insertion
of a central venous and/or an arterial catheter from July 1, 1992 to
October 31, 1993. INTERVENTIONS: Patients were randomly assigned to one
of two groups according to the antiseptic solution used for insertion
and catheter care. The same solution was used for skin disinfection from
the time of catheter insertion to the time of removal of each catheter.
MEASUREMENTS AND MAIN RESULTS: Catheter distal tips were quantitatively
cultured when catheters were no longer necessary, if there was a
suspicion of catheter-related infection, and routinely after 7 days of
use for arterial catheters, or after 15 days of use for central venous
catheters. The rate of significant catheter colonization (i.e., \> or =
10(3) colony-forming units \[cfu\]/mL by quantitative culture), and
catheter-related sepsis (as defined by sepsis abating following catheter
removal per 1,000 catheter-days), were significantly lower in the
chlorhexidine group (12 vs. 31 \[relative risk 0.4, 95% confidence
interval 0.1 to 0.9, p \< .01\] and 6 vs. 16 \[relative risk 0.4, 95%
confidence interval 0.1 to 1, p = 0.5\], respectively). The rate of
central venous catheter colonization and central venous catheter-related
sepsis per 1,000 catheter-days were also significantly lower in the
chlorhexidine group (8 vs. 31 \[relative risk 0.3, 95% confidence
interval 0.1 to 1, p = .03\] and 5 vs. 19 \[relative risk 0.3, 95%
confidence interval 0.1 to 1, p = .02\], respectively). Finally, the
rate of arterial catheter colonization per 1,000 catheter-days was
significantly lower in the chlorhexidine group (15 vs. 32 \[relative
risk 0.5, 95% confidence interval 0.1 to 1, p = .05\]), whereas the rate
of arterial catheter-related sepsis per 1,000 catheter-days was similar
for the two study groups (8 in the chlorhexidine group vs. 10 in the
povidone iodine group \[relative risk 0.8, 95% confidence interval 0.1
to 2.2, p = .6\]). The 0.25% chlorhexidine solution was superior to the
10% povidone iodine solution in preventing catheter colonizations and
catheter-related sepsis due to Gram-positive bacteria (5 vs. 20 \[p \<
.001\], and 2 vs. 10 \[p \< .001\], respectively), whereas the activity
of the 0.25% chlorhexidine solution was nonsignificantly superior in
preventing Gram-negative infections (7 vs. 4 \[p = .5\], and 4 vs. 2 \[p
= .8\], respectively). CONCLUSIONS: The 4% alcohol-based solution of
0.25% chlorhexidine gluconate and 0.025% benzalkonium chloride was more
effective than 10% povidone iodine for insertion site care of short-term
central venous and arterial catheters. This effect appeared related to a
more efficacious prevention of infections with Gram-positive bacteria.

**Raad II, Hohn DC, Gilbreath J, et al. (1994) Prevention of Central
Venous Catheter-Related infections by Using Maximal Sterile Barrier
Precautions During Insert. *Infect Control Hosp Epidemiol,* 15,
231--238.**

**Abstract:** OBJECTIVE: In many hospitals, the only sterile precautions
used during the insertion of a nontunneled central venous catheter are
sterile gloves and small sterile drapes. We investigated whether the use
of maximal sterile barrier (consisting of mask, cap, sterile gloves,
gown, and large drape) would lower the risk of acquiring
catheter-related infections. DESIGN: Prospective randomized trial.
SETTING: A 500-bed cancer referral center. METHODS: We randomized
patients to have their nontunneled central catheter inserted under
maximal sterile barrier precautions or control precautions (sterile
gloves and small drape only). All patients were followed for 3 months
postinsertion or until the catheter was removed, whichever came first.
Catheter-related infections were diagnosed by quantitative catheter
cultures and/or simultaneous quantitative blood cultures. RESULTS: The
176 patients whose catheters were inserted by using maximal sterile
barrier precautions were comparable to the 167 control patients in
underlying disease, degree of immuno-suppression, therapeutic
interventions, and catheter risk factors for infections (duration and
site of catheterization, number of catheter lumen, catheter insertion
difficulty, reason for catheter removal). There were a total of four
catheter infections in the test group and 12 in the control group (P =
0.03, chi-square test). The catheter-related septicemia rate was 6.3
times higher in the control group (P = 0.06, Fisher\'s exact test). Most
(67%) of the catheter infections in the control group occurred during
the first 2 months after insertion, whereas 25% of the catheter
infections in the maximal sterile precautions group occurred during the
same period (P \< 0.01, Fisher\'s exact test). Cost-benefit analysis
showed the use of such precautions to be highly cost-effective.
CONCLUSION: Maximal sterile barrier precautions during the insertion of
nontunneled catheters reduce the risk of catheter infection. This
practice is cost-effective and is consistent with the practice of
universal precautions during an invasive procedure.

[**Sherertz RJ, Ely EW, Westbrook DM, et
al.**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10766683&query_hl=10&itool=pubmed_docsum)
**Education of Physicians-In-Training Can Decrease the Risk for Vascular
Catheter Infection. *Ann Intern Med*. 2000 Apr 18;132(8):641-8**

Abstract: BACKGROUND: Procedure instruction for physicians-in-training
is usually nonstandardized. The authors observed that during insertion
of central venous catheters (CVCs), few physicians used full-size
sterile drapes (an intervention proven to reduce the risk for
CVC-related infection). OBJECTIVE: To improve standardization of
infection control practices and techniques during invasive procedures.
DESIGN: Nonrandomized pre-post observational trial. SETTING: Six
intensive care units and one step-down unit at Wake Forest University
Baptist Medical Center, Winston-Salem, North Carolina. PARTICIPANTS:
Third-year medical students and physicians completing their first
postgraduate year. INTERVENTION: A 1-day course on infection control
practices and procedures given in June 1996 and June 1997. MEASUREMENTS:
Surveys assessing physician attitudes toward use of sterile techniques
during insertion of CVCs were administered during the baseline year and
just before, immediately after, and 6 months after the first course.
Preintervention and postintervention use of full-size sterile drapes was
measured, and surveillance for vascular catheter-related infection was
performed. RESULTS: The perceived need for full-size sterile drapes was
22% in the year before the course and 73% 6 months after the course (P
\< 0.001). The perceived need for small sterile towels at the insertion
site decreased reciprocally (P \< 0.001). Documented use of full-size
sterile drapes increased from 44% to 65% (P \< 0.001). The rate of
catheter-related infection decreased from 4.51 infections per 1000
patient-days before the first course to 2.92 infections per 1000
patient-days 18 months after the first course (average decrease, 3.23
infections per 1000 patient-days; P \< 0.01). The estimated cost savings
of this 28% decrease was at least \$63000 and may have exceeded
\$800000. CONCLUSIONS: Standardization of infection control practices
through a course is a cost-effective way to decrease related adverse
outcomes. If these findings can be reproduced, this approach may serve
as a model for physicians-in-training.

**Soufir L, Timsit JF, Mahe C et al (1999) Attributable Morbidity and
Mortality of Catheter-Related Septicemia in Critically Ill Patients: a
Matched, Risk-Adjusted, Cohort Study. *Infection Control Hosp
Epidemiol*, 20(6), 396-401.**

**Abstract:** OBJECTIVE: To determine the attributable risk of death due
to catheter-related septicemia (CRS) in critically ill patients when
taking into account severity of illness during the intensive-care unit
(ICU) stay but before CRS. DESIGN: Pairwise-matched (1:2)
exposed-unexposed study. SETTING: 10-bed medical-surgical ICU and an
18-bed medical ICU. PATIENTS: Patients admitted to either ICU between
January 1, 1990, and December 31, 1995, were eligible. Exposed patients
were defined as patients with CRS; unexposed controls were selected
according to matching variables. METHODS: Matching variables were
diagnosis at ICU admission, length of central catheterization before the
infection, McCabe Score, Simplified Acute Physiologic Score (SAPS) II at
admission, age, and gender. Severity scores (SAPS II, Organ System
Failure Score, Organ Dysfunction and Infection Score, and Logistic Organ
Dysfunction System) were calculated four times for each patient: the day
of ICU admission, the day of CRS onset, and 3 and 7 days before CRS.
Matching was successful for 38 exposed patients. Statistical analysis
was based on nonparametric tests for epidemiological data and on Cox\'s
models for the exposed-unexposed study, with adjustment on matching
variables and prognostic factors of mortality. RESULTS: CRS complicated
1.17 per 100 ICU admissions during the study period. Twenty (53%) of the
CRS cases were associated with septic shock. CRS was associated with a
28% increase in SAPS II. Crude ICU mortality rates from exposed and
unexposed patients were 50% and 21%, respectively. CRS remained
associated with mortality even when adjusted on other prognostic factors
at ICU admission (relative risk \[RR\], 2.01; 95% confidence interval
\[CI95\], 1.08-3.73; P=.03). However, after adjustment on severity
scores calculated between ICU admission and 1 week before CRS, the
increased mortality was no longer significant (RR, 1.41; CI95,
0.76-2.61; P=.27). CONCLUSION: CRS is associated with subsequent
morbidity and mortality in the ICU, even when adjusted on severity
factors at ICU admission. However, after adjustment on severity factors
during the ICU stay and before the event, there was only a trend toward
CRS-attributable mortality. The evolution of patient severity should be
taken into account when evaluating excess mortality induced by
nosocomial events in ICU patients.

**Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD (1999) Efficacy of
Antiseptic-Impregnated Central Venous Catheters in Preventing
Catheter-Related Bloodstream Infection; A Meta-analysis. *JAMA*. 281:
261-267.**

**Abstract:** CONTEXT: Central venous catheters impregnated with
chlorhexidine and silver sulfadiazine have recently been introduced for
the prevention of catheter-related infections. However, there remains
some uncertainty regarding the efficacy of these catheters because of
conflicting reports in the literature. OBJECTIVE: To evaluate the
efficacy of chlorhexidine-silver sulfadiazine-impregnated central venous
catheters in the prevention of catheter-related bloodstream infection.
DATA SOURCES: Studies identified from a computerized search of the
MEDLINE database from January 1966 to January 1998, reference lists of
identified articles, and queries of principal investigators and the
catheter manufacturer. STUDY SELECTION: Randomized trials comparing
chlorhexidine-silver sulfadiazine-impregnated central venous catheters
with nonimpregnated catheters were included. The outcomes assessed were
catheter colonization and catheter-related bloodstream infection
confirmed by catheter culture. DATA EXTRACTION: Twelve studies met the
inclusion criteria for catheter colonization and included a total of
2611 catheters. Eleven studies with a total of 2603 catheters met the
inclusion criteria for catheter-related bloodstream infection. Most
patients in these studies were from groups considered to be at high risk
for catheter-related infections. Summary statistics were calculated
using Mantel-Haenszel methods under a fixed-effects model. DATA
SYNTHESIS: The summary odds ratio for catheter colonization was 0.44
(95% confidence interval \[CI\], 0.36-0.54; P\<.001), indicating a
significant decrease in catheter colonization associated with
impregnated catheters. The studies examining the outcome of primary
interest, catheter-related bloodstream infection, had a summary odds
ratio of 0.56 (95% CI, 0.37-0.84; P = .005). CONCLUSIONS: Central venous
catheters impregnated with a combination of chlorhexidine and silver
sulfadiazine appear to be effective in reducing the incidence of both
catheter colonization and catheter-related bloodstream infection in
patients at high risk for catheter-related infections.

**Veenstra DL, Saint, S, Sullivan SD (1999) Cost-effectiveness of
Antiseptic-Impregnated Central Venous Catheters for the Prevention of
Catheter-related Bloodstream Infection. *JAMA* 282:554-560.**

**Abstract:** CONTEXT: A recent randomized controlled trial and
meta-analysis indicated that central venous catheters impregnated with
an antiseptic combination of chlorhexidine and silver sulfadiazine are
efficacious in reducing the incidence of catheter-related bloodstream
infection (CR-BSI); however, the ultimate clinical and economic
consequences of their use have not been formally evaluated. OBJECTIVE:
To estimate the incremental clinical and economic outcomes associated
with the use of antiseptic-impregnated vs standard catheters. DESIGN:
Decision analytic model using data from randomized controlled trials,
meta-analyses, and case-control studies, as well as safety data from the
US Food and Drug Administration. SETTING AND PATIENTS: A hypothetical
cohort of hospitalized patients at high risk for catheter-related
infections (eg, patients in intensive care units, immunosuppressed
patients, and patients receiving total parenteral nutrition) requiring
use of a central venous catheter. INTERVENTION: Short-term use (2-10
days) of chlorhexidine-silver sulfadiazine-impregnated multilumen
central venous catheters and nonimpregnated catheters. MAIN OUTCOME
MEASURES: Expected incidence of CR-BSI and death attributable to
antiseptic-impregnated and standard catheter use; direct medical costs
for both types of catheters. RESULTS: In the base-case analysis, use of
antiseptic-impregnated catheters resulted in a decrease in the incidence
of CR-BSI of 2.2% (5.2% for standard vs 3.0% for antiseptic-impregnated
catheters), a decrease in the incidence of death of 0.33% (0.78% for
standard vs 0.45% for antiseptic-impregnated), and a decrease in costs
of \$196 per catheter used (\$532 for standard vs \$336 for
antiseptic-impregnated). The decrease in CR-BSI ranged from 1.2% to
3.4%, the decrease in death ranged from 0.09% to 0.78%, and the costs
saved ranged from \$68 to \$391 in a multivariate sensitivity analysis.
CONCLUSION: Our analyses suggest that use of chlorhexidine-silver
sulfadiazine-impregnated central venous catheters in patients at high
risk for catheter-related infections reduces the incidence of CR-BSI and
death and provides significant saving in costs. Use of these catheters
should be considered as part of a comprehensive nosocomial infection
control program.

**Wall RJ, Ely EW, Elasy TA, et al (2005) Using Real Time Process
Measurements to Reduce Catheter Related Bloodstream Infections in the
Intensive Care Unit. *Qual Saf Health Care* (14)295-302.**

**Abstract:** PROBLEM: Measuring a process of care in real time is
essential for continuous quality improvement (CQI). Our inability to
measure the process of central venous catheter (CVC) care in real time
prevented CQI efforts aimed at reducing catheter related bloodstream
infections (CR-BSIs) from these devices. DESIGN: A system was developed
for measuring the process of CVC care in real time. We used these new
process measurements to continuously monitor the system, guide CQI
activities, and deliver performance feedback to providers. SETTING:
Adult medical intensive care unit (MICU). KEY MEASURES FOR IMPROVEMENT:
Measured process of CVC care in real time; CR-BSI rate and time between
CR-BSI events; and performance feedback to staff. STRATEGIES FOR CHANGE:
An interdisciplinary team developed a standardized, user friendly
nursing checklist for CVC insertion. Infection control practitioners
scanned the completed checklists into a computerized database, thereby
generating real time measurements for the process of CVC insertion.
Armed with these new process measurements, the team optimized the impact
of a multifaceted intervention aimed at reducing CR-BSIs. EFFECTS OF
CHANGE: The new checklist immediately provided real time measurements
for the process of CVC insertion. These process measures allowed the
team to directly monitor adherence to evidence-based guidelines. Through
continuous process measurement, the team successfully overcame barriers
to change, reduced the CR-BSI rate, and improved patient safety. Two
years after the introduction of the checklist the CR-BSI rate remained
at a historic low. LESSONS LEARNT: Measuring the process of CVC care in
real time is feasible in the ICU. When trying to improve care, real time
process measurements are an excellent tool for overcoming barriers to
change and enhancing the sustainability of efforts. To continually
improve patient safety, healthcare organizations should continually
measure their key clinical processes in real time.