epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England

Executive SummaryNational evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were A rst published in January 2001 1 and updated in 2007. 2 A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identiA ed, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority.The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identiA ed in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated.These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

## Guideline advisory group

## Acknowledgements
We would like to acknowledge the assistance of the Infection Prevention Society, British Infection Association and the Healthcare Infection Society for their input into the development of these guidelines; and other associations, learned societies, professional organisations, Royal Colleges and patient groups who took an active role in the external review of the guidelines. We would also like to acknowledge the support received from Professor Brian Duerden CBE in chairing the Guideline Development Advisory Group, and Carole Fry in the Chief Medical OfA cer's Team at the Department of Health (England).

# Source of funding
The Department of Health (England).

## Disclosure of potential cona ict of interest

## Summary of guidelines

## Standard principles for preventing healthcareassociated infections in hospital and other acute care settings
This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. Some recommendations from the previous guide lines have been revised to improve clarity; where a new recom mendation has been made, this is indicated in the text. These recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. None are regarded as optional.
Standard infection control precautions need to be applied by all healthcare practitioners to the care of all patients (i.e. adults, children and neonates). The recommendations are divided into A ve distinct interventions: - hospital environmental hygiene; - hand hygiene; - use of personal protective equipment (PPE); - safe use and disposal of sharps; and - principles of asepsis.
These guidelines do not address the additional infection control requirements of specialist settings, such as the operating department or outbreak situations.

## Hospital environmental hygiene

## Sp1
The hospital environment must be visibly clean; free from non-essential items and equipment, dust and dirt; and acceptable to patients, visitors and staff.

## Class d/gpp
SP2 Levels of cleaning should be increased in cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.

## Class d/gpp

## Sp3
The use of disinfectants should be considered for cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.

## Class d/gpp
SP4 Shared pieces of equipment used in the delivery of patient care must be cleaned and decontaminated after each use with products recommended by the manufacturer.

## Class d/gpp

## Sp5
All healthcare workers need to be educated about the importance of maintaining a clean and safe care environment for patients. Every healthcare worker needs to know their speciA c responsibilities for cleaning and decontaminating the clinical environment and the equipment used in patient care.

## Class d/gpp
Hand hygiene Hands must be decontaminated:
- immediately before each episode of direct patient contact or care, including clean/aseptic procedures; - immediately after each episode of direct patient contact or care; - immediately after contact with body A uids, mucous membranes and non-intact skin; - immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated; and - immediately after the removal of gloves.

## Class c

## Sp7
Use an alcohol-based hand rub for decontamination of hands before and after direct patient contact and clinical care, except in the following situations when soap and water must be used:
- when hands are visibly soiled or potentially contaminated with body A uids; and - when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.
Class A

## Sp8
Healthcare workers should ensure that their hands can be decontaminated effectively by:
- removing all wrist and hand jewellery;
- wearing short-sleeved clothing when delivering patient care; - making sure that A ngernails are short, clean, and free from false nails and nail polish; and - covering cuts and abrasions with waterproof dressings.

## Sp9
Effective handwashing technique involves three stages: preparation, washing and rinsing, and drying.
- Preparation: wet hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation. - Washing: the handwash solution must come into contact with all of the surfaces of the hand. The hands should be rubbed together vigorously for a minimum of 10-15 s, paying particular attention to the tips of the A ngers, the thumbs and the areas between the A ngers. Hands should be rinsed thoroughly. - Drying: use good-quality paper towels to dry the hands thoroughly.

## Class d/gpp

## Sp10
When decontaminating hands using an alcohol-based hand rub, hands should be free of dirt and organic material, and:
- hand rub solution must come into contact with all surfaces of the hand; and - hands should be rubbed together vigorously, paying particular attention to the tips of the A ngers, the thumbs and the areas between the A ngers, until the solution has evaporated and the hands are dry.

## Class d/gpp

## Sp11
Clinical staff should be made aware of the potentially damaging effects of hand decontamination products, and encouraged to use an emollient hand cream regularly to maintain the integrity of the skin. Consult the occupational health team or a general practitioner if a particular liquid soap, antiseptic handwash or alcohol-based hand rub causes skin irritation.

## Class d/gpp

## Sp12
Alcohol-based hand rub should be made available at the point of care in all healthcare facilities.

## Class c

## Sp13
Hand hygiene resources and healthcare worker adherence to hand hygiene guidelines should be audited at regular intervals, and the results should be fed back to healthcare workers to improve and sustain high levels of compliance.

## Class c

## Sp14
Healthcare organisations must provide regular training in risk assessment, effective hand hygiene and glove use for all healthcare workers.

## Class d/gpp

## Sp15
Local programmes of education, social marketing, and audit and feedback should be refreshed regularly and promoted by senior managers and clinicians to maintain focus, engage staff and produce sustainable levels of compliance.

## New recommendation class c

## Sp16
Patients and relatives should be provided with information about the need for hand hygiene and how to keep their own hands clean.

## New recommendation class d/gpp

## Sp17
Patients should be offered the opportunity to clean their hands before meals; after using the toilet, commode or bedpan/urinal; and at other times as appropriate. Products available should be tailored to patient needs and may include alcohol-based hand rub, hand wipes and access to handwash basins.

## New recommendation class d/gpp

## Use of personal protective equipment

## Sp18
Selection of personal protective equipment must be based on an assessment of the: - risk of transmission of microorganisms to the patient or carer; - risk of contamination of healthcare practitioners' clothing and skin by patients' blood or body A uids; and - suitability of the equipment for proposed use.

## Class d/gpp/h&s

## Sp19
Healthcare workers should be educated and their competence assessed in the: - assessment of risk;
- selection and use of personal protective equipment; and - use of standard precautions.

## Class d/gpp/h&s

## Sp20
Supplies of personal protective equipment should be made available wherever care is delivered and risk assessment indicates a requirement. Gloves must be worn for:
- invasive procedures;
- contact with sterile sites and nonintact skin or mucous membranes; - all activities that have been assessed as carrying a risk of exposure to blood or body A uids; and - when handling sharps or contaminated devices.

## Class d/gpp/h&s

## Sp22
Gloves must be:
- worn as single-use items;
- put on immediately before an episode of patient contact or treatment; - removed as soon as the episode is completed; - changed between caring for different patients; and - disposed of into the appropriate waste stream in accordance with local policies for waste management.

## Class d/gpp/h&s

## Sp23
Hands must be decontaminated immediately after gloves have been removed.

## Class d/gpp/h&s

## Sp24
A range of CE-marked medical and protective gloves that are acceptable to healthcare personnel and suitable for the task must be available in all clinical areas.

## Class d/gpp/h&s

## Sp25
Sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented, and alternatives to natural rubber latex gloves must be available.

## Class d/gpp/h&s

## Sp26
Disposable plastic aprons must be worn when close contact with the patient, materials or equipment pose a risk that clothing may become contaminated with pathogenic microorganisms, blood or body A uids.

## Class d/gpp/h&s

## Sp27
Full-body A uid-repellent gowns must be worn where there is a risk of extensive splashing of blood or body A uids on to the skin or clothing of healthcare workers.

## Class d/gpp/h&s

## Sp28
Plastic aprons/A uid-repellent gowns should be worn as single-use items for one procedure or episode of patient care, and disposed of into the appropriate waste stream in accordance with local policies for waste management. When used, nondisposable protective clothing should be sent for laundering.

## Class d/gpp/h&s
SP29 Fluid-repellent surgical face masks and eye protection must be worn where there is a risk of blood or body A uids splashing into the face and eyes.

## Class d/gpp h&s

## Sp30
Appropriate respiratory protective equipment should be selected according to a risk assessment that takes account of the infective microorganism, the anticipated activity and the duration of exposure.

## Class d/gpp/h&s

## Sp31
Respiratory protective equipment must A t the user correctly and they must be trained in how to use and adjust it in accordance with health and safety regulations.

## Class d/gpp/h&s

## Sp32
Personal protective equipment should be removed in the following sequence to minimise the risk of cross/self-contamination: - gloves; - apron; - eye protection (when worn); and - mask/respirator (when worn). Hands must be decontaminated following the removal of personal protective equipment.

## New recommendation class d/gpp/h&s

## Safe use and disposal of sharps

## Sp33
Sharps must not be passed directly from hand to hand, and handling should be kept to a minimum.

## Class d/gpp/h&s
SP34 Needles must not be recapped, bent or disassembled after use.

## Class d/gpp/h&s

## Sp35
Used sharps must be discarded at the point of use by the person generating the waste.

## Class d/gpp/h&s

## Sp36
All sharps containers must:
- conform to current national and international standards; - be positioned safely, away from public areas and out of the reach of children, and at a height that enables safe disposal by all members of staff; - be secured to avoid spillage; - be temporarily closed when not in use; - not be A lled above the A ll line; and - be disposed of when the A ll line is reached. All clinical and non-clinical staff must be educated about the safe use and disposal of sharps and the action to be taken in the event of an injury.

## Class d/gpp/h&s

## Class d/gpp/h&s
SP38 Use safer sharps devices where assessment indicates that they will provide safe systems of working for healthcare workers.

## Class c/h&s

## Sp39
Organisations should involve end-users in evaluating safer sharps devices to determine their effectiveness, acceptability to practitioners, impact on patient care and cost benefi t prior to widespread introduction.

## Class d/gpp/h&s

## Asepsis

## Sp40
Organisations should provide education to ensure that healthcare workers are trained and competent in performing the aseptic technique.

## New recommendation class d/gpp

## Sp41
The aseptic technique should be used for any procedure that breaches the body's natural defences, including:
- insertion and maintenance of invasive devices; - infusion of sterile fl uids and medication; and - care of wounds and surgical incisions.

## New recommendation class d/gpp

## Guidelines for preventing infections associated with the use of short-term indwelling urethral catheters
This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. Some recommendations from the previous guidelines have been revised to improve clarity; where a new recommen dation has been made, this is indicated in the text. These recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. None are regarded as optional.
These guidelines apply to adults and children aged 1 year who require a short-term indwelling urethral catheter (28 days), and should be read in conjunction with the guidance on Standard Principles. The recommendations are divided into six distinct interventions: - assessing the need for catheterisation; - selection of catheter type and system; - catheter insertion; - catheter maintenance; - education of patients, relatives and healthcare workers; and - system interventions for reducing the risk of infection.

## Assessing the need for catheterisation

## Uc1
Only use a short-term indwelling urethral catheter in patients for whom it is clinically indicated, following assessment of alternative methods and discussion with the patient. Class D/GPP UC2 Document the clinical indication(s) for catheterisation, date of insertion, expected duration, type of catheter and drainage system, and planned date of removal.

## Class d/gpp
UC3 Assess and record the reasons for catheterisation every day. Remove the catheter when no longer clinically indicated.

## Class d/gpp

## Selection of catheter type

## Uc4
Assess patient's needs prior to catheterisation in terms of: - latex allergy;
- length of catheter (standard, female, paediatric); - type of sterile drainage bag and sampling port (urometer, 2-L bag, leg bag) or catheter valve; and - comfort and dignity.

## New recommendation class d/gpp

## Uc5
Select a catheter that minimises urethral trauma, irritation and patient discomfort, and is appropriate for the anticipated duration of catheterisation.

## Class d/gpp
UC6 Select the smallest gauge catheter that will allow urinary outfl ow and use a 10-mL retention balloon in adults (follow manufacturer's instructions for paediatric catheters). Urological patients may require larger gauge sizes and balloons.

## Class d/gpp
UC22 Ensure patients, relatives and carers are given information regarding the reason for the catheter and the plan for review and removal. If discharged with a catheter, the patient should be given written information and shown how to:
- manage the catheter and drainage system; - minimise the risk of urinary tract infection; and - obtain additional supplies suitable for individual needs.

## Class d/gpp

## System interventions for reducing the risk of infection
UC23 Use quality improvement systems to support the appropriate use and management of short-term urethral catheters and ensure their timely removal. These may include:
- protocols for catheter insertion;
- use of bladder ultrasound scanners to assess and manage urinary retention; - reminders to review the continuing use or prompt the removal of catheters; - audit and feedback of compliance with practice guidelines; and - continuing professional education

## Guidelines for preventing infections associated with the use of intravascular access devices
This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. Some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. These recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. None are regarded as optional.

## Education of healthcare workers and patients
IVAD1 Healthcare workers caring for patients with intravascular catheters should be trained and assessed as competent in using and consistently adhering to practices for the prevention of catheter-related bloodstream infection.

## Class d/gpp
IVAD2 Healthcare workers should be aware of the manufacturer's advice relating to individual catheters, connection and administration set dwell time, and compatibility with antiseptics and other A uids to ensure the safe use of devices.

## New recommendation class d/gpp
IVAD3 Before discharge from hospital, patients with intravascular catheters and their carers should be taught any techniques they may need to use to prevent infection and manage their device.

## Class d/gpp

## General asepsis
IVAD4 Hands must be decontaminated, with an alcohol-based hand rub or by washing with liquid soap and water if soiled or potentially contaminated with blood or body A uids, before and after any contact with the intravascular catheter or insertion site.

## Class a
IVAD5 Use the aseptic technique for the insertion and care of an intravascular access device and when administering intravenous medication.

## Class b

## Selection of catheter type
IVAD6 Use a catheter with the minimum number of ports or lumens essential for management of the patient.

## Class a
IVAD7 Preferably use a designated singlelumen catheter to administer lipidcontaining parenteral nutrition or other lipid-based solutions.

## Class d/gpp
IVAD8 Use a tunnelled or implanted central venous access device with a subcutaneous port for patients in whom long-term vascular access is required.

## Class a
IVAD9 Use a peripherally inserted central catheter for patients in whom mediumterm intermittent access is required.

## New recommendation class d/gpp
IVAD10 Use an antimicrobial-impregnated central venous access device for adult patients whose central venous catheter is expected to remain in place for >5 days if catheter-related bloodstream infection rates remain above the locally agreed benchmark, despite the implementation of a comprehensive strategy to reduce catheter-related bloodstream infection.

## Class a

## Selection of catheter insertion site
IVAD11 In selecting an appropriate intravascular insertion site, assess the risks for infection against the risks of mechanical complications and patient comfort.

## Class d/gpp
IVAD12 Use the upper extremity for nontunnelled catheter placement unless medically contraindicated.

## Class c

## Maximal sterile barrier precautions during catheter insertion
IVAD13 Use maximal sterile barrier precautions for the insertion of central venous access devices.

## Class

## Class d/gpp
IVAD36 When safer sharps devices are used, healthcare workers should ensure that all components of the system are compatible and secured to minimise leaks and breaks in the system.

## Class d/gpp
IVAD37 Administration sets in continuous use do not need to be replaced more frequently than every 96 h, unless device-speciA c recommendations from the manufacturer indicate otherwise, they become disconnected or the intravascular access device is replaced.

## Class a
IVAD38 Administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 h (whichever is sooner).

## Class d/gpp
IVAD39 Administration sets used for lipidcontaining parenteral nutrition should be changed every 24 h.

## Class d/gpp
IVAD40 Use quality improvement interventions to support the appropriate use and management of intravascular access devices (central and peripheral venous catheters) and ensure their timely removal. These may include:
- protocols for device insertion and maintenance; - reminders to review the continuing use or prompt the removal of intravascular devices; - audit and feedback of compliance with practice guidelines; and - continuing professional education.

## New recommendation

## What are national evidence-based guidelines?
These are systematically developed broad statements (principles) of good practice. They are driven by practice need, based on evidence and subject to multi-professional debate, timely and frequent review, and modiA cation. National guidelines are intended to inform the development of detailed operational protocols at local level, and can be used to ensure that these incorporate the most important principles for preventing HCAI in the NHS and other acute healthcare settings.

## Why do we need national guidelines for preventing healthcare-associated infections?
During the past two decades, HCAI have become a signiA cant threat to patient safety. The technological advances made in the treatment of many diseases and disorders are often undermined by the transmission of infections within healthcare settings, particularly those caused by antimicrobial-resistant strains of disease-causing microorganisms that are now endemic in many healthcare environments. The A nancial and personal costs of these infections, in terms of the economic consequences to the NHS and the physical, social and psychological costs to patients and their relatives, have increased both government and public awareness of the risks associated with healthcare interventions, especially the risk of acquiring a new infection.
Many, although not all, HCAI can be prevented. Clinical effectiveness (i.e. using prevention measures that are based on reliable evidence of efA cacy) is a core component of an effective strategy designed to protect patients from the risk of infection, and when combined with quality improvement methods can account for signiA cant reductions in HCAI such as meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difA cile.

## What is the purpose of the guidelines?
These guidelines describe clinically effective measures that are used by healthcare workers for preventing infections in hospital and other acute healthcare settings.

## What is the scope of the guidelines?
Three sets of guidelines were developed originally and have now been updated. They include: - standard infection control principles: including best practice recommendations for hospital environmental hygiene, effective hand hygiene, the appropriate use of PPE, the safe use and disposal of sharps, and the principles of asepsis; - guidelines for preventing infections associated with the use of short-term indwelling urethral catheters; and - guidelines for preventing infections associated with the use of intravascular access devices.

## What is the evidence for these guidelines?
The evidence for these guidelines was identiA ed by multiple systematic reviews of peer-reviewed research. In addition, evidence from expert opinion as reA ected in systematically identiA ed professional, national and international guidelines was considered following formal assessment using a validated appraisal tool.All evidence was critically appraised for its methodological rigour and clinical practice applicability, and the best-available evidence inA uenced the guideline recommendations.

## Who developed these guidelines?
A team of specialist infection prevention and control researchers and clinical specialists and a Guideline Development Advisory Group, comprising lay members and specialist clinical practitioners, developed the epic3 guidelines (see Sections 1.1 and 1.2).

## Who are these guidelines for?
These guidelines can be appropriately adapted and used by all hospital practitioners. This will inform the development of more detailed local protocols and ensure that important standard principles for infection prevention are incorporated. Consequently, they are aimed at hospital managers, members of hospital infection prevention and control teams, and individual healthcare practitioners. At an individual level, they are intended to inA uence the quality and clinical effectiveness of infection prevention decision-making. The dissemination of these guidelines will also help patients and carers/relatives to understand the standard infection prevention precautions they can expect all healthcare workers to implement to protect them from HCAI.

## How are these guidelines structured?
Each set of guidelines follows an identical format, which consists of: - a brief introduction; - the intervention heading; - a headline statement describing the key issues being addressed; - a synthesis of the related evidence; and - guideline recommendation(s) classiA ed according to the strength of the underpinning evidence.

## How frequently are the guidelines reviewed and updated?
A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identiA ed, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. The evidence base for these guidelines will be reviewed in 2 years (2015) and the guidelines will be considered for updating approximately 4 years after publication (2017). Following publication the DH will ask the Advisory Group on Antimicrobial Resistance and Healthcare Associated Infection to advise whether the S12 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1-S70 evidence base has progressed signiA cantly to alter the guideline recommendations and warrant an update.

## How can these guidelines be used to improve your clinical effectiveness?
In addition to informing the development of detailed local operational protocols, these guidelines can be used as a benchmark for determining appropriate infection prevention decisions and, as part of reA ective practice, to assess clinical effectiveness. They also provide a baseline for clinical audit, evaluation and education, and facilitate on-going quality improvements. There are a number of audit tools available locally, nationally and internationally that can be used to audit compliance with guidance including high-impact intervention tools for auditing care bundles.

## How much will it cost to implement these guidelines?
SigniA cant additional costs are not anticipated in implement ing these guidelines. However, where current equipment or resources do not facilitate the implementation of the guidelines or where staff levels of adherence to current guidance are poor, there may be an associated increase in costs. Given the social and economic costs of HCAI, the consequences associated with not implementing these guidelines would be unacceptable to both patients and healthcare professionals.

# Guideline development methodology
The guidelines were developed using a systematic review process (Appendix A.1). In each set of guidelines, a summary of the relevant guideline development methodology is provided.

## Search process
Electronic databases were searched for national and international guidelines and research studies published during the periods identiA ed for each search question. A two-stage search process was used.

## Stage 1: identia cation of systematic reviews and guidelines
For each set of epic guidelines, an electronic search was conducted for systematic reviews of randomised controlled trials (RCTs) and current national and international guidelines. International and national guidelines were retrieved and subjected to critical appraisal using the AGREE II Instrument,an evaluation method used internationally for assessing the methodological quality of clinical guidelines.
Following appraisal, accepted guidelines were included as part of the evidence base supporting guideline development and, where appropriate, for delineating search limits. They were also used to verify professional consensus and, in some instances, as the primary source of evidence.

## Stage 2: systematic search for additional evidence
Review questions for the systematic reviews of the literature were developed for each set of epic guideline topics following recommendations from scientiA c advisors and the Guideline Development Advisory Group.
Searches were constructed using relevant MeSH (medical subject headings) and free-text terms. The following databases were searched: - Medline; - Cumulated Index of Nursing and Allied Health Literature; - Embase; - the Cochrane Library; and - PsycINFO (only searched for hand hygiene).

## Abstract review -identifying studies for appraisal
Search results were downloaded into a RefworksTM database, and titles and abstracts were printed for review. Titles and abstracts were assessed independently by two reviewers, and studies were retrieved where the title or abstract: addressed one or more of the review questions; identiA ed primary research or systematically conducted secondary research; or indicated a theoretical/clinical/in-use study. Where no abstract was available and the title indicated one or more of the above criteria, the study was retrieved. Due to the limited resources available for this review, foreign language studies were not identiA ed for retrieval.
Full-text studies were retrieved and read in detail by two experienced reviewers; those meeting the study inclusion criteria were independently quality assessed for inclusion in the systematic review.

## Quality assessment and data extraction
Included studies were appraised using tools based on systems developed by the Scottish Intercollegiate Guideline Network (SIGN) for study quality assessment.Studies were appraised independently by two reviewers and data were extracted by one experienced reviewer. Any disagreement between reviewers was resolved through discussion. Evidence tables were constructed from the quality assessments, and the studies were summarised in adapted considered judgement forms. The evidence was classiA ed using methods from SIGN, and adapted to include interrupted time series design and controlled before-after studies using criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) Group [fig_ref] Table 1: Levels of evidence for intervention studies5 [/fig_ref].This system is similar that used in the previous epic guidelines. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] The evidence tables and considered judgement reports were presented to the Guideline Development Advisory Group for discussion. The guidelines were drafted after extensive discussion.
Factors inA uencing the guideline recommendations included: - the nature of the evidence; - the applicability of the evidence to practice; - patient preference and acceptability; and - costs and knowledge of healthcare systems.
The classiA cation scheme adopted by SIGN was used to deA ne the strength of recommendation (

## Consultation process
These guidelines have been subject to extensive external consultation with key stakeholders, including Royal Colleges, professional societies and organisations, patients and trade unions (Appendix A.2). Comments were requested on: - format; - content; - practice applicability of the guidelines; - patient preference and acceptability; and - speciA c sections or recommendations.
All the comments were collated and sent to the scientiA c advisors and the Guideline Development Advisory Group for consideration prior to virtual meetings for discussion and agreement on any changes in the light of comments. Final agreement was sought from the scientiA c advisors and the Guideline Development Advisory Group following revision.

## 1++
High-quality meta-analyses, systematic reviews of RCTs or RCTs with a very low risk of bias 1+
Well-conducted meta-analyses, systematic reviews or RCTs with a low risk of bias 1-Meta-analyses, systematic reviews or RCTs with a high risk of bias* 2++
High-quality systematic reviews of case-control or cohort studies.
High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal. Interrupted time series with a control group: (i) there is a clearly deA ned point in time when the intervention occurred; and (ii) at least three data points before and three data points after the intervention 2+
Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.
Controlled before-after studies with two or more intervention and control sites 2-Case-control or cohort studies with a high risk of confounding or bias and a signiA cant risk that the relationship is not causal.
Interrupted time series without a parallel control group: (i) there is a clearly deA ned point in time when the intervention occurred; and (ii) at least three data points before and three data points after the intervention. Controlled before-after studies with one intervention and one control site 3
Non-analytic studies (e.g. uncontrolled before-after studies, case reports, case series) 4
Expert opinion. Legislation *Studies with an evidence level of '1-' and '2-' should not be used as a basis for making a recommendation. RCT, randomised controlled trial.

# Introduction
This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. Some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. These recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. None are regarded as optional.
Standard infection control precautions need to be applied by all healthcare practitioners to the care of all patients (i.e. adults, children and neonates). The recommendations are divided into A ve distinct interventions: - hospital environmental hygiene; - hand hygiene; - use of PPE; - safe use and disposal of sharps; and - principles of asepsis.
These guidelines do not address the additional infection control requirements of specialist settings, such as the operating department or outbreak situations.

## Hospital environmental hygiene

## Hospital hygiene is important for the prevention of healthcare-associated infections in hospitals
This section discusses the evidence upon which recommendations for hospital environmental hygiene are based. The evidence identiA ed in the previous systematic review was used as the basis for updating the searches, and searches were conducted for new evidence published since 2006. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Hospital environmental hygiene encompasses a wide range of routine activities. Guidelines are provided here for: - cleaning the general hospital environment; - cleaning items of shared equipment; and - education and training of staff.

## Maintain a clean hospital environment
Current legislation, regulatory frameworks and quality standards emphasise the importance of the healthcare environment and shared clinical equipment being clean and properly decontaminated to minimise the risk of transmission of HCAI and to maintain public conA dence.Patients and their relatives expect the healthcare environment to be clean and infection hazards to be controlled adequately.The term 'cleaning' is used to describe the physical removal of soil, dirt or dust from surfaces. Conventionally, this is achieved in healthcare settings using cloths and mops. Dust may be removed using dry dust-control mops/cloths. Detergent and water is used for cleaning of soiled or contaminated surfaces, although microA bre cloths and water can also be used for surface cleaning.Enhanced cleaning describes the use of methods in addition to standard cleaning speciA cations. These may include increased cleaning frequency for all or some surfaces, or the use of additional cleaning equipment. Enhanced cleaning may be applied to all areas of the healthcare environment or in speciA c circumstances, such as cleaning of rooms or bed spaces following the transfer or discharge of patients who are colonised or infected with a pathogenic microorganism. This is sometimes referred to as 'terminal cleaning'.
Disinfection is the use of chemical or physical methods to reduce the number of pathogenic microorganisms on surfaces. These methods need to be used in combination with cleaning as they have limited ability to penetrate organic material. The term 'decontamination' is used for the process that results in the removal of hazardous substances (e.g. microorganisms, chemicals) and therefore may apply to cleaning or disinfection.
Research evidence in this A eld remains largely limited to ecological studies and weak quasi-experimental and observational study designs. There is evidence from outbreak reports and observational research which demonstrates that the hospital environment becomes contaminated with microorganisms responsible for HCAI. Pathogens may be recovered from a variety of surfaces in clinical environments, including those near to the patient that are touched frequently by healthcare workers. [bib_ref] Widespread environmental contamination associated with patients with diarrhea and methicillin-resistant Staphylococcus aureus..., Boyce [/bib_ref] [bib_ref] Importance of the environment in meticillin-resistant Staphylococcus aureus acquisition: the case for..., Dancer [/bib_ref] [bib_ref] Reservoirs of MRSA in the acute hospital setting: a systematic review, Grifa Ths [/bib_ref] [bib_ref] BloomA eld SF. Effects of cleaning and disinfection in reducing the spread..., Barker [/bib_ref] [bib_ref] Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on..., Denton [/bib_ref] [bib_ref] Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination..., Wilcox [/bib_ref] [bib_ref] Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications, Boyce [/bib_ref] [bib_ref] Contamination of room door handles by methicillin-sensitive/methicillin-resistant Staphylococcus aureus, Oie [/bib_ref] [bib_ref] Bacterial contamination of computer keyboards in a teaching hospital, Schultz [/bib_ref] [bib_ref] Chlorhexidine resistance in antibiotic-resistant bacteria isolated from the surfaces of dispensers of..., Brooks [/bib_ref] However, no studies have provided high-quality evidence of direct transmission of the same strain of microorganisms found in the environment to those found in colonised or infected patients.
We identiA ed one prospective cohort study that found a signiA cant independent association between acquisition of two multi-drug-resistant pathogens and a prior room occupant with the same organism [multi-drug-resistant Pseudomonas aeruginosa odds ratio (OR) 2.3, 95% conA dence interval (CI) 1.2-4.3, p=0.012; multi-drug-resistant Acinetobacter baumanii OR 4.2, 95% CI 1.1-1.3, p=0.04] after adjustment for severity of underlying illness, comorbidities, antimicrobial exposure and some other risk factors. [bib_ref] Risk of acquiring multidrug-resistant Gram-negative bacilli from prior room occupants in the..., Nseir [/bib_ref] A further study reported an association between MRSA and vancomycin-resistant enterococcus (VRE), [bib_ref] Risk of acquiring antibioticresistant bacteria from prior room occupants, Huang [/bib_ref] but conclusions that can be drawn from the A ndings are limited by the retrospective study design and lack of adjustment for severity of underlying illness, colonisation pressure and antibiotic exposure. Similarly, another retrospective cohort study found an association between acquisition of C. difA cile and prior room occupant with the same infection; however, this was based solely on clinical diagnosis rather than active surveillance. [bib_ref] Evaluation of hospital room assignment and acquisition of Clostridium difA cile infection, Shaughnessy [/bib_ref] Many microorganisms recovered from the hospital environment do not cause HCAI. Cleaning will not completely eliminate microorganisms from environmental surfaces, and reductions in their numbers will be transient. [bib_ref] Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on..., Denton [/bib_ref] There is some evidence that enhanced cleaning regimens are associated with the control of outbreaks of HCAI; 24 however, these study designs do not provide robust evidence of cause and effect.
Enhanced cleaning has been recommended, particularly 'terminal cleaning', after a bed area has been used by a patient colonised or infected with an HCAI. We searched for robust evidence from studies conducted in the healthcare environment which demonstrated cleaning interventions that were associated with reductions in both environmental contamination and HCAI. A randomised crossover study of daily enhanced cleaning of high-touch surfaces in an intensive care unit (ICU) demonstrated a reduction in the daily number of S15 sites in a bed area contaminated with MRSA (OR 0.59, 95% CI 0.4-0.86, p=0.006), and the aerobic colony count in communal areas (OR 0.65, 95% CI 0.47-0.92, p=0.013). Although the reduction in MRSA in the environment was associated with a large reduction in MRSA contaminating doctors' hands (OR 0.26, 95% CI 0.07-0.95, p=0.025), there was no effect on the incidence of MRSA acquisition by patients (OR 0.98, 95% CI 0.58-1.65, p=0.93). [bib_ref] The impact of enhanced cleaning within the intensive care unit on contamination..., Wilson [/bib_ref] Disinfectants have been recommended for cleaning the hospital environment; 1,2 however, a systematic review failed to conA rm a link between disinfection and the prevention of HCAI, although contamination of detergent and inadequate disinfection strength could have been an important confounder. [bib_ref] Does disinfection of environmental surfaces inA uence nosocomial infection rates? A systematic..., Dettenkofer [/bib_ref] Whilst subsequent studies may have demonstrated a link between disinfection and reduced environmental contamination, and sometimes the acquisition of HCAI, the study designs are weak with no control groups or randomisation of intervention, and/or the introduction of multiple interventions at the same time. This makes it difA cult to draw deA nitive conclusions about the speciA c effect of disinfection or cleaning.

## Emerging technology
New technologies for cleaning and decontaminating the healthcare environment have become available over the past 10 years, including hydrogen peroxide, and others are in the early stages of development. Whilst hydrogen peroxide has been used for decontamination of selected rooms in a US hospital following use by patients with a multi-drug-resistant organism or C. difA cile, this study found that it was not possible to use hydrogen peroxide routinely for this purpose. [bib_ref] Feasibility of routinely using hydrogen peroxide vapor to decontaminate rooms in a..., Otter [/bib_ref] The effectiveness, cost-effectiveness and practicality of this and other new technologies in terms of reducing HCAI and routine use in the variety of facilities in UK hospitals has yet to be demonstrated.
We identiA ed three studies conducted in patient care environments that provided evidence for the effectiveness of different products, containing chemical or other disinfection agents, on environmental contamination but not reductions in HCAI. A prospective randomised crossover study provided evidence for the effectiveness of daily cleaning of high-touch surfaces with microA bre/copper-impregnated cloths on the reduction of MRSA, as discussed above. [bib_ref] The impact of enhanced cleaning within the intensive care unit on contamination..., Wilson [/bib_ref] An RCT demonstrated the efA cacy of daily high-touch surface cleaning with peracetic acid on MRSA and C. difA cile contamination of the environment, with a signiA cant reduction in MRSA and C. difA cile isolated from samples taken from surfaces with gloved hands (p<0.001) and the hands of healthcare workers (3/27 in peractic acid group vs 15/38 in standard cleaning group, p=0.13). [bib_ref] Daily disinfection of high-touch surfaces in isolation rooms to reduce contamination of..., Kundrapu [/bib_ref] A nonrandomised controlled trial (NRCT) in two wards at a single hospital provided evidence that an additional cleaner was associated with a 32.5% reduction in environmental microbial contamination of hand-touch sites (95% CI 20.2-42.9, p<0.0001) and 26.6% reduction in acquisition of MRSA infection (95% CI 7.7-92.3, p=0.032), although the infection types were not speciA ed. [bib_ref] Measuring the effect of enhanced cleaning in a UK hospital: a prospective..., Dancer [/bib_ref] Hydrogen peroxide has been used as a method of decontamination of the environment in situations where wards/ beds can be closed or left unused for the required period of time [bib_ref] Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a..., French [/bib_ref] [bib_ref] The role of 'no-touch' automated room disinfection systems in infection prevention and..., Otter [/bib_ref] [bib_ref] EfA cacy, efA ciency and safety aspects of hydrogen peroxide vapour and..., Fu [/bib_ref] We identiA ed a prospective, randomised beforeafter study that compared the efA cacy of hypochlorite and a hydrogen peroxide decontamination system for terminal cleaning of rooms used by a patient with C. difA cile infection in reducing environmental contamination with C. difA cile. Although both methods reduced environmental contamination signiA cantly compared with cleaning alone, hydrogen peroxide achieved a signiA cantly greater reduction (91% vs 30% decrease in proportion of samples with C. difA cile, p<0.005). [bib_ref] Comparison of the efA cacy of a hydrogen peroxide dry-mist disinfection system..., Barbut [/bib_ref] A prospective cohort study provided evidence for the efA cacy of hydrogen peroxide when used for terminal decontamination after standard cleaning in signiA cantly reducing the acquisition of multi-drug-resistant organisms in patients subsequently admitted to the rooms (adjusted incidence rate ratio 0.36, 95% CI 0.19-0.7). However, the effect was mainly driven by reduction in acquisition of VRE, and the results could have been confounded by the concurrent implementation of chlorhexidine baths, incomplete surveillance data and nonrandom assignment of rooms to the intervention. [bib_ref] An evaluation of environmental decontamination with hydrogen peroxide vapor for reducing the..., Passaretti [/bib_ref] The efA cacy of antimicrobial surfaces in the clinical environment in reducing surface contamination and HCAI is an area of emerging research. Four non-randomised, experimental studies, conducted in clinical environments, demonstrated signiA cant reductions in microbial burden of between 80% and 90% on high-touch surfaces coated with metallic copper and/or its alloys compared with similar noncopper surfaces. [bib_ref] Sustained reduction of microbial burden on common hospital surfaces through introduction of..., Schmidt [/bib_ref] [bib_ref] Copper continuously limits the concentration of bacteria resident on bed rails within..., Schmidt [/bib_ref] [bib_ref] Role of copper in reducing hospital environment contamination, Casey [/bib_ref] [bib_ref] The antimicrobial efA cacy of copper alloy furnishing in the clinical environment:..., Karpanen [/bib_ref] One RCT conducted in three ICUs reported a signiA cantly lower acquisition of HCAI in patients allocated to rooms with six high-touch copper-coated surfaces (3.4% vs 8.1%, p=0.013). A multi-variate analysis suggested that both severity of underlying illness and room assignment were independently associated with the acquisition of HCAI or colonisation. However, these A ndings may have been biased by poor discrimination of patients colonised on admission because of limited surveillance cultures, poor agreement in deA ning cases of HCAI, and incomplete adjustment for confounders in the multi-variate analysis. [bib_ref] Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care..., Salgado [/bib_ref] Evidence of the effectiveness and cost-effectiveness of these technologies and their contribution to reductions in HCAI is therefore not currently available.

## Assessing environmental cleanliness
Indicators of cleanliness based on levels of microbial or adenosine triphosphate (ATP) contamination have been recommended; however, relationships between ATP and aerobic colony counts are not consistent, and neither method distinguishes normal environmental A ora and pathogens responsible for HCAI. [bib_ref] Finding a benchmark for monitoring hospital cleanliness, Mulvey [/bib_ref] [bib_ref] Monitoring the effectiveness of hospital cleaning practices by use of an adenosine..., Boyce [/bib_ref] Benchmark values of between 250 and 500 relative light units have been proposed as a more objective measure of assessing the efA cacy of cleaning than visual assessment, although these are based on arbitrary standards of acceptable contamination that have not been shown to be associated with reductions in HCAI. [bib_ref] A modiA ed ATP benchmark for evaluating the cleaning of some hospital..., Lewis [/bib_ref] [bib_ref] The effectiveness of existing and modiA ed cleaning regimens in a Welsh..., Grifa Th [/bib_ref] [bib_ref] Use of audit tools to evaluate the efA cacy of cleaning systems..., Malik [/bib_ref] We identiA ed a number of uncontrolled before-after studies that used ATP in various forms to highlight the extent of contamination of the healthcare environment. In addition, some studies described the use of ATP monitoring as an intervention to improve cleaning, but the lack of a control group in the study design precluded their inclusion in this review. As cleaning will only have a transient effect on the numbers of microorganisms, regular cleaning or disinfection of hospital surfaces will not guarantee a pathogenfree environment. Preventing the transfer of pathogens from the environment to patients therefore still depends on ensuring that hands are decontaminated prior to patient contact.

## Sp1
The hospital environment must be visibly clean; free from non-essential items and equipment, dust and dirt; and acceptable to patients, visitors and staff.

## Class d/gpp
SP2 Levels of cleaning should be increased in cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.

## Class d/gpp

## Sp3
The use of disinfectants should be considered for cases of infection and/ or colonisation when a suspected or known pathogen can survive in the environment, and environmental contamination may contribute to the spread of infection.

## Class d/gpp

## Decontamination of equipment
Shared clinical equipment used to deliver care in the clinical environment comes into contact with intact skin and is therefore unlikely to introduce infection directly. However, it can act as a vehicle by which microorganisms are transferred between patients, which may subsequently result in infection. Equipment should therefore be cleaned and decontaminated after each use with cleaning agents compatible with the piece of equipment being cleaned. In some outbreak situations, the use of chlorine-releasing agents and detergent should be considered.SP4
Shared pieces of equipment used in the delivery of patient care must be cleaned and decontaminated after each use with products recommended by the manufacturer.

## Class d/gpp

## Healthcare workers' role in maintaining a clean environment
In a systematic review of healthcare workers' knowledge about MRSA and/or frequency of cleaning practices, three studies indicated that staff were not using appropriate cleaning practices with sufA cient frequency to ensure minimisation of MRSA contamination of personal equipment. [bib_ref] Reservoirs of MRSA in the acute hospital setting: a systematic review, Grifa Ths [/bib_ref] Staff education was lacking on optimal cleaning practices in the clinical areas. The A nding of the review is reinforced by a later observational study, which noted that lapses in adherence to the cleaning protocol were linked with an increase in environmental contamination with isolates of A. baumannii. [bib_ref] Role of environmental cleaning in controlling an outbreak of Acinetobacter baumannii on..., Denton [/bib_ref] A second systematic review of four cohort studies that compared the use of detergents and disinfectants on microbial-contaminated hospital environmental surfaces suggested that a lack of effectiveness was, in many instances, due to inadequate strengths of disinfectants, probably resulting from a lack of knowledge. [bib_ref] Does disinfection of environmental surfaces inA uence nosocomial infection rates? A systematic..., Dettenkofer [/bib_ref] We identiA ed no new, robust research studies of education or system interventions for this review. However, creating a culture of responsibility for maintaining a clean environment and increasing knowledge about how to decontaminate equipment and high-touch surfaces effectively requires education and training of both healthcare cleaning professionals and clinical staff.

## Sp5
All healthcare workers need to be educated about the importance of maintaining a clean and safe care environment for patients. Every healthcare worker needs to know their speciA c responsibilities for cleaning and decontaminating the clinical environment and the equipment used in patient care.

## Class d/gpp

# Search results
Total number of articles located = 5944

## Sift 1 criteria
Abstract indicates that the article: relates to infections associated with hospital hygiene; is written in English; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

## Articles retrieved
Total number of articles retrieved from Sift 1 = 164

## Sift 2 criteria
Full text conA rms that the article: relates to infections associated with hospital hygiene; is written in English; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental, experimental studies answering speciA c questions), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions.

## Articles selected for appraisal
Total number of studies selected for appraisal during Sift 2 = 26

## Critical appraisal
All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

## Accepted and rejected evidence
Total number of studies accepted after critical appraisal = 12 Total number of studies rejected after critical appraisal = 14

## Hand hygiene
This section discusses the evidence for recommendations concerning hand hygiene practice. Designing and conducting robust, ethical RCTs in the A eld of hand hygiene is challenging, meaning that recommendations are based on evidence from NRCTs, quasi-experimental studies, observational studies and laboratory studies with volunteers. In addition, expert opinion derived from systematically retrieved and appraised professional, national and international guidelines is used. The areas discussed in this section include: - assessment of the need to decontaminate hands; - efA cacy of hand decontamination agents and preparations; - rationale for choice of hand decontamination practice; - technique for hand decontamination; - care required to protect hands from the adverse effects of hand decontamination practice; - promoting adherence to hand hygiene guidelines; and - involving patients and carers in hand hygiene.

## Why is hand decontamination crucial to the prevention of healthcare-associated infection?
The transfer of organisms between humans can occur directly via hands, or indirectly via an environmental source (e.g. commode or wash basin). Epidemiological evidence indicates that hand-mediated transmission is a major contributing factor in the acquisition and spread of infection in hospitals. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] The hands are colonised by two categories of microbial A ora. The resident A ora are found on the surface, just below the uppermost layer of skin, are adapted to survive in the local conditions and are generally of low pathogenicity, although some, such as Stapylococcus epidermidis, may cause infection if transferred on to a susceptible site such as an invasive device. The transient A ora are made up of microorganisms acquired by touching contaminated surfaces such as the environment, patients or other people, and are readily transferred to the next person or object touched. They may include a range of antimicrobial-resistant pathogens such as MRSA, Acinetobacter or other multi-resistant Gram-negative bacteria. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] If transferred into susceptible sites such as invasive devices or wounds, these microorganisms can cause life-threatening infections. Transmission to non-vulnerable sites may leave a patient colonised with pathogenic and antibiotic-resistant organisms, which may result in an HCAI at some point in the future.
Outbreak reports and observational studies of the dynamics of bacterial hand contamination have demonstrated an association between patient care activities that involve direct patient contact and hand contamination. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] [bib_ref] Outbreak of extendedspectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit..., Gupta [/bib_ref] [bib_ref] Bacterial contamination of the hands of hospital staff during routine patient care, Pittet [/bib_ref] [bib_ref] Dynamics of bacterial hand contamination during routine neonatal care, Pessoa-Silva [/bib_ref] The association between hand decontamination, using liquid soap and water and waterless alcohol-base hand rub (ABHR), and reductions in infection have been conA rmed by clinically-based nonrandomised trials [bib_ref] The impact of alcohol hand sanitizer use on infection rates in an..., Fendler [/bib_ref] [bib_ref] Handwashing and respiratory illness among young adults in military training, Ryan [/bib_ref] and observational studies. [bib_ref] Effectiveness of a hospital-wide programme to improve compliance with hand hygiene, Pittet [/bib_ref] [bib_ref] Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based..., Gordin [/bib_ref] Current national and international guidance has consistently identiA ed that effective hand decontamination results in signiA cant reductions in the carriage of potential pathogens on the hands, and therefore it is logical that the incidence of preventable HCAI is decreased, leading to a reduction in patient morbidity and mortality. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] 

## When must you decontaminate your hands in relation to patient care?
Patients are put at risk of developing an HCAI when informal carers or healthcare workers caring for them have contaminated hands. Decontamination refers to a process for the physical removal of dirt, blood and body A uids, and the removal or destruction of microorganisms from the hands.The World Health Organization's (WHO) 'Five Moments for Hand Hygiene' 53 provides a framework for training healthcare workers, audit and feedback of hand hygiene practice, and has been adopted without modiA cation in many countries and adapted in others (e.g. Canada).Hands must be decontaminated at critical points before, during and after patient care activity to prevent crosstransmission of microorganisms. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] [bib_ref] My A ve moments for hand hygiene': a user-centred design approach to..., Sax [/bib_ref] Evidence considered by the National Institute for Health and Clinical Excellence (NICE)indicated increases in hand decontamination compliance before and after patient contact associated with implementation of the WHO 'Five Moments' and US Centers for Disease Control and Prevention 2002 guidelines, but no difference in compliance after contact with patient surroundings. The following recommendations are derived from the WHO framework and NICE guidelines,and include additional points of emphasis.

## Sp6
Hands must be decontaminated:
- immediately before each episode of direct patient contact or care, including clean/aseptic procedures; - immediately after each episode of direct patient contact or care; - immediately after contact with body A uids, mucous membranes and non-intact skin; - immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated; and - immediately after the removal of gloves.

## Class c

## Is any one hand-cleaning preparation better than another?
Current national and international guidelines 2,45,53 consider the efA cacy of various preparations for the decontamination of hands using liquid soap and water, antiseptic handwash agents and ABHR in laboratory studies and their effectiveness in clinical use. Overall, there is no compelling evidence to favour the general use of antiseptic handwashing agents over liquid soap or one antiseptic agent over another. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] [bib_ref] Infection control: prevention of healthcare-associated infection in primary and community care, Pellowe [/bib_ref] All hand hygiene products for use in clinical care must comply with current British Standards.Many studies have been conducted during the past 15 years to compare hand hygiene preparations, including ABHR and gels, antiseptic handwash and liquid soap.RCTs and other quasiexperimental studies have generally demonstrated alcoholbased preparations to be more effective hand hygiene agents than non-medicated soap and antiseptic handwashing agents, although a small number of studies reported no statistically signiA cant difference. [bib_ref] Hand contamination before and after different hand hygiene techniques: a randomized clinical..., Lucet [/bib_ref] [bib_ref] Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital..., Winnefeld [/bib_ref] [bib_ref] Assessment of two hand hygiene regimens for intensive care unit personnel, Larson [/bib_ref] [bib_ref] EfA cacy of handrubbing with alcohol based solution versus standard handwashing with..., Girou [/bib_ref] [bib_ref] Handwashing with soap or alcoholic solutions? A randomized clinical trial of its..., Zaragoza [/bib_ref] [bib_ref] Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in..., Larson [/bib_ref] [bib_ref] Clinical assay of N-duopropenide alcohol solution on hand application in newborn and..., Herruzo-Cabrera [/bib_ref] [bib_ref] A new alcohol solution (N-duopropenide) for hygienic (or routine) hand disinfection is..., Herruzo-Cabrera [/bib_ref] [bib_ref] Assessment of alternative hand hygiene regimens to improve skin health among neonatal..., Larson [/bib_ref] [bib_ref] Limited efA cacy of alcohol-based hand gels, Kramer [/bib_ref] [bib_ref] Effectiveness of a nonrinse, alcohol-free antiseptic hand wash, Moadab [/bib_ref] [bib_ref] Effectiveness of hand-cleansing agents for removing methicillin-resistant Staphylococcus aureus from contaminated hands, Guilhermetti [/bib_ref] [bib_ref] A close look at alcohol gel as an antimicrobial sanitizing agent, Paulson [/bib_ref] [bib_ref] Effectiveness of hand-cleansing agents for removing Acinetobacter baumannii strain from contaminated hands, Cardoso [/bib_ref] [bib_ref] Limited effectiveness of chlorhexidine based hand disinfectants against methicillinresistant Staphylococcus aureus (MRSA), Kampf [/bib_ref] [bib_ref] Testing a new alcohol-free hand sanitizer to combat infection, Dyer [/bib_ref] [bib_ref] Comparison of waterless hand antisepsis agents at short application times: raising the..., Dharan [/bib_ref] [bib_ref] Comparative efA cacy of hand hygiene agents in the reduction of bacteria..., Sickbert-Bennett [/bib_ref] Many of these studies involved the use of ABHR as part of a number of interventions, or multimodal campaigns, to improve hand hygiene practice, and had methodological A aws that weaken the causal relationship between the introduction of ABHR and reductions in HCAI. [bib_ref] Interventions to improve hand hygiene compliance in patient care, Gould [/bib_ref] We identiA ed one multi-variate, interrupted time series which suggested that the amount of ABHR used per patientday was the only factor associated with a reduction in MRSA incidence density (p=0.011) in a neonatal ICU in Japan. [bib_ref] Increased use of alcohol-based hand sanitizers and successful eradication of methicillin-resistant Staphylococcus..., Sakamoto [/bib_ref] Incidence density fell over a 4-year period from an average of 15 per 1000 patient-days, with a peak of 20 per 1000 patientdays in August 2006, to 0 per 1000 patient-days in October 2008 and was sustained to July 2009 (average incidence density 7.5 per 1000 patient-days). The supporting evidence from laboratory studies of the efA cacy of ABHR indicates that these products are highly effective at reducing hand carriage, whilst overcoming some of the recognised barriers to handwashing; most importantly, the ease of use at the point of patient care.
These studies underpin a continuing trend to adopt ABHR for routine use in clinical practice. However, some studies highlight the need for continued evaluation of the use of ABHR within the clinical environment to ensure staff adherence to guidelines and effective hand decontamination technique. [bib_ref] Comparison of waterless hand antisepsis agents at short application times: raising the..., Dharan [/bib_ref] [bib_ref] Comparative efA cacy of hand hygiene agents in the reduction of bacteria..., Sickbert-Bennett [/bib_ref] 

## Choice of decontamination: is it always necessary to wash hands to achieve decontamination?
Choosing the method of hand decontamination will depend upon the assessment of what is appropriate for the episode of care, the availability of resources at or near the point of care, what is practically possible and, to some degree, personal preferences based on the acceptability of preparations or materials.
In general, effective handwashing with liquid soap and water or the effective use of ABHR will remove transient microorganisms and render the hands socially clean. The effective use of ABHR will also substantially reduce resident microorganisms. This level of decontamination is sufA cient for general social contact and most clinical care activities. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Liquid soap preparations that contain an antiseptic affect both transient microorganisms and resident A ora, and some exert a residual effect. The use of preparations containing an antiseptic is required in situations where prolonged reduction in microbial A ora on the skin is necessary (e.g. surgery, some invasive procedures or in outbreak situations). [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] ABHR is not effective against all microorganisms (e.g. some viruses such as Norovirus and spore-forming microorganisms such as C. difA cile). It will not remove dirt and organic material, and may not be effective in some outbreak situations. [bib_ref] Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based..., Gordin [/bib_ref] [bib_ref] Comparison of the antibacterial efA cacy of 4% chlorhexidine gluconate and 1%..., Faoagali [/bib_ref] We identiA ed two laboratory studies which demonstrated that ABHR was not effective in removing C. difA cile spores from hands. [bib_ref] Hand hygiene with soap and water is superior to alcohol rub and..., Oughton [/bib_ref] In the A rst study, a comparison of liquid soap and water, chlorhexidine gluconate (CHG) soap and water, antiseptic hand wipes and ABHR resulted in all the soap and water protocols yielding greater mean colony-forming unit (cfu) reductions, followed by the antiseptic hand wipes, than ABHR. ABHR was equivalent to no intervention (0.06 log 10 cfu/mL, 95% CI -0.34 to 0.45 log 10 cfu/mL). [bib_ref] Hand hygiene with soap and water is superior to alcohol rub and..., Oughton [/bib_ref] In the second study, three ABHR preparations with a minimum 60% alcohol S19 concentration were compared with antiseptic (CHG) soap and water. Antiseptic soap and water reduced spore counts signiA cantly compared with each of the ABHRs (CHG vs Isagel, p=0.005; CHG vs Endure, p=0.010; CHG vs Purell, p=0.005). In addition, 30% of the residual spores were readily transferred by handshake following the use of ABHR.Recent evidence from a laboratory study that compared the efA cacy of liquid soap and water and ABHR with and without CHG against H1N1 inA uenza virus demonstrated that all the hand hygiene protocols were effective in reducing virus copies. [bib_ref] EfA cacy of soap and water and alcohol-based hand-rub preparations against live..., Grayson [/bib_ref] A further study that compared the use of liquid soap and water and 65% ethanol hand sanitisers for the removal of Rhinovirus indicated that the hand sanitisers were more effective than soap and water. [bib_ref] Effectiveness of hand sanitizers with and without organic acids for removal of..., Turner [/bib_ref] Two economic evaluations from the USA, included in recent NICE primary care guidelines, suggest that non-compliance with hand hygiene guidelines results in increased infection-related costs.Although compliance increases procurement costs of hand hygiene products, even a small increase in compliance is likely to result in reduced infection costs. We identiA ed a further economic analysis of a hand hygiene programme based on the introduction of point-of-use ABHR and associated implementation materials. This demonstrated a reduction in episodes of HCAI and a saving of $23.7 for every $1 spent on the programme when future costs were considered. Sensitivity analyses showed that the programme remained cost saving in all alternative scenarios. [bib_ref] Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections, Chen [/bib_ref] ABHR is likely to be less costly and result in greater compliance.
National and international guidelines suggest that the acceptability of agents and techniques is an essential criterion for the selection of preparations for hand hygiene. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Acceptability of preparations is dependent upon the ease with which the preparation can be used in terms of time and access, together with their dermatological effects.ABHR is preferable for routine use due to its efA cacy, availability at the point of care and acceptability to healthcare workers.However, ABHR does not remove organic matter and is ineffective against some microorganisms; therefore, handwashing is required.

## Sp7
Use an alcohol-based hand rub for decontamination of hands before and after direct patient contact and clinical care, except in the following situations when soap and water must be used:
- when hands are visibly soiled or potentially contaminated with body A uids; and - when caring for patients with vomiting or diarrhoeal illness, regardless of whether or not gloves have been worn.

## Class a

## Is hand decontamination technique important?
Investigations of technique for hand decontamination are limited and generally laboratory-based or small-scale observational designs. Hand hygiene technique involves both the preparation and the physical process of decontamination. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Hands and wrists need to be fully exposed to the hand hygiene product and therefore should be free from jewellery and long-sleeved clothing. A number of small-scale observational studies have demonstrated that wearing rings and false nails is associated with increased carriage of microorganisms and, in some cases, linked to the carriage of outbreak strains. Department of Health guidance on uniforms and work wear and NICE guidelines indicate that healthcare workers should remove rings and wrist jewellery, and wear short-sleeved clothing whilst delivering patient care.Evidence for the duration of hand decontamination has been considered in previous systematic reviews underpinning guidelines, and suggests that different durations of handwashing and hand rubbing do not signiA cantly affect the reduction of bacteria. [bib_ref] Hand contamination before and after different hand hygiene techniques: a randomized clinical..., Lucet [/bib_ref] [bib_ref] Comparative efA cacy of hand hygiene agents in the reduction of bacteria..., Sickbert-Bennett [/bib_ref] The WHO guidelines indicate that decontamination using ABHR should take 20-30 s for a seven-step process, and that handwashing should take 40-60 s for a nine-step process.We identiA ed one recent RCT in a single hospital which demonstrated that allowing staff to decontaminate their hands 'in no particular order' took less time and was as effective as using the WHO seven-step technique using ABHR or liquid antimicrobial soap and water (p=0.04 and p<0.001, respectively). All three of the protocols tested in this study were effective in reducing hand bacterial load (p<0.01). [bib_ref] Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: a randomized..., Chow [/bib_ref] A similar result was reported by authors of a laboratory study that tested the EN1500 six-step technique against a range of other protocols. They reported that allowing volunteers to use their own 'responsible application' or a new A ve-step technique resulted in better coverage of the hands during hand decontamination. [bib_ref] InA uence of rub-in technique on required application time and hand coverage..., Kampf [/bib_ref] A number of laboratory-based studies that investigated methods of hand drying suggested that there is no signiA cant difference in the efA cacy of different methods of drying hands, but that good-quality paper towels dry hands efA ciently and remove bacteria effectively. [bib_ref] Effects of 4 handdrying methods for removing bacteria from washed hands: a..., Gustafson [/bib_ref] [bib_ref] EfA ciency of hand drying for removing bacteria from washed hands: comparison..., Yamamoto [/bib_ref] Current guidance on infection control in the built environment suggests that air and jet driers are not appropriate for use in clinical areas.We identiA ed one systematic review of studies on hand drying that failed to meet the quality criteria for inclusion. [bib_ref] The hygienic efA cacy of different hand-drying methods: a review of the..., Huang [/bib_ref] Due to the methodological limitations of studies, evidence recommendations are based on national and international guidelines which state that the duration of hand decontamination, the exposure of all aspects of the hands and wrists to the preparation being used, the use of vigorous rubbing to create friction, thorough rinsing in the case of handwashing, and ensuring that hands are completely dry are key factors in effective hand hygiene and the maintenance of skin integrity.

## Sp8
Healthcare workers should ensure that their hands can be decontaminated effectively by:
- removing all wrist and hand jewellery;
- wearing short-sleeved clothing when delivering patient care; - making sure that A ngernails are short, clean, and free from false nails and nail polish; and - covering cuts and abrasions with waterproof dressings.

## Class d/gpp

## Sp9
Effective handwashing technique involves three stages: preparation, washing and rinsing, and drying.
- Preparation: wet hands under tepid running water before applying the recommended amount of liquid soap or an antimicrobial preparation. - Washing: the handwash solution must come into contact with all of the surfaces of the hand. The hands should be rubbed together vigorously for a minimum of 10-15 s, paying particular attention to the tips of the A ngers, the thumbs and the areas between the A ngers. Hands should be rinsed thoroughly. - Drying: use good-quality paper towels to dry the hands thoroughly.

## Class d/gpp

## Sp10
When decontaminating hands using an alcohol-based hand rub, hands should be free of dirt and organic material and:
- hand rub solution must come into contact with all surfaces of the hand; and - hands should be rubbed together vigorously, paying particular attention to the tips of the A ngers, the thumbs and the areas between the A ngers, until the solution has evaporated and the hands are dry.

## Class d/gpp

## Does hand decontamination damage skin?
Expert opinion suggests that skin damage is generally associated with the detergent base of the preparation and/or poor handwashing technique. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] In addition, the frequent use of some hand hygiene agents may cause damage to the skin and alter normal hand A ora. Sore hands are associated with increased colonisation by potentially pathogenic microorganisms and increase the risk of transmission. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] The irritant and drying effects of liquid soap and antiseptic soap preparations have been identiA ed as one of the reasons why healthcare practitioners fail to adhere to hand hygiene guidelines. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] [bib_ref] Hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels, Pietsch [/bib_ref] In addition, washing hands regularly with liquid soap and water before or after the use of ABHR is associated with dermatitis and is not necessary.Systematic reviews conducted to underpin national guidelines 1,2,45,53,57 have identiA ed a range of studies that compared the use of alcohol-based preparations with liquid soap and water using self-assessment of skin condition by nurses. These studies found that ABHR was associated with less skin irritation than liquid soap and water. [bib_ref] Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital..., Winnefeld [/bib_ref] [bib_ref] Assessment of two hand hygiene regimens for intensive care unit personnel, Larson [/bib_ref] [bib_ref] Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in..., Larson [/bib_ref] [bib_ref] Assessment of alternative hand hygiene regimens to improve skin health among neonatal..., Larson [/bib_ref] [bib_ref] Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing..., Boyce [/bib_ref] [bib_ref] Hand dermatitis in intensive care units, Forrester [/bib_ref] [bib_ref] Dermal tolerance of Sterillium, a propanol-based hand rub, Kampf [/bib_ref] In addition, a longitudinal study of the introduction and subsequent use of ABHR over a 7-year period observed no reports of irritant and contact dermatitis associated with the use of ABHR. [bib_ref] Effectiveness of a hospital-wide programme to improve compliance with hand hygiene, Pittet [/bib_ref] We identiA ed a recent study which suggested that two ABHR preparations containing a glycerol emollient were more acceptable to staff (p<0.001). [bib_ref] Double-blind, randomized, crossover trial of 3 hand rub formulations: fast-track evaluation of..., Pittet [/bib_ref] Hand moisturisers/ emollients that are for shared use are more likely to become contaminated, and have been associated with an outbreak of infection in a neonatal unit. [bib_ref] Pseudomonas aeruginosa outbreak in a neonatal intensive care unit: a possible link..., Becks [/bib_ref] Current national and international guidance suggests that skin care, through the appropriate use of hand lotion or moisturisers added to hand hygiene preparations, is an important factor in maintaining skin integrity, encouraging adherence to hand decontamination practices and assuring the health and safety of healthcare practitioners. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] 

## Sp11
Clinical staff should be made aware of the potentially damaging effects of hand decontamination products, and encouraged to use an emollient hand cream regularly to maintain the integrity of the skin. Consult the occupational health team or a general practitioner if a particular liquid soap, antiseptic handwash or alcohol-based hand rub causes skin irritation.

## Class d/gpp

## How can adherence to hand hygiene guidance be promoted?
National and international guidelines emphasise the importance of adherence to hand hygiene guidance, and provide an overview of the barriers and factors that inA uence hand hygiene compliance. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] The use of multi-modal approaches to improving hand hygiene practice and behaviour has been advocated for over 10 years. Observational studies have consistently reported an association between multi-modal interventions involving the introduction of near-patient ABHR, audit and feedback, reminders and education, and greater compliance by healthcare staff. [bib_ref] Effectiveness of a hospital-wide programme to improve compliance with hand hygiene, Pittet [/bib_ref] [bib_ref] Use of alcohol hand sanitizer as an infection control strategy in an..., Hilburn [/bib_ref] [bib_ref] Reduction in nosocomial infection with improved hand hygiene in intensive care units..., Rosenthal [/bib_ref] [bib_ref] Effect of education and performance feedback on rates of catheter-associated urinary tract..., Rosenthal [/bib_ref] [bib_ref] Handwashing program for the prevention of nosocomial infections in a neonatal intensive..., Won [/bib_ref] [bib_ref] Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant,..., Macdonald [/bib_ref] [bib_ref] Differences in hand hygiene behavior related to the contamination risk of healthcare..., Wendt [/bib_ref] [bib_ref] Factors associated with hand hygiene practices in two neonatal intensive care units, Cohen [/bib_ref] [bib_ref] Use of an alcohol-based hand rub and quality improvement interventions to improve..., Brown [/bib_ref] [bib_ref] Compliance with hand hygiene and glove use in a university-afA liated hospital, Kuzu [/bib_ref] [bib_ref] Rates of hand disinfection associated with glove use, patient isolation, and changes..., Kim [/bib_ref] [bib_ref] Evaluation of a patient education model for increasing hand hygiene compliance in..., Mcguckin [/bib_ref] [bib_ref] Evaluation of a patientempowering hand hygiene programme in the UK, Mcguckin [/bib_ref] An early systematic review of 21 studies involving interventions to improve hand hygiene compliance concludes that: - single interventions have a short-term inA uence on hand hygiene; - reminders have a modest but sustained effect; - feedback increases rates of hand hygiene but must be regular; - near-patient alcohol-based preparations improve the frequency with which healthcare workers clean their hands; and - multi-faceted approaches have a more marked effect on hand hygiene and rates of HCAI. [bib_ref] The effectiveness of interventions aimed at increasing handwashing in healthcare workers -a..., Naikoba [/bib_ref] H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1-S70

## S21
National hand hygiene campaigns have been modelled on the multi-modal approach and implemented across the world. [bib_ref] Effectiveness of a hospital-wide programme to improve compliance with hand hygiene, Pittet [/bib_ref] [bib_ref] Euro surveillance: bulletin Europeen sur les maladies transmissibles, Magiorakos [/bib_ref] [bib_ref] Outcomes from the A rst 2 years of the Australian national hand..., Grayson [/bib_ref] In England and Wales, the National Patient Safety Agency's 'Cleanyourhands Campaign' was piloted and implemented between 2004 and 2008 with the aim of creating sustainable change in hand hygiene compliance. The campaign comprised the use of near-patient ABHR, national poster materials, audit and feedback, and materials for patient engagement.
Recent Cochrane reviews of randomised and controlled clinical trials, interrupted time series and controlled before-after studies have suggested that the majority of studies conducted in this A eld have methodological biases that exclude them from this review. [bib_ref] Interventions to improve hand hygiene compliance in patient care, Gould [/bib_ref] [bib_ref] Interventions to improve hand hygiene compliance in patient care, Gould [/bib_ref] We identiA ed four systematic reviews of interventions to improve hand hygiene compliance. [bib_ref] Interventions to improve hand hygiene compliance in patient care, Gould [/bib_ref] [bib_ref] An integrative review of the current evidence on the relationship between hand..., Backman [/bib_ref] [bib_ref] Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review..., Aboelela [/bib_ref] [bib_ref] Features of educational interventions that lead to compliance with hand hygiene in..., Cherry [/bib_ref] The most recent Cochrane review identiA ed 84 studies published after 2006 for potential inclusion, but only four studies (one RCT, two interrupted time series and one controlled before-after study) were included following detailed quality assessment. [bib_ref] Interventions to improve hand hygiene compliance in patient care, Gould [/bib_ref] The heterogeneity of interventions and methods precluded the pooling and meta-analysis of results, and it was concluded that multi-faceted campaigns that include social marketing or staff engagement may be more effective than campaigns without these components, and that education or product substitution alone were less effective.
An integrative systematic review of 35 studies that reported a wide range of interventions, including multi-modal interventions and hand hygiene product changes, only scored nine of the included studies as having limited or no fatal A aws. [bib_ref] An integrative review of the current evidence on the relationship between hand..., Backman [/bib_ref] The authors concluded that design limitations made it difA cult to generalise the study results or isolate the speciA c effects of hand hygiene (or other interventions) on reductions in HCAI.
An earlier systematic review of 'bundled' behavioural intervention studies that reported HCAI or rates of colonisation as the primary outcome identiA ed 33 potential studies for inclusion; of these, only four had quality scores >80%. Again, due to the heterogeneity of study interventions and outcomes, the results were narratively synthesised. [bib_ref] Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review..., Aboelela [/bib_ref] The authors concluded that the formation of multi-disciplinary quality improvement teams and educational interventions might be effective strategies to improve hand hygiene and reduce rates of HCAI.
The A nal systematic review focused speciA cally on educational interventions to improve hand hygiene compliance and competence in hospital settings, and included all study designs that reported at least one outcome measure of hand hygiene competence and had a follow-up of at least 6 months. [bib_ref] Features of educational interventions that lead to compliance with hand hygiene in..., Cherry [/bib_ref] Thirty studies met the inclusion criteria for the review, but it was not possible to separate competence from compliance. Educational interventions taught or re-taught the correct methods for hand hygiene and then assessed compliance. The authors concluded that educational interventions had a greater impact if compliance with hand hygiene was low. Multiple interventions were better than single interventions in sustaining behaviour change, as were continuous, rather than one-off, interventions. However, it was not possible to determine the duration or sustainability of behaviour change in these studies.
We identiA ed six new studies in our systematic review: one cluster RCT and process evaluation, 117,118 one step-wedge cluster RCT, [bib_ref] The Feedback Intervention Trial (FIT) -improving hand-hygiene compliance in UK healthcare workers:..., Fuller [/bib_ref] two interrupted time series studies 84,120 and one controlled before-after study [bib_ref] Multiple component patient safety intervention in English hospitals: controlled evaluation of second..., Benning [/bib_ref] that evaluated multi-modal interventions with varying components. In a cluster RCT that also included a process evaluation, the authors tested a set of core elements in a 'state-of-the-art strategy' (SAS) against a team-leader-directed strategy (TDS) at baseline (T1), immediately following the intervention (T2) and 6 months later (T3) to ascertain the additional beneA ts of leadership and staff engagement components. [bib_ref] Impact of a team and leaders-directed strategy to improve nurses' adherence to..., Huis [/bib_ref] [bib_ref] Explaining the effects of two different strategies for promoting hand hygiene in..., Huis [/bib_ref] In the intention-to-treat analysis (ITT), an OR of 1.64 (95% CI 1.33-2.02, p<0.001) in favour of the TDS between T2 and T3 suggested that engaging ward leadership and the involvement of teams in setting norms and targets resulted in greater compliance with hand hygiene. However, there was no signiA cant difference between the groups' compliance at T3 in the ITT (p=0.187), with the SAS also having a sustained effect. [bib_ref] Impact of a team and leaders-directed strategy to improve nurses' adherence to..., Huis [/bib_ref] The process evaluation examined the extent to which the content, dosage and coverage of the intervention had been delivered. [bib_ref] Explaining the effects of two different strategies for promoting hand hygiene in..., Huis [/bib_ref] An as-treated analysis demonstrated a greater effect size for the TDS at T3 with a signiA cant difference in hand hygiene compliance (p<0.01). The process evaluation also suggested that feedback about individual hand hygiene performance at T2 and T3 (p<0.05 and p<0.01, respectively), challenging colleagues on undesirable hand hygiene practice (p<0.01), and support from colleagues in performing hand hygiene (p<0.01) were positively correlated with changes in nurses' hand hygiene compliance. [bib_ref] Explaining the effects of two different strategies for promoting hand hygiene in..., Huis [/bib_ref] The second cluster RCT used a step-wedge design to assess a behavioural feedback intervention in intensive therapy units (ITUs) and acute care of the elderly (ACE) wards at sites participating in the 'Cleanyourhands Campaign'. [bib_ref] The Feedback Intervention Trial (FIT) -improving hand-hygiene compliance in UK healthcare workers:..., Fuller [/bib_ref] The primary and secondary outcome measures were hand hygiene compliance measured by covert direct observation for 1 h every 6 weeks, and soap and ABHR procurement, respectively. Sixty wards were recruited, of which 33 implemented the intervention. The ITT analysis (60 wards) showed a signiA cant effect of the intervention in the ITUs but not the ACE wards, equating to a 7-9% increase in compliance, with estimated OR of 1.44 (95% CI 1.018-1.76, p=<0.001) in ITUs and estimated OR of 1.06 (95% CI 0.87-1.25, p=0.5) in ACE wards. The perprotocol analysis (33 wards) showed a signiA cant increase in compliance in both ACE wards and ITUs of 10-13% and 13-18%, respectively, with estimated OR of 1.67 (95% CI 1.26-2.22, p0.001) in ACE wards and estimated OR of 2.09 (95% CI 1.55-2.81, p0.001) in ITUs. The authors concluded that individual feedback and team action planning resulted in moderate but sustained improvements in hand hygiene adherence. The difA culties in implementing this intervention point to the problems that might be faced in a non-trial context.
Two interrupted time series studies of the 4-year national 'Cleanyourhands Campaign' in England and a 4-year hospitalwide programme in Taiwan demonstrated increased hand hygiene compliance (measured by procurement of ABHR and liquid soap) and reductions in HCAI [MRSA and C. difA cile, and MRSA and extensively-drug-resistant Acinetobacter (XDRAB)]. [bib_ref] Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections, Chen [/bib_ref] [bib_ref] Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and..., Stone [/bib_ref] In the national study, increased procurement of soap was independently associated with reductions in C. difA cile infection (adjusted incidence rate ratio for 1-mL increase per patient-bed-day 0.993, 95% CI 0.990-0.996, p<0.0001) and MRSA in the last four quarters of the study (adjusted incidence rate ratio for 1-mL increase per patient-bed-day 0.990, 95% CI 0.985-0.995, p<0.0001). [bib_ref] Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and..., Stone [/bib_ref] The 'Cleanyourhands Campaign' was not independent of other national programmes to reduce Analysis also identiA ed that the publication of the Health Act and the Department of Health improvement team visits were associated with reductions in MRSA and C.difA cile. In the hospital-wide study, [bib_ref] Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections, Chen [/bib_ref] the authors demonstrated a decrease in the cumulative incidence of HCAI caused by MRSA (change in level, p=0.03; change in trend, p=0.04) and XDRAB (change in level, p=0.78; change in trend, p<0.001) during the intervention period. Hand hygiene compliance was signiA cantly correlated with increased consumption of ABHR, and improved overall from 43.3% in 2004 to 95.6% in 2007 (p<0.001). Hand hygiene compliance was also signiA cantly correlated with professional categories of healthcare workers (p<0.001) in both general wards and ICUs (p<0.001).
The controlled before-after study 121 of a range of patient safety interventions in England, including hand hygiene, as measured by ABHR and soap consumption in non-specialist acute hospitals, reported no signiA cant differences in the rate of increase in consumption of ABHR (p=0.760 favouring controls and p=0.889 favouring intervention) and non-signiA cant decreases in C. difA cile (p=0.652) and MRSA (p=0.693).

## Sp12
Alcohol-based hand rub should be made available at the point of care in all healthcare facilities.

## Class c

## Sp13
Hand hygiene resources and healthcare worker adherence to hand hygiene guidelines should be audited at regular intervals, and the results should be fed back to healthcare workers to improve and sustain high levels of compliance.

## Class c

## Sp14
Healthcare organisations must provide regular training in risk assessment, effective hand hygiene and glove use for all healthcare workers.

## Class d/gpp

## Sp15
Local programmes of education, social marketing, and audit and feedback should be refreshed regularly and promoted by senior managers and clinicians to maintain focus, engage staff and produce sustainable levels of compliance.

## New recommendation class c

## Patient involvement in hand hygiene
Patient involvement in multi-modal strategies to improve hand hygiene among healthcare workers is established, and includes making it acceptable for patients and carers to request that healthcare workers clean their hands.However, research suggests that many patients and carers do not feel empowered to challenge staff, particularly doctors. [bib_ref] Evaluation of a patient education model for increasing hand hygiene compliance in..., Mcguckin [/bib_ref] [bib_ref] Evaluation of a patientempowering hand hygiene programme in the UK, Mcguckin [/bib_ref] [bib_ref] Patients' beliefs and perceptions of their participation to increase healthcare worker compliance..., Longtin [/bib_ref] [bib_ref] Evaluation of patient participation in a patient empowerment initiative to improve hand..., Lent [/bib_ref] Many NHS trusts have promoted hand hygiene among visitors by placing ABHR at the entrances to wards and patient rooms, but there is no evidence that this reduces HCAI. Despite being highlighted as an important gap in research, the role of patients' hands in the cross-transmission of microorganisms has not been investigated systematically, other than in ecologic studies that describe hand or skin contamination [bib_ref] Recovery of coliforms from the hands of nurses and patients: activities leading..., Sanderson [/bib_ref] [bib_ref] Differences in skin A ora between inpatients and chronically ill outpatients, Larson [/bib_ref] [bib_ref] Could hospital patients' hands constitute a missing link?, Bana Eld [/bib_ref] or observations of non-use of hand hygiene products. [bib_ref] Use of alcohol hand rub (AHR) at ward entrances and use of..., Savage [/bib_ref] Studies of effective interventions to enable patients to clean their hands remain small scale and descriptive in nature. [bib_ref] Patient hand hygiene: a clinical inquiry, Lawrence [/bib_ref] [bib_ref] An exploratory study of patient's feelings about asking healthcare professionals to wash..., Duncan [/bib_ref] [bib_ref] Hand hygiene: what about our patients?, Burnett [/bib_ref] [bib_ref] Perceptions, attitudes, and behavior towards patient hand hygiene, Burnett [/bib_ref] We identiA ed three studies that described interventions to improve patient hand hygiene: one in an outbreak situation, one uncontrolled before-after study of parent education in a single paediatric ICU, and one as part of a prospective observational study in a community hospital. None of these studies met the quality criteria for inclusion in this systematic review. [bib_ref] Outbreak of human metapneumovirus infection in psychiatric inpatients: implications for directly observed..., Cheng [/bib_ref] [bib_ref] Effectiveness of hand-washing teaching programs for families of children in paediatric intensive..., Chen [/bib_ref] [bib_ref] Systematic patients' hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in..., Gagne [/bib_ref] However, all of these studies suggested that improving patient/carer hand hygiene had some effect on crosstransmission of microorganisms and hand hygiene technique. National guidelines indicate that it is important to educate patients and carers about the importance of hand hygiene, and inform them about the availability of hand hygiene facilities and their role in maintaining standards of healthcare workers' hand hygiene.

## Sp16
Patients and relatives should be provided with information about the need for hand hygiene and how to keep their own hands clean.

## New recommendation class d/gpp

## Sp17
Patients should be offered the opportunity to clean their hands before meals; after using the toilet, commode or bedpan/urinal; and at other times as appropriate. Products available should be tailored to patient needs and may include alcohol-based hand rub, hand wipes and access to handwash basins.

## New recommendation class d/gpp

# Search results
Total number of articles located = 8223

## Sift 1 criteria
Abstract indicates that the article: relates to infections associated with hand hygiene; is written in English; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

## Articles retrieved
Total number of articles retrieved from Sift 1 = 255

## Sift 2 criteria
Full text conA rms that the article: relates to infections associated with hand hygiene; is written in English; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental, experimental studies answering speciA c questions), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions.

## Articles selected for appraisal
Total number of studies selected for appraisal during Sift 2 = 78

## Critical appraisal
All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

## Accepted and rejected evidence
Total number of studies accepted after critical appraisal = 17 Total number of studies rejected after critical appraisal = 61

## Use of personal protective equipment
This section discusses the evidence and associated recommendations for the use of PPE by healthcare workers in acute care settings and includes the use of aprons, gowns, gloves, eye protection and face masks/respirators to prevent potential transmission of pathogenic microorganisms to staff, patients and the healthcare environment. The use of gloves for other purposes does not form part of these guidelines. Where health and safety legislation underpins a recommendation, this is indicated by 'Health & Safety (H&S)' in addition to the classiA cation of any clinical evidence underpinning the recommendations.

## Infection prevention and control dress code -protect your patients and yourself
The primary roles of PPE are to protect staff and reduce opportunities for cross-transmission of microorganisms in hospitals. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] There is no evidence that uniforms or work clothing are associated with HCAI. However, there is a public expectation that healthcare workers will wear work and protective clothing to minimise any potential risk to patients and themselves. [bib_ref] Uniform: an evidence review of the microbiological signiA cance of uniforms and..., Wilson [/bib_ref] The decision to use or wear PPE must be based upon an assessment of the level of risk associated with a speciA c patient care activity or intervention, and take account of current health and safety legislation.There is evidence that both a lack of knowledge of guidelines and non-adherence to guideline recommendations are common, and that regular in-service education and training is required. [bib_ref] Compliance with hand hygiene and glove use in a university-afA liated hospital, Kuzu [/bib_ref] [bib_ref] Knowledge of standard and isolation precautions in a large teaching hospital, Sax [/bib_ref] [bib_ref] Healthcare workers' knowledge of inoculation injuries and glove use, Trim [/bib_ref] [bib_ref] Critical incidents of nonadherence with standard precautions guidelines among community hospital-based health..., Ferguson [/bib_ref] [bib_ref] Contact precautions for Clostridium diffcile and methicillin-resistant Staphylococcus aureus (MRSA): assessing the..., Prieto [/bib_ref] 

## Sp18
Selection of personal protective equipment must be based on an assessment of the: - risk of transmission of microorganisms to the patient or carer; - risk of contamination of healthcare practitioners' clothing and skin by patients' blood or body A uids; and - suitability of the equipment for proposed use.

## Class d/gpp/h&s

## Sp19
Healthcare workers should be educated and their competence assessed in the: - assessment of risk;
- selection and use of personal protective equipment; and - use of standard precautions.

## Class d/gpp/h&s

## Sp20
Supplies of personal protective equipment should be made available wherever care is delivered and risk assessment indicates a requirement.

## Gloves: use them appropriately
The use of gloves as an element of PPE and contact precautions is an everyday part of clinical practice for healthcare workers. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] There are other indications unrelated to preventing the cross-transmission of infection that require gloves to be worn (e.g. the use of some chemicals or medications). The two main indications for the use of gloves in the prevention of HCAI 1 are: - to protect hands from contamination with organic matter and microorganisms; and - to reduce the risk of cross-transmission of microorganisms to staff and patients. Gloves should be selected on the basis of a risk assessment, and should be suitable for the proposed task and the materials being handled.Gloves are categorised as medical gloves (examination and surgical) and protective gloves.Examination gloves are available as sterile or non-sterile for use by healthcare workers during clinical care to prevent contamination with microorganisms, blood and body A uids. Surgical gloves are available as sterile for use by healthcare workers during surgical and other invasive procedures. Protective gloves are used to protect healthcare workers from chemical hazards.Gloves should not be worn as a substitute for hand hygiene. Their prolonged and unnecessary use may cause adverse reactions and skin sensitivity, and may lead to crosscontamination of the patient environment. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] The need to wear gloves and the selection of appropriate glove materials requires careful assessment of the task to be performed and its related risks to patients and healthcare workers. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Risk assessment should include consideration of: - who is at risk (patient or healthcare worker) and whether sterile or non-sterile gloves are required; - potential for exposure to blood, body A uids, secretions and excretions; - contact with non-intact skin or mucous membranes during care and invasive procedures; and - healthcare worker and patient sensitivity to glove materials. We identiA ed four observational studies which suggested that clinical gloves are not used in line with current guidance, and that glove use impacts negatively on hand hygiene. [bib_ref] The dirty hand in the latex glove'': a study of hand hygiene..., Fuller [/bib_ref] [bib_ref] Impact of improving glove usage on the hand hygiene compliance, Eveillard [/bib_ref] [bib_ref] Measurement of hand hygiene compliance and gloving practices in different settings for..., Eveillard [/bib_ref] [bib_ref] Hand decontamination practices and the appropriate use of gloves in two adult..., Katherason [/bib_ref] In addition, a cluster RCT of screening and enhanced contact precautions for patients colonised with MRSA or VRE found no reduction in transmission, but also found that adherence to contact precautions was less than ideal. [bib_ref] Intervention to reduce transmission of resistant bacteria in intensive care, Huskins [/bib_ref] Gloves must be removed immediately following each care activity for which they have been worn, and hands must be decontaminated in order to prevent the cross-transmission of microorganisms to other susceptible sites in that individual or to other patients. Gloves should not be washed or decontaminated with ABHR as a substitute for changing gloves between care activities. 45

## Gloves are not infallible
There is evidence that hands become contaminated when clinical gloves are worn, even when the integrity of the glove appears undamaged. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] In terms of leakage, gloves made from natural rubber latex (NRL) perform better than vinyl gloves in laboratory test conditions. 1,2 Standards for the manufacture of medical gloves for single use require gloves to perform to European standards. [bib_ref] Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus..., Tenorio [/bib_ref] However, the integrity of gloves cannot be guaranteed, and hands may become contaminated during the removal of gloves. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] [bib_ref] Impact of improving glove usage on the hand hygiene compliance, Eveillard [/bib_ref] [bib_ref] Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus..., Tenorio [/bib_ref] The appropriate use of medical gloves provides barrier protection and reduces the risk of hand contamination from blood, body A uids, secretions and excretions, but does not eliminate the risk. Hands cannot be considered to be clean because gloves have been worn, and should be decontaminated following the removal of gloves. Used gloves must be disposed of in accordance with the requirements of current legislation and local policy for waste management. 157

## Sp21
Gloves must be worn for:
- invasive procedures;
- contact with sterile sites and nonintact skin or mucous membranes; - all activities that have been assessed as carrying a risk of exposure to blood or body A uids; and - when handling sharps or contaminated devices.

## Class d/gpp/h&s

## Sp22
Gloves must be:
- worn as single-use items;
- put on immediately before an episode of patient contact or treatment; - removed as soon as the episode is completed; - changed between caring for different patients; and - disposed of into the appropriate waste stream in accordance with local policies for waste management.

## Class d/gpp/h&s

## Sp23
Hands must be decontaminated immediately after gloves have been removed.

## Class d/gpp/h&s

## Making choices
Clinical gloves should be used by healthcare workers to prevent the risk of hand contamination with blood, body A uids, secretions and excretions, and to protect patients from potential cross-contamination of susceptible body sites or invasive devices. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] Having decided that gloves should be used for a healthcare activity, the healthcare worker must make a choice between the use of: - sterile or non-sterile gloves, based on contact with susceptible sites or clinical devices; and - surgical or examination gloves, based on the aspect of care or treatment to be undertaken. Healthcare organisations must provide gloves that conform to European standards (EN455-1, 455-2, 455-3), and which are acceptable to healthcare practitioners.Medical gloves are available in a range of materials, the most common being NRL, which remains the material of choice due to its efA cacy in protecting against bloodborne viruses and properties that enable the wearer to maintain dexterity. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] To determine the effects of gloves stress, type of material (vinyl, nitrile,..., Korniewicz [/bib_ref] Patient or healthcare practitioner sensitivity to NRL proteins must also be taken into account when deciding on glove materials. Synthetic gloves are generally more expensive than NRL gloves and may not be suitable for all purposes. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] Nitrile gloves have the same chemical range as NRL gloves and may also lead to sensitivity problems in healthcare workers and patients. Polythene gloves are not suitable for clinical use due to their permeability and tendency to damage easily. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] A study that compared the performance of nitrile, latex, copolymer and vinyl gloves under stressed and unstressed conditions found that nitrile gloves had the lowest failure rate, suggesting that nitrile gloves are a suitable alternative to NRL gloves, provided that there are no sensitivity issues. Importantly, the study noted variation in performance of the same type of glove produced by different manufacturers. [bib_ref] To determine the effects of gloves stress, type of material (vinyl, nitrile,..., Korniewicz [/bib_ref] The Health and Safety Executive (HSE) also provide a guide-to-glove selection for employers. 147

## Sp24
A range of CE-marked medical and protective gloves that are acceptable to healthcare personnel and suitable for the task must be available in all clinical areas.

## Class d/gpp/h&s

## Sp25
Sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented, and alternatives to natural rubber latex gloves must be available.

## Class d/gpp/h&s

## Aprons or gowns?
National and international guidelines recommend that PPE should be worn by all healthcare workers when close contact with the patient, materials or equipment may lead to contamination of uniforms or other clothing with microorganisms, or when there is a risk of contamination with blood or body A uids. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Disposable plastic aprons are recommended for general clinical use. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Full-body gowns need only be used where there is the possibility of extensive splashing of blood or body A uids, and should be A uid repellent. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] We identiA ed a systematic review of the evidence that microbial contaminants found on the work clothing of healthcare practitioners are a signiA cant factor in cases of HCAI. [bib_ref] Uniform: an evidence review of the microbiological signiA cance of uniforms and..., Wilson [/bib_ref] The reviewers identiA ed seven small-scale studies that described the progressive contamination of work clothing during clinical care, and a further three studies that suggested a link with microbial contamination and infection. [bib_ref] Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications, Boyce [/bib_ref] [bib_ref] Provision and decontamination of uniforms in the NHS, Nye [/bib_ref] [bib_ref] Contamination of nurses' uniforms with Staphylococcus aureus, Speers [/bib_ref] [bib_ref] Contamination of protective clothing and nurses' uniforms in an isolation ward, Babb [/bib_ref] [bib_ref] Bacterial contamination of nurses' uniforms: a study, Callaghan [/bib_ref] [bib_ref] Bacterial contamination of uniforms, Perry [/bib_ref] [bib_ref] Microbial A ora on doctors' white coats, Wong [/bib_ref] [bib_ref] Bacterial A ora on the white coats of medical students, Loh [/bib_ref] [bib_ref] Transfer of Staphylococcus aureus via nurses' uniforms, Hambraeus [/bib_ref] [bib_ref] Bacillus cereus meningitis in two neurosurgical patients: an investigation into the source..., Barrie [/bib_ref] [bib_ref] Contamination of hospital linen by Bacillus cereus, Barrie [/bib_ref] One of the three studies was conducted in a simulated scenario and demonstrated that it was possible to transfer S. aureus from nurses' gowns to patients' bed sheets, but this was not associated with clinical infection. [bib_ref] Transfer of Staphylococcus aureus via nurses' uniforms, Hambraeus [/bib_ref] A further pair of linked studies, associated with an outbreak of Bacillus cereus, showed an epidemiological link between contaminated clothing and HCAI, but this occurred when surgical scrub suits became highly contaminated in an industrial laundry, rather than as a result of clinical care. [bib_ref] Bacillus cereus meningitis in two neurosurgical patients: an investigation into the source..., Barrie [/bib_ref] [bib_ref] Contamination of hospital linen by Bacillus cereus, Barrie [/bib_ref] A further study demonstrated high levels of contamination of gowns, gloves and stethoscopes with VRE following examination of patients known to be infected.A systematic review of eight studies that assessed the effects of gowning by attendants and visitors found no evidence to suggest that over-gowns are effective in reducing mortality, clinical infection or bacterial colonisation in infants admitted to newborn nurseries. [bib_ref] Gowning by attendants and visitors in newborn nurseries for prevention of neonatal..., Webster [/bib_ref] One quasi-experimental study investigated the use of gowns and gloves as opposed to gloves alone for prevention of acquisition of VRE in a medical ICU setting. [bib_ref] To gown or not to gown: the effect on acquisition of vancomycin-resistant..., Puzniak [/bib_ref] A further prospective observational study investigated the use of a similar intervention in a medical ICU. [bib_ref] A prospective study to determine whether cover gowns in addition to gloves..., Srinivasan [/bib_ref] These studies suggested that the use of gloves and gowns may minimise the transmission of VRE when colonisation pressure is high.

## Sp26
Disposable plastic aprons must be worn when close contact with the patient, materials or equipment pose a risk that clothing may become contaminated with pathogenic microorganisms, blood or body A uids.

## Class d/gpp/h&s

## Sp27
Full-body A uid-repellent gowns must be worn where there is a risk of extensive splashing of blood or body A uids on to the skin or clothing of healthcare workers.

## Class d/gpp/h&s

## Sp28
Plastic aprons/A uid-repellent gowns should worn as single-use items for one procedure or episode of patient care, and disposed of into the appropriate waste stream in accordance with local policies for waste management. When used, non-disposable protective clothing should be sent for laundering.

## Class d/gpp/h&s

## When are a face mask, respiratory protection and eye protection necessary?
Healthcare workers (and sometimes patients) may use standard, A uid-repellent surgical face masks to prevent respiratory droplets from the mouth and nose being expelled into the environment. Face masks are also used, often in conjunction with eye protection, to protect the mucous membranes of the wearer from exposure to blood and/or body A uids when splashing may occur. Our previous systematic reviews failed to reveal any robust experimental studies that demonstrated that healthcare workers wearing surgical face masks protected patients from HCAI during routine ward procedures, such as wound dressing or invasive medical procedures. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] Face masks are also used to protect the wearer from inhaling aerosolised droplet nuclei expelled from the respiratory tract. As surgical face masks are not effective at A ltering out such particles, specialised respiratory protective equipment (respirators) may be recommended for the care of patients with certain respiratory diseases [e.g. active multiple drugresistant pulmonary tuberculosis,severe acute respiratory syndrome (SARS) and pandemic inA uenza].The A ltration efA ciency of these respirators will protect the wearer from inhaling small respiratory particles, but to be effective, they must A t closely to the face to minimise leakage around the mask. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] The selection of the most appropriate respiratory protective equipment (RPE) should be based on a suitable risk assessment that includes the task being undertaken, the characteristics of the biological agent to which there is a risk of exposure, as well as the duration of the task and the local environment. Where the activity involves procedures likely to generate aerosols of biological agents transmitted by an airborne route (e.g. intubation), RPE with an assigned protection factor (APF) of 20 (equivalent to FFP3) should be used. In other circumstances, such as where the agent is transmitted via droplet rather than aerosol or where the level of aerosol exposure is low, the risk assessment may conclude that other forms of RPE (e.g. APF10/ FFP2) or a physical barrier (e.g. surgical face mask) may be appropriate, such as when caring for patients with inA uenza. Where RPE is required, it must A t the user properly and the user must be fully trained in how to wear and adjust it. [bib_ref] Respiratory protective equipment at work: a practical guide, Health [/bib_ref] We identiA ed four systematic reviews of the use of facial protection, all of which had been undertaken in the aftermath of the SARS outbreak and in response to the H1N1 inA uenza pandemic. A range of study designs were considered in each of the reviews, including cluster RCTs, RCTs, cohort studies and descriptive before-after studies. Overall, many studies were poorly controlled, with no accounting for confounders, such as poor compliance in the weaker studies. The authors of each of the reviews concluded that there was no strong evidence that masks/respirators alone are effective for the prevention of respiratory viral infections. Masks/respirators should be used together with other protective measures to reduce transmission. [bib_ref] Physical interventions to interrupt or reduce the spread of respiratory viruses, Jefferson [/bib_ref] [bib_ref] Face masks to prevent transmission of inA uenza virus: a systematic review, Cowling [/bib_ref] [bib_ref] Protecting healthcare workers from pandemic inA uenza: N95 or surgical masks?, Gralton [/bib_ref] [bib_ref] The use of masks and respirators to prevent transmission of inA uenza:..., Bin-Reza [/bib_ref] Our previous systematic review indicated that different protective eyewear offered protection against physical splashing of infected substances into the eyes (although not on all occasions), but that compliance was poor. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] Expert opinion recommends that face and eye protection reduce the risk of occupational exposure of healthcare workers to splashes of blood or body A uids. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] SP29
Fluid-repellent surgical face masks and eye protection must be worn where there is a risk of blood or body A uids splashing into the face and eyes.

## Class d/gpp h&s

## Sp30
Appropriate respiratory protective equipment should be selected according to a risk assessment that takes account of the infective microorganism, the anticipated activity and the duration of exposure.

## Class d/gpp/h&s

## Sp31
Respiratory protective equipment must A t the user correctly and they must be trained in how to use and adjust it in accordance with health and safety regulations.

## Class d/gpp/h&s

## Sp32
Personal protective equipment should be removed in the following sequence to minimise the risk of cross/self-contamination: - gloves; - apron; - eye protection (when worn); and - mask/respirator (when worn). Hands must be decontaminated following the removal of personal protective equipment.

## New recommendation class d/gpp/h&s

# Search results
Total number of articles located = AG (867), FP (8160)

## Sift 1 criteria
Abstract indicates that the article: relates to infections associated with protective clothing; is written in English; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

## Articles retrieved
Total number of articles retrieved from Sift 1 = AG (32), FP (25)

## Sift 2 criteria
Full text conA rms that the article: relates to infections associated with protective clothing; is written in English; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions.

## Articles selected for appraisal
Total number of studies selected for appraisal during Sift 2 = AG (6), FP (6)

## Critical appraisal
All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

## Accepted and rejected evidence
Total number of studies accepted after critical appraisal = AG (6), FP (4) Total number of studies rejected after critical appraisal = AG (0), FP (2)

## Safe use and disposal of sharps
This section discusses the evidence and associated recommendations for the safe use and disposal of sharps in general care settings. This includes minimising the potential infection risks associated with sharps use and disposal, and the use of needle protection devices. The use and disposal of sharps is subject to the Health and Safety at Work Act 1974and several elements of health and safety legislation including:Where health and safety legislation underpins a recommendation, this is indicated by 'H&S' in addition to the classiA cation of any clinical evidence underpinning the recommendations.
[formula] - [/formula]

## Sharps injuries -what's the problem?
The HSE deA ne a sharp as a needle, blade or other medical instrument capable of cutting or piercing the skin. [bib_ref] Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Guidance for employers..., Health [/bib_ref] Similarly, a sharps injury is an incident that causes a needle, blade or other medical instrument to penetrate the skin (percutaneous injury). The safe handling and disposal of needles and other sharp instruments forms part of an overall strategy of clinical waste disposal to protect staff, patients and visitors from exposure to bloodborne pathogens.The National Audit OfA ce identiA ed that needlestick and sharps injuries ranked alongside moving and handling, falls, trips and exposure to hazardous substances as the main types of accidents experienced by NHS staff.A later Royal College of Nursing survey of 4407 nurses found that almost half (48%) had, at some point in their career, sustained a sharps injury from a device that had previously been used on a patient. A similar number (52%) reported fearing sharps injuries, and nearly half (45%) reported that they had not received training from their employer on safe needle use.The 2012 'Eye of the Needle' report from the Health Protection Agency conA rms that healthcare workers continue to be exposed to bloodborne virus infections, even though such exposures are largely preventable.The average risk of transmission of bloodborne viruses following a single percutaneous exposure from an infected person, in the absence of appropriate post-exposure prophylaxis, has been estimated to be: [bib_ref] Risk factors for hepatitis C virus transmission to health care workers after..., Yazdanpanah [/bib_ref] - hepatitis B virus, one in three; - hepatitis C virus, one in 30; and - human immunodeA ciency virus, one in 300.

## Avoiding sharps injuries is everybody's responsibility
National and international guidelines are consistent in their recommendations for the safe use and disposal of sharp instruments and needles, and the management of healthcare workers who are exposed to potential infection from bloodborne viruses.As with many infection prevention and control policies, the assessment and management of the risks associated with the use of sharps is paramount, and safe systems of work and engineering controls must be in place to minimise any identiA ed risks.National 184 and European Union 196 legislation requires the UK and all EU member states to provide protection for all healthcare workers exposed to the risk of sharps injuries. In summary, the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 require all employers, under existing health and safety law, to: - conduct risk assessments; - avoid unnecessary use of sharps and, where this is not possible, use safer sharps that incorporate protection mechanisms; - prevent the recapping of needles; - ensure safe disposal by placing secure sharps containers close to the point of use; - provide employees with adequate information and training on the safe use and disposal of sharps, what to do in the event of a sharps injury and the arrangements for testing, immunisation and post-exposure prophylaxis, where appropriate; - record and investigate sharps incidents; and - provide employees who have been injured with access to medical advice, and offer testing, immunisation, post-exposure prophylaxis and counselling, where appropriate. [bib_ref] Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Guidance for employers..., Health [/bib_ref] Legislation also includes a duty for employees who receive a sharps injury whilst undertaking their work to inform their employer as soon as is practicable. [bib_ref] Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Guidance for employers..., Health [/bib_ref] All healthcare workers must be aware of their responsibility in avoiding sharps injuries.
We identiA ed a systematic review which included studies that focused on education and training interventions to minimise the incidence of occupational injuries involving sharps devices.The authors identiA ed A ve primary beforeafter studies that demonstrated a consistent reduction in the incidence of percutaneous injuries when other safety initiatives (e.g. training) were implemented before and during the introduction of safer sharps devices. [bib_ref] Educational programmes and sharps injuries in health care workers, Brusaferro [/bib_ref] [bib_ref] Use of safety devices and the prevention of percutaneous injuries among healthcare..., Valls [/bib_ref] [bib_ref] Impact of safety needle devices on occupationally acquired needlestick injuries: a four-year..., Adams [/bib_ref] [bib_ref] Introducing safety syringes into a UK dental school -a controlled study, Zakrzewska [/bib_ref] [bib_ref] The effectiveness of a training program on reducing needlestick injuries/sharp object injuries..., Yang [/bib_ref] These studies used a range of interventions in one setting and are not generalisable. However, education is essential in ensuring that staff understand safe ways of working and how to use safer sharps devices. This should form a part of induction programmes for new staff and on-going in-service education.
The introduction of new devices should include an appropriate training programme as part of staff introduction.

## Sp33
Sharps must not be passed directly from hand to hand, and handling should be kept to a minimum.

## Class d/gpp/h&s

## Sp34
Needles must not be recapped, bent or disassembled after use.

## Class d/gpp/h&s

## Sp35
Used sharps must be discarded at the point of use by the person generating the waste.

## Class d/gpp/h&s

## Sp36
All sharps containers must:
- conform to current national and international standards; - be positioned safely, away from public areas and out of the reach of children, and at a height that enables safe disposal by all members of staff; - be secured to avoid spillage; - be temporarily closed when not in use;
- not be A lled above the A ll line; and - be disposed of when the A ll line is reached.

## Class d/gpp/h&s

## Sp37
All clinical and non-clinical staff must be educated about the safe use and disposal of sharps and the action to be taken in the event of an injury.

## Class d/gpp/h&s

## Needle protection devices reduce avoidable injuries
To improve patient and staff safety, legislation and the Department of Health require healthcare providers and their employees to pursue safer methods of working through risk assessment to eliminate the use of sharps and, where this is not possible, the use of safer sharps. [bib_ref] Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Guidance for employers..., Health [/bib_ref] The incidence of sharps injuries has led to the development of safety devices in many different product groups.They are designed to minimise the risk of operator injury during sharps use, as well as 'downstream' injuries that occur after disposal, often involving the housekeeping or portering staff responsible for the collection of sharps disposal units.
The lack of well-designed, controlled intervention studies means that evidence to show whether or not safety devices are effective in reducing rates of infection is limited. However, a small number of studies have shown signiA cant reductions in injuries associated with the use of safety devices 2 in cannulation, 206,207 phlebotomy 208-210 and injections. [bib_ref] A comparative user evaluation of three needle-protective devices, Adams [/bib_ref] It is logical that where needle-free or other safety devices are used, there is a resulting reduction in sharps injuries. A review of needlestick injuries in Scotland suggested that 56% of injuries would 'probably' or 'deA nitely' have been prevented if a safety device had been used. [bib_ref] Potential for reported needlestick injury prevention among healthcare workers through safety device..., Cullen [/bib_ref] However, some studies have identiA ed a range of barriers to the expected reduction in injuries, including staff resistance to using new devices, complexity of device operation or improper use, and poor training. [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] A comprehensive report and product review S29 conducted in the USA provides background information and guidance on the need for and use of needlestick-prevention devices, but also gives advice on establishing and evaluating a sharps injury prevention programme.It reported that all devices have limitations in relation to cost, applicability and/or effectiveness. Some of the devices available are more expensive than standard devices, may not be compatible with existing equipment, and may be associated with an increase in bloodstream infection rates if used incorrectly.NICE identiA ed three RCTs that compared safety cannulae with standard cannulae. The studies were all in hospital settings and of low/very-low quality. The quality of evidence for safety needle devices was low, with no RCTs identiA ed and the A ve before-after implementation studies being of very-low quality. The quality of evidence for training was similarly low, with the type of training varying across the A ve observational studies identiA ed.We identiA ed a systematic review undertaken by the HSE which reviewed 41 studies that provided evidence for reductions in the incidence of occupational sharps injuries associated with use of sharps safety devices, education and training, and the acceptability of sharps safety devices.Thirteen studies, predominantly with observational designs, demonstrated that safer sharps devices were associated with a signiA cant reduction in the incidence of healthcare worker needlestick injury. [bib_ref] Use of safety devices and the prevention of percutaneous injuries among healthcare..., Valls [/bib_ref] [bib_ref] Introducing safety syringes into a UK dental school -a controlled study, Zakrzewska [/bib_ref] [bib_ref] A comprehensive approach to percutaneous injury prevention during phlebotomy: results of a..., Alvarado-Ramy [/bib_ref] [bib_ref] Impact of safety devices for preventing percutaneous injuries related to phlebotomy procedures..., Rogues [/bib_ref] [bib_ref] Evaluation of a safety resheathable winged steel needle for prevention of percutaneous..., Mendelson [/bib_ref] [bib_ref] Blunt S57 needles for the reduction of needlestick injuries during cesarean delivery:..., Sullivan [/bib_ref] [bib_ref] A retractable winged steel (butterA y) needle performance improvement project, Hotaling [/bib_ref] [bib_ref] Role of safetyengineered devices in preventing needlestick injuries in 32 French hospitals, Lamontagne [/bib_ref] [bib_ref] Effect of the introduction of an engineered sharps injury prevention device on..., Azar-Cavanagh [/bib_ref] [bib_ref] Safety-engineered device implementation: does it introduce bias in percutaneous injury reporting?, Sohn [/bib_ref] [bib_ref] Guarded A stula needle reduces needlestick injuries in hemodialysis, Mccleary [/bib_ref] [bib_ref] Evaluation of interventions to prevent needlestick injuries in health care occupations, Rogers [/bib_ref] [bib_ref] Assessing the effect of long-term availability of engineering controls on needlestick injuries..., Reddy [/bib_ref] However, safety devices were not the total solution to reducing occupational injury. The beneA cial outcome of consulting with end-users of safer sharps devices before they are introduced was demonstrated in A ve studies identiA ed in this review. [bib_ref] A comprehensive approach to percutaneous injury prevention during phlebotomy: results of a..., Alvarado-Ramy [/bib_ref] [bib_ref] A comparative user evaluation of three needle-protective devices, Adams [/bib_ref] [bib_ref] A prospective randomized trial of two safety peripheral intravenous catheters, Prunet [/bib_ref] [bib_ref] Use of needle safety devices by clinical laboratories in North Carolina hospitals, Bamberg [/bib_ref] [bib_ref] The usability and acceptability of a needleless connector system, Casey [/bib_ref] [bib_ref] Organizational climate, stafA ng, and safety equipment as predictors of needlestick injuries..., Clarke [/bib_ref] In the USA, the Occupational Safety Health Administration and the National Institute for Occupational Safety and Health suggest that a thorough evaluation of any device is essential before purchasing decisions are made.Similarly, the HSE suggests that the end-users of any safer sharps device should be involved in the assessment of user acceptability and clinical applicability of any needle safety devices. [bib_ref] Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Guidance for employers..., Health [/bib_ref] The evaluation should ensure that the safety feature works effectively and reliably, that the device is acceptable to healthcare practitioners and that it does not have an adverse effect on patient care.

## Sp38
Use safer sharps devices where assessment indicates that they will provide safe systems of working for healthcare workers.

## Class c/h&s

## Sp39
Organisations should involve end-users in evaluating safer sharps devices to determine their effectiveness, acceptability to practitioners, impact on patient care and cost beneA t prior to widespread introduction.

## Class d/gpp/h&s

## Sharps -systematic review process
Systematic Review Questions

# Search results
Total number of articles located = 3989

## Sift 1 criteria
Abstract indicates that the article: relates to infections associated with sharps; is written in English, is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

## Articles retrieved
Total number of articles retrieved from Sift 1 = 18

## Sift 2 criteria
Full text conA rms that the article: relates to infections associated with sharps; is written in English; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions.

## Articles selected for appraisal
Total number of studies selected for appraisal during Sift 2 = 2

## Critical appraisal
All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

## Accepted and rejected evidence

## Asepsis
The term 'asepsis' means the absence of potentially pathogenic microorganisms.Asepsis applies to both medical and surgical procedures. Medical asepsis aims to minimise the risk of contamination by microorganisms, and prevent their transmission by applying standard principles of infection prevention, including decontaminating hands, use of PPE, maintaining an aseptic area, and not touching susceptible sites or the surface of invasive devices.Surgical asepsis is a more complex process, including procedures to eliminate microorganisms from an area (thus creating an aseptic environment), and is practised in operating theatres and for invasive procedures, such as the insertion of a central venous catheter (CVC).'Aseptic technique' is a term applied to a set of specifi c practices and procedures used to assure asepsis and prevent the transfer of potentially pathogenic microorganisms to a susceptible site on the body (e.g. an open wound or insertion site for an invasive medical device) or to sterile equipment/devices. It involves ensuring that susceptible body sites and the sterile parts of devices in contact with a susceptible site are not contaminated during the procedure.
The aseptic technique is an essential element of the prevention of HCAI, particularly when the body's natural defence mechanisms are compromised. However, similar to NICE,we identifi ed no clinical or economic evidence that any one approach to the aseptic technique is more clinically or cost-effective than another. Thus, all recommendations here are Class D/GPP.

## Improving the practice of the aseptic technique
No studies that met the inclusion criteria and compared education interventions for improving the aseptic technique generally were identifi ed. We identifi ed one systematic review that assessed education interventions to improve competence in the aseptic insertion and maintenance of CVCs. [bib_ref] What features of educational interventions lead to competence in aseptic insertion and..., Cherry [/bib_ref] The review included 47 studies of educational interventions that were designed to change staff behaviour related to: general asepsis, maximal sterile barrier (MSB) precautions during insertion, cutaneous antisepsis, and other aspects of insertion and maintenance practice. The studies all described multi-modal education approaches alone or combined with demonstration, simulation, video and self-study. Only one of these studies reported improvements in competence with performing the aseptic technique as a discrete outcome, and nine studies measured overall compliance with the total insertion bundle.
Variations in terminology are used in the literature to describe the aseptic technique. Inconsistencies in the use of terms and application of the principles of asepsis in clinical practice have been addressed in a framework referred to as 'aseptic non-touch technique'. [bib_ref] ANTT v2: an updated practice framework for aseptic technique, Rowley [/bib_ref] This provides a practice structure and educational materials aimed at minimising variation and developing competence in practice. [bib_ref] ANTT v2: an updated practice framework for aseptic technique, Rowley [/bib_ref] However, no comparative evidence indicating the effi cacy of this approach was identifi ed.

## Sp40
Organisations should provide education to ensure that healthcare workers are trained and competent in performing the aseptic technique.

## New recommendation class d/gpp

## Sp41
The aseptic technique should be used for any procedure that breaches the body's natural defences, including the: - insertion and maintenance of invasive devices; - infusion of sterile fl uids and medication; and - care of wounds and surgical incisions.

## New recommendation class d/gpp

# Search results

## Total number of articles located = asepsis-uc (55), asepsis-ivad (205)

## Sift 1 criteria
Abstract indicates that the article: relates to infections associated with asepsis; is written in English; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

## Articles retrieved

## Total number of articles retrieved from sift 1 = asepsis-uc (10), asepsis-ivad (25)

## Sift 2 criteria
Full text conA rms that the article: relates to infections associated with asepsis; is written in English; is primary research (randomised controlled trialsRCT), prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions.

## Articles selected for appraisal
Total number of studies selected for appraisal during Sift 2 = 1

## Critical appraisal
All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

## Accepted and rejected evidence
Total number of studies accepted after critical appraisal = 0 Total number of studies rejected after critical appraisal = 1

## Guidelines for preventing infections associated with the use of short-term indwelling urethral catheters

# Introduction
This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. Evidence identiA ed in the Healthcare Infection Control Practices Advisory Committee (HICPAC) systematic review was used to support the recommendations in these guidelines.Some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. These recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. None are regarded as optional.
These guidelines apply to adults and children aged 1 year who require a short-term indwelling urethral catheter (28 days), and should be read in conjunction with the guidance on Standard Principles. The recommendations are divided into six distinct interventions: - assessing the need for catheterisation; - selection of catheter type and system; - catheter insertion; - catheter maintenance; - education of patients, relatives and healthcare workers; and - system interventions for reducing the risk of infection.

## Background and context of the guidelines
Urinary tract infection (UTI) is the most common infection acquired as a result of health care, accounting for 19% of HCAI, with between 43% and 56% of UTIs associated with a urethral catheter. [bib_ref] Four country healthcare associated infection prevalence survey 2006: overview of the results, Smyth [/bib_ref] Catheters predispose to infection because microorganisms are able to bypass natural host mechanisms, such as the urethra and micturition, and gain entry to the bladder.Most microorganisms causing catheterassociated UTI (CAUTI) gain access to the urinary tract either extraluminally or intraluminally. Extraluminal contamination may occur as the catheter is inserted, by contamination of the catheter from healthcare workers' hands or from the patient's own perineal A ora. Extraluminal contamination is also thought to occur from microorganisms ascending from the perineum. Intraluminal contamination occurs by reA ux of microorganisms from a contaminated urine drainage bag. [bib_ref] Preventing catheter-associated urinary tract infections in the intensive care unit, Chenoweth [/bib_ref] The bladder is normally sterile; in the non-catheterised patient, a UTI is usually identiA ed from the symptoms of dysuria and frequency of urination. Patients who develop a UTI with a short-term indwelling urethral catheter in place may not experience these symptoms, and diagnosis may be based on other signs, such as fever or suprapubic or loin tenderness. [bib_ref] Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in..., Johnson [/bib_ref] After a few days of catheterisation, microorganisms may be isolated from urine and, in the absence of any symptoms of UTI, this is called 'bacteriuria'. [bib_ref] A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral..., Warren [/bib_ref] The duration of catheterisation is the dominant risk factor for CAUTI, and virtually all catheterised patients develop bacteriuria within 1 month.For the purpose of these guidelines, a duration of catheterisation of 28 days is considered to be a short-term catheterisation. [bib_ref] Preventing catheter-associated urinary tract infections in the intensive care unit, Chenoweth [/bib_ref] 

## S32

## H. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70
Several factors contribute to the potential development of CAUTI, including the formation of bioA lms and encrustation of the catheter. Bacteria on the catheter surface and drainage bag multiply rapidly, adhering to the surface by excreting extracellular polysaccharides and forming a layer known as a 'bioA lm'. Bacteria within the bioA lm are morphologically and physiologically different from free-living planktonic bacteria in the urine, and have considerable survival advantages as they are protected from the action of antibiotic therapy. [bib_ref] Preventing catheter-associated urinary tract infections in the intensive care unit, Chenoweth [/bib_ref] Whilst bioA lms commonly form on devices inserted into the body, they can cause additional problems on urethral catheters if the bacteria produce the enzyme urease, such as Proteus mirabilis. [bib_ref] Preventing catheter-associated urinary tract infections in the intensive care unit, Chenoweth [/bib_ref] This enzyme causes the urine to become alkaline, inducing crystallisation of calcium and magnesium phosphate within the urine. These crystals are incorporated into the bioA lm and, over time, result in encrustation of the catheter. Encrustation is generally associated with long-term catheterisation, as it has a direct relationship with the length of catheterisation. [bib_ref] Preventing catheter-associated urinary tract infections in the intensive care unit, Chenoweth [/bib_ref] Urinary catheterisation is a frequent intervention during clinical care in hospital, affecting a signiA cant number of patients. It has been estimated that 15-25% of hospitalised patients have a urinary catheter inserted during their stay. [bib_ref] Catheter-associated urinary tract infections, Warren [/bib_ref] [bib_ref] Are physicians aware of which of their patients have indwelling urinary catheters?, Saint [/bib_ref] [bib_ref] Appropriateness of use of indwelling urinary catheters in patients admitted to the..., Munasinghe [/bib_ref] [bib_ref] Overuse of the indwelling urinary tract catheter in hospitalized medical patients, Jain [/bib_ref] This number is much higher in ICUs. [bib_ref] Trends in catheter-associated urinary tract infections in adult intensive care units -United..., Burton [/bib_ref] The risk of infection is associated with the method and duration of catheterisation, the quality of catheter care and patient susceptibility. [bib_ref] Clinical and economic consequences of nosocomial catheter-related bacteriuria, Saint [/bib_ref] Bacteriuria develops in approximately 30% of catheterised patients after 2-10 days, and 24% (95% CI 23-29%) of these will develop symptoms of CAUTI. [bib_ref] Clinical and economic consequences of nosocomial catheter-related bacteriuria, Saint [/bib_ref] Approximately 3.6% (95% CI 3.4-3.8%) of those with CAUTI develop life-threatening secondary infections, such as bacteraemia or sepsis, where mortality rates range from 10% to 33%. [bib_ref] Recognition and prevention of healthcare-associated urinary tract infections in the intensive care..., Shuman [/bib_ref] [bib_ref] Epidemiology of hospital-acquired urinary tract-related bloodstream infection at a university hospital, Chang [/bib_ref] CAUTI is associated with prolonged hospitalisation, re-admission and increased mortality. [bib_ref] Silver alloy vs. uncoated urinary catheters: a systematic review of the literature, Beattie [/bib_ref] Patients at particular risk are those who are immunocompromised, the elderly and patients with diabetes. [bib_ref] Catheter-associated urinary tract infections: new aspects of novel urinary catheters, Ha [/bib_ref] Physical and psychological discomfort associated with insertion, removal and the catheter in situ are common. [bib_ref] A review of strategies to decrease the duration of indwelling urethral catheters..., Bernard [/bib_ref] Complications such as inA ammation, urethral strictures, mechanical trauma, bladder calculi and other infections of the renal system also occur. [bib_ref] Catheter-associated urinary tract infections, Warren [/bib_ref] [bib_ref] Enhancing the safety of critically ill patients by reducing urinary and central..., Saint [/bib_ref] [bib_ref] Comparison of urethral reaction to full silicone, hydrogen-coated and siliconised latex catheters, Talja [/bib_ref] [bib_ref] Effect of catheter material on the incidence of urethral strictures, Robertson [/bib_ref] Urine retention after catheter removal is also a frequent occurrence. [bib_ref] Randomised study of the effect of midnight versus 0600 removal of urinary..., Crowe [/bib_ref] In some instances, especially in older people, CAUTI may contribute to falls and delirium. [bib_ref] The association between indwelling urinary catheter use in the elderly and urinary..., Hazelett [/bib_ref] The treatment of both CAUTI and other infection sequelae contribute to the emerging problem of antibiotic resistance in hospitals, and uropathogens are a major source of infections caused by antimicrobial-resistant organisms. [bib_ref] Aiming to reduce catheter associated urinary tract infections (CAUTI) by adopting a..., Curran [/bib_ref] CAUTI also increases the cost of health care due to delayed discharge from hospital, antimicrobial treatment and staff resources. The A nancial burden of CAUTI on the NHS has been estimated as 99 million per year, with an estimated cost per episode of 1968. [bib_ref] Evidence for the use of silver-alloycoated urethral catheters, Davenport [/bib_ref] [bib_ref] The high impact actions for nursing and midwifery 5: protection from infection, Ward [/bib_ref] However, there are no robust economic assessments of the cost of CAUTI.

## Assessing the need for catheterisation

## Catheters place patients at signia cant risk of acquiring a urinary tract infection. the longer a catheter is in place, the greater the danger
There is a strong association between the duration of catheterisation and the risk of infection (i.e. the longer the catheter is in place, the higher the incidence of UTI). [bib_ref] Clinical and economic consequences of nosocomial catheter-related bacteriuria, Saint [/bib_ref] [bib_ref] Preventing catheter-related bacteriuria: should we? Can we? How?, Saint [/bib_ref] [bib_ref] Epidemiology of urinary tract infections: incidence, morbidity, and economic costs, Foxman [/bib_ref] In acute care facilities, the risk of developing bacteriuria increases 5% for each day of catheterisation. Approximately 24% of bacteriuric patients will develop CAUTI, and of these, up to 4% develop a severe secondary infection such as bloodstream infection. [bib_ref] Clinical and economic consequences of nosocomial catheter-related bacteriuria, Saint [/bib_ref] Current best practice emphasises the importance of documenting all procedures involving the catheter or drainage system in the patient's records, [bib_ref] The high impact actions for nursing and midwifery 5: protection from infection, Ward [/bib_ref] and providing patients with adequate information in relation to the need for catheterisation, details of the insertion, catheter and drainage system, maintenance procedures and plan for removal of the catheter. [bib_ref] The high impact actions for nursing and midwifery 5: protection from infection, Ward [/bib_ref] [bib_ref] Guideline for prevention of catheter-associated urinary tract infections, Wong [/bib_ref] There is some evidence to suggest that computer management systems improve documentation and are associated with reduced duration of catheterisation. 259

## What are the indications for using a short-term indwelling urethral catheter?
Using a short-term indwelling urethral catheter only when necessary after considering alternatives and ensuring the catheter is removed as soon as possible are simple and effective methods to prevent CAUTI. The use of a short-term indwelling urethral catheter may be appropriate in patients with acute urinary retention or obstruction, those who require precise urine output measures to monitor an underlying condition, and patients undergoing certain surgical procedures (especially urological procedures and those of prolonged duration). A short-term indwelling urethral catheter may also be appropriate to minimise discomfort or distress (e.g. during end-of-life care or in the management of open sacral or perineal wounds when the patient is incontinent).However, short-term indwelling urethral catheterisation should not be used as a method of managing urinary incontinence.
While the use of a short-term indwelling urethral catheter is sometimes unavoidable, there is evidence that catheters are inserted without a clear clinical indication, clinicians are not always aware they are in situ, and they are not removed promptly when no longer required. [bib_ref] Are physicians aware of which of their patients have indwelling urinary catheters?, Saint [/bib_ref] [bib_ref] Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary..., Fakih [/bib_ref] Interventions that prompt or facilitate the removal of unnecessary catheters may, therefore, reduce the risk of CAUTI. These interventions have been categorised as reminder systems which prompt clinicians that the catheter is in place and removal should be considered, or stop orders, which indicate that catheters should be removed after a set period of time or when deA ned clinical criteria have been met. [bib_ref] Computerbased order entry decreases duration of indwelling urinary catheterization in hospitalized patients, Cornia [/bib_ref] [bib_ref] Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized..., Loeb [/bib_ref] [bib_ref] Reduction of urinary tract infection and antibiotic use after surgery: a controlled,..., Stephan [/bib_ref] A systematic review of 14 studies (one RCT, one NRCT, three controlled before-after studies and nine uncontrolled beforeafter studies) on reminder and stop order systems found that these interventions signiA cantly decreased the rate of CAUTI and did not increase the need for re-catheterisation, although, as some of the studies were not controlled, they were susceptible to bias in favour of the intervention. 261

## H. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70

## S33
A second systematic review identiA ed a number of uncontrolled before-after studies that used ultrasound bladder scanners to assess for urinary retention and support appropriate catheterisation. [bib_ref] Interventions to minimise the initial use of indwelling urinary catheters in acute..., Murphy [/bib_ref] When used in combination with guidelines, [bib_ref] Non-invasive measurement of bladder volume as an indication for bladder catheterization after..., Slappendel [/bib_ref] insertion checklist/kit, education, audit and feedback, [bib_ref] A collaborative, nurse-driven initiative to reduce hospital-acquired urinary tract infections, Patrizzi [/bib_ref] and reminder/stop orders, [bib_ref] Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians..., Topal [/bib_ref] ultrasound bladder scanners were found to decrease the use of urethral catheters by 5-15%. [bib_ref] Interventions to minimise the initial use of indwelling urinary catheters in acute..., Murphy [/bib_ref] 

## Uc1
Only use a short-term indwelling urethral catheter in patients for whom it is clinically indicated, following assessment of alternative methods and discussion with the patient.

## Class d/gpp
UC2 Document the clinical indication(s) for catheterisation, date of insertion, expected duration, type of catheter and drainage system, and planned date of removal.

## Class d/gpp

## Uc3
Assess and record the reasons for catheterisation every day. Remove the catheter when no longer clinically indicated.

## Class d/gpp

## Selection of catheter type

## Is one catheter better than another?
Evidence from best practice indicates that the incidence of CAUTI in patients catheterised for a short time (up to 1 week) is not inA uenced by any particular type of catheter material. [bib_ref] Continence clinic. Catheters: design, selection and management, Pomfret [/bib_ref] However, many practitioners have strong preferences for one type of catheter over another. This preference is often based on clinical experience, patient assessment and materials that induce the least allergic response. Smaller gauge catheters with a 10-mL balloon minimise urethral trauma, mucosal irritation and residual urine in the bladder; all factors that predispose to CAUTI. [bib_ref] Prevention of catheter-associated urinary tract infections, Dieckhaus [/bib_ref] [bib_ref] Study of patients with indwelling catheters, Roe [/bib_ref] There is also a risk of urethral trauma associated with using a female length catheter in a male patient, and systems should be in place to ensure that this does not occur.However, in adults that have recently undergone urological surgery, larger gauge catheters may be indicated to allow for the passage of blood clots. Our previous evidence-based guidelines 1 identiA ed three experimental studies that compared the use of latex with silicone catheters, which found no signiA cant difference in the incidence of bacteriuria. [bib_ref] Comparison of urethral reaction to full silicone, hydrogen-coated and siliconised latex catheters, Talja [/bib_ref] [bib_ref] Effect of a siliconized latex urinary catheter on bacterial adherence and human..., Lopez-Lopez [/bib_ref] [bib_ref] Incidence and importance of bacteriuria in postoperative, short-term urinary catheterization, Nickel [/bib_ref] We identiA ed one new systematic review which included three trials that compared different types of standard (nonantiseptic-/non-antimicrobial-impregnated) catheters. These studies did not provide sufA cient evidence to suggest that one type of catheter may be more effective than another for the prevention of bacteriuria. [bib_ref] Incidence and importance of bacteriuria in postoperative, short-term urinary catheterization, Nickel [/bib_ref] [bib_ref] Types of urethral catheters for management of short-term voiding problems in hospitalized..., Schumm [/bib_ref] [bib_ref] A controlled trial of a new material for coating urinary catheters, Chene [/bib_ref] [bib_ref] Comparison of hydrophilic polymer-coated latex, uncoated latex and PVC indwelling balloon catheters..., Tidd [/bib_ref] In our previous systematic review, [bib_ref] The epic project: updating the evidence base for national evidence-based guidelines for..., Pellowe [/bib_ref] we found evidence related to the efA cacy of using short-term indwelling urethral catheters coated or impregnated with antiseptic or antimicrobial agents from four systematic reviews and one meta-analysis. In general, all of these A ve studies suggested that antiseptic-impregnated or antimicrobial-coated shortterm indwelling urethral catheters can signiA cantly prevent or delay the onset of CAUTI compared with standard untreated urinary catheters. [bib_ref] Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in..., Johnson [/bib_ref] [bib_ref] Types of urethral catheters for management of short-term voiding problems in hospitalised..., Brosnahan [/bib_ref] [bib_ref] The efA cacy of silver alloy-coated urinary catheters in preventing urinary tract..., Saint [/bib_ref] [bib_ref] Management of short term indwelling urethral catheters to prevent urinary tract infections...., Dunn [/bib_ref] [bib_ref] Is there evidence for recommending silver-coated urinary catheters in guidelines?, Niel-Weise [/bib_ref] The consensus in these A ve reviews of evidence, however, is that the individual studies reviewed are generally of poor quality; for instance, in one case, only eight studies out of 117 met the inclusion criteria, [bib_ref] The efA cacy of silver alloy-coated urinary catheters in preventing urinary tract..., Saint [/bib_ref] and in another, of the six reports describing seven trials included, only one scored A ve in the quality assessment. The other A ve reports only scored one. [bib_ref] Is there evidence for recommending silver-coated urinary catheters in guidelines?, Niel-Weise [/bib_ref] The studies included in these reviews investigated a wide range of coated or impregnated catheters, including catheters coated or impregnated with: silver alloy, [bib_ref] Types of urethral catheters for management of short-term voiding problems in hospitalised..., Brosnahan [/bib_ref] [bib_ref] The efA cacy of silver alloy-coated urinary catheters in preventing urinary tract..., Saint [/bib_ref] [bib_ref] Is there evidence for recommending silver-coated urinary catheters in guidelines?, Niel-Weise [/bib_ref] [bib_ref] Clinical application of the Bardex IC Foley catheter, Verleyen [/bib_ref] [bib_ref] A randomized crossover study of silver-coated urinary catheters in hospitalized patients, Karchmer [/bib_ref] [bib_ref] The potential clinical and economic beneA ts of silver alloy urinary catheters..., Saint [/bib_ref] [bib_ref] A comparison of the effect of early insertion of standard latex and..., Newton [/bib_ref] [bib_ref] Using silver to reduce catheter-associated urinary tract infections, Gentry [/bib_ref] [bib_ref] The impact of using silver alloy urinary catheters in reducing the incidence..., Madeo [/bib_ref] [bib_ref] Effect of silver-coated urinary catheters: efA cacy, cost-effectiveness, and antimicrobial resistance, Rupp [/bib_ref] silver oxide, [bib_ref] The efA cacy of silver alloy-coated urinary catheters in preventing urinary tract..., Saint [/bib_ref] gendine, [bib_ref] A rapid method of impregnating endotracheal tubes and urinary catheters with gendine:..., Chaiban [/bib_ref] gentamicin, 291 silverhydrogel, 292-294 minocycline, [bib_ref] Evaluation of the antimicrobial efA cacy of urinary catheters impregnated with antiseptics..., Gaonkar [/bib_ref] rifampicin, [bib_ref] EfA cacy of antimicrobialimpregnated bladder catheters in reducing catheter-associated bacteriuria: a prospective,..., Darouiche [/bib_ref] chlorhexidinesilver-sulfadiazine, [bib_ref] Evaluation of the antimicrobial efA cacy of urinary catheters impregnated with antiseptics..., Gaonkar [/bib_ref] chlorhexideine-sulfadiazine-triclosan, [bib_ref] Evaluation of the antimicrobial efA cacy of urinary catheters impregnated with antiseptics..., Gaonkar [/bib_ref] nitrofurazone 294 and nitrofuroxone. [bib_ref] Assessment of nosocomial urinary tract infections in orthopaedic patients: a prospective and..., Al-Habdan [/bib_ref] Four studies compared the use of silver-coated (silver alloy or silver oxide) catheters with silicone, hydrogel or TeA on  latex. 297-300 A systematic review and meta-analysis of these and other studies found that silver-alloy-coated (but not silver-oxide-coated) catheters were associated with a lower incidence of bacteriuria. [bib_ref] Preventing catheter-related bacteriuria: should we? Can we? How?, Saint [/bib_ref] [bib_ref] The efA cacy of silver alloy-coated urinary catheters in preventing urinary tract..., Saint [/bib_ref] Despite their unit cost, these devices may provide a costeffective option if overall numbers of infections are reduced signiA cantly through their use. However, the few studies that have explored the cost-beneA t/cost-effectiveness of using these devices have been inconclusive. [bib_ref] The potential clinical and economic beneA ts of silver alloy urinary catheters..., Saint [/bib_ref] [bib_ref] Using silver to reduce catheter-associated urinary tract infections, Gentry [/bib_ref] [bib_ref] Effect of silver-coated urinary catheters: efA cacy, cost-effectiveness, and antimicrobial resistance, Rupp [/bib_ref] [bib_ref] Gentamicin-releasing urethral catheter for short-term catheterization, Cho [/bib_ref] We identiA ed two new systematic reviews of the efA cacy of silver-coated or antimicrobial-impregnated catheters for the prevention of CAUTI. [bib_ref] Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in..., Johnson [/bib_ref] [bib_ref] Types of urethral catheters for management of short-term voiding problems in hospitalized..., Schumm [/bib_ref] The A rst systematic review included 22 RCTs, as well as one NRCT, and concluded that silver-coated (alloy or oxide) short-term indwelling urethral catheters reduced the risk of bacteriuria but did not demonstrate an effect on CAUTI. [bib_ref] Types of urethral catheters for management of short-term voiding problems in hospitalized..., Schumm [/bib_ref] Catheters impregnated with antimicrobial agents (minocycline, rifampicin or nitrofurazone) were found to reduce the rate of bacteriuria during the A rst week of catheterisation, but not for catheter durations exceeding 1 week. Although antimicrobial-impregnated catheters reduced the risk of CAUTI, the number of cases was too small to demonstrate a signiA cant effect. The second systematic review, which included nine RCTs and three quasi-experimental studies, concluded that, compared with standard catheters, both nitrofurazone-impregnated and silver-alloy-coated catheters can prevent and delay the onset of bacteriuria during short-term use. However, there were no data on the risk of CAUTI. [bib_ref] Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in..., Johnson [/bib_ref] We identiA ed one multi-centre RCT that compared silveralloy-coated and nitrofurazone-impregnated catheters with standard TeA on-coated latex for short-term catheterisation. [bib_ref] Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring..., Pickard [/bib_ref] Although the nitrofurazone-impregnated and silver-alloycoated catheters were associated with a reduced risk of CAUTI compared with the TeA on-coated latex, the effect was not considered to be clinically effective (adjusted OR 0.81, 95% CI 0.66-1.01 and adjusted OR 0.96, 95% CI 0.78-1.19, respectively). The nitrofurazone-impregnated catheter, but not the silver-alloy-coated catheter, was associated with a signiA cantly lower incidence of bacteriuria (OR 0.68, 95% CI 0.48-0.99, p=0.017). However, the nitrofurazone-impregnated catheter was associated with increased discomfort during the period the catheter was in place. A major limitation of this study was that the median duration of catheterisation was 2 S34 H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1-S70 days (range 1-3 days) and the risk of CAUTI associated with this short period is correspondingly low. Also, UTIs developing up to 6 weeks post randomisation were included in the outcome measurement, even though they may not have been directly associated with catheterisation. The economic analysis suggested that nitrofurazone-impregnated catheters, but not silver-alloy-coated catheters, may be cost-effective, but the measures of cost were associated with a large amount of uncertainty.
Overall, the evidence suggests that silver-coated urethral catheters reduce the risk of bacteriuria, but there is insufA cient evidence to indicate whether they reduce the risk of CAUTI in short-term catheterised patients.

## Uc4
Assess patient's needs prior to catheterisation in terms of: - latex allergy;
- length of catheter (standard, female, paediatric); - type of sterile drainage bag and sampling port (urometer, 2-L bag, leg bag) or catheter valve; and - comfort and dignity.

## New recommendation class d/gpp

## Uc5
Select a catheter that minimises urethral trauma, irritation and patient discomfort, and is appropriate for the anticipated duration of catheterisation.

## Class d/gpp
UC6 Select the smallest gauge catheter that will allow urinary outA ow and use a 10-mL retention balloon in adults (follow manufacturer's instructions for paediatric catheters). Urological patients may require larger gauge sizes and balloons.

## Class d/gpp

## Catheter insertion

## What technique should be used to insert a catheter?
In our previous review, 2 we found evidence from one systematic review which suggested that the use of the aseptic technique has not demonstrated a reduction in the rate of CAUTI. [bib_ref] Management of short term indwelling urethral catheters to prevent urinary tract infections...., Dunn [/bib_ref] However, principles of good practice, clinical guidance [bib_ref] Guideline for prevention of catheter-associated urinary tract infections, Wong [/bib_ref] and expert opinion, [bib_ref] Prevention of catheter-associated urinary tract infections, Dieckhaus [/bib_ref] [bib_ref] Entry of bacteria into the urinary tracts of patients with inlying catheters, Kass [/bib_ref] [bib_ref] Technical advances in the prevention of urinary tract infection, Desautels [/bib_ref] [bib_ref] Prevention of catheter-induced urinary-tract infections by sterile closed drainage, Kunin [/bib_ref] [bib_ref] Factors predisposing to bacteriuria during indwelling urethral catheterization, Garibaldi [/bib_ref] together with A ndings from another systematic review, [bib_ref] Preventing catheter-related bacteriuria: should we? Can we? How?, Saint [/bib_ref] agree that shortterm indwelling urethral catheters must be inserted using sterile equipment and the aseptic technique.
Expert opinion indicates that there is no advantage in using antiseptic preparations for cleansing the urethral meatus prior to catheter insertion. [bib_ref] Guideline for prevention of catheter-associated urinary tract infections, Wong [/bib_ref] [bib_ref] Prevention of catheter-associated urinary tract infections, Dieckhaus [/bib_ref] Whilst there is low-quality evidence to suggest that pre-lubrication of the catheter decreases the risk of bacteriuria, it is also important to use lubricant or anaesthetic gel in order to minimise urethral trauma and discomfort.There is no evidence suggesting a general beneA t of securing the catheter in terms of preventing the risk of CAUTI, but it is important in order to minimise patient discomfort.Ensuring healthcare practitioners are trained and competent in the insertion of short-term indwelling urethral catheters will minimise trauma, discomfort and the potential for CAUTI. [bib_ref] Prevention of catheter-associated urinary tract infections, Dieckhaus [/bib_ref] [bib_ref] Prevention of catheter-induced urinary-tract infections by sterile closed drainage, Kunin [/bib_ref] [bib_ref] Factors predisposing to bacteriuria during indwelling urethral catheterization, Garibaldi [/bib_ref] Neither we nor HICPAC identiA ed any additional evidence of acceptable quality whilst updating our systematic review.

## Uc7
Catheterisation is an aseptic procedure and should only be undertaken by healthcare workers trained and competent in this procedure.

## Class d/gpp
UC8 Clean the urethral meatus with sterile, normal saline prior to the insertion of the catheter.

## Class d/gpp
UC9 Use lubricant from a sterile singleuse container to minimise urethral discomfort, trauma and the risk of infection. Ensure the catheter is secured comfortably.

## Class d/gpp

## Catheter maintenance

## How should the drainage system be managed?
Maintaining a sterile, continuously closed urinary drainage system is central to the prevention of CAUTI. [bib_ref] Guideline for prevention of catheter-associated urinary tract infections, Wong [/bib_ref] [bib_ref] Prevention of catheter-associated urinary tract infections, Dieckhaus [/bib_ref] [bib_ref] Prevention of catheter-induced urinary-tract infections by sterile closed drainage, Kunin [/bib_ref] [bib_ref] Bacteriuria during indwelling catheter drainage: II. Effect of a closed sterile draining..., Thornton [/bib_ref] [bib_ref] Does the addition of disinfectant to urine drainage bags prevent infection in..., Gillespie [/bib_ref] The risk of infection reduces from 97% with an open system to 8-15% when a sterile closed system is employed. [bib_ref] Factors predisposing to bacteriuria during indwelling urethral catheterization, Garibaldi [/bib_ref] [bib_ref] Prevention of urinary tract infection in gynaecology, Gillespie [/bib_ref] Breaches in the closed system, such as unnecessary emptying, changing of the urinary drainage bag or taking a urine sample, will increase the risk of CAUTI and therefore should be avoided. [bib_ref] Reduction of mortality associated with nosocomial urinary tract infection, Platt [/bib_ref] Hands must be decontaminated, and clean and non-sterile gloves should be worn before manipulation of the catheter or the closed system, including drainage taps. A systematic review has suggested that sealed (e.g. taped, pre-sealed) drainage systems contribute to preventing bacteriuria. [bib_ref] Management of short term indwelling urethral catheters to prevent urinary tract infections...., Dunn [/bib_ref] However, there is limited evidence regarding how often catheter bags should be changed. One study showed that higher rates of symptomatic and asymptomatic CAUTI were associated with a 3-day urinary drainage bag change regimen compared with no routine change regimen. [bib_ref] Incidence of urinary tract infections in patients with short-term indwelling urethral catheters:..., Keerasuntonpong [/bib_ref] Best practice suggests that drainage bags should only be changed when necessary (i.e. according either to the manufacturer's recommendations or the patient's clinical need). [bib_ref] Guideline for prevention of catheter-associated urinary tract infections, Wong [/bib_ref] ReA ux of urine is associated with infection and, consequently, drainage bags should be positioned in a way that ensures the free A ow of urine and prevents back-A ow. [bib_ref] Prevention of catheter-associated urinary tract infections, Dieckhaus [/bib_ref] It is also recommended that urinary drainage bags should be hung on an appropriate stand that prevents contact with the A oor.A number of studies have investigated the addition of disinfectants and antimicrobials to drainage bags as a way of preventing CAUTI. [bib_ref] Preventing catheter-related bacteriuria: should we? Can we? How?, Saint [/bib_ref] Three acceptable studies 313-315 from our original systematic review 1 demonstrated no reduction in the incidence of bacteriuria following the addition of hydrogen peroxide or chlorhexidine to urinary drainage bags. These A ndings are supported by a further systematic review, which suggested that adding bacterial solutions to drainage bags had no effect on catheter-associated infection. 281

## H. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70

## S35
Neither we nor HICPAC identiA ed any additional evidence of acceptable quality whilst updating our systematic review.UC10 Connect a short-term indwelling urethral catheter to a sterile closed urinary drainage system with a sampling port.

## Class a
UC11 Do not break the connection between the catheter and the urinary drainage system unless clinically indicated.

## Class a
UC12 Change short-term indwelling urethral catheters and/or drainage bags when clinically indicated and in line with the manufacturer's recommendations.

## New recommendation class d/gpp
UC13 Decontaminate hands and wear a new pair of clean non-sterile gloves before manipulating each patient's catheter. Decontaminate hands immediately following the removal of gloves.

## Class d/gpp
UC14 Use the sampling port and the aseptic technique to obtain a catheter sample of urine.

## Class d/gpp
UC15 Position the urinary drainage bag below the level of the bladder on a stand that prevents contact with the A oor.

## Class d/gpp
UC16 Do not allow the urinary drainage bag to A ll beyond three-quarters full.

## Class d/gpp
UC17 Use a separate, clean container for each patient and avoid contact between the urinary drainage tap and the container when emptying the drainage bag.

## Class d/gpp
UC18 Do not add antiseptic or antimicrobial solutions to urinary drainage bags.

## Class a

## Routine meatal cleansing with antiseptic solutions is unnecessary
Our previous systematic reviews 1,2 found eight acceptable studies that compared meatal cleansing with a variety of antiseptic/antimicrobial agents or soap and water. No reduction in bacteriuria was demonstrated when using any of these preparations for meatal/peri-urethral hygiene compared with routine bathing or showering. [bib_ref] Management of short term indwelling urethral catheters to prevent urinary tract infections...., Dunn [/bib_ref] [bib_ref] Prevention of bacteriuria in female patients with indwelling catheters, Cleland [/bib_ref] [bib_ref] Prevention of catheter-associated urinary tract infections. EfA cacy of daily meatal care..., Burke [/bib_ref] [bib_ref] Evaluation of daily meatal care with poly-antibiotic ointment in prevention of urinary..., Burke [/bib_ref] [bib_ref] Prevention of catheter-associated bacteriuria: clinical trial of methods to block three known..., Classen [/bib_ref] [bib_ref] Daily meatal care for prevention of catheter-associated bacteriuria: results using frequent applications..., Classen [/bib_ref] [bib_ref] Randomized trial of meatal care with silver sulfadiazine cream for the prevention..., Huth [/bib_ref] [bib_ref] Water or antiseptic for periurethral cleaning before urinary catheterization: a randomized controlled..., Webster [/bib_ref] Expert opinion and other systematic reviews support the view that active meatal cleansing is not necessary and may increase the risk of infection. [bib_ref] Preventing catheter-related bacteriuria: should we? Can we? How?, Saint [/bib_ref] [bib_ref] Guideline for prevention of catheter-associated urinary tract infections, Wong [/bib_ref] [bib_ref] Prevention of catheter-associated urinary tract infections, Dieckhaus [/bib_ref] Daily routine bathing or showering is all that is needed in order to maintain patient comfort.
Neither we nor HICPAC identiA ed any additional evidence of acceptable quality whilst updating our systematic review.UC19 Routine daily personal hygiene is all that is required for meatal cleansing.

## Class a

## Irrigation, instillation and washout do not prevent infection
Evidence from our previous systematic review did not demonstrate any beneA cial effect of bladder irrigation, instillation or washout with a variety of antiseptic or antimicrobial agents for the prevention of CAUTI. [bib_ref] The epic project: developing national evidence-based guidelines for preventing healthcare associated infections...., Pratt [/bib_ref] [bib_ref] National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England, Pratt [/bib_ref] [bib_ref] Does instillation of chlorhexidine into the bladder of catheterized geriatric patients help..., Davies [/bib_ref] [bib_ref] Bladder irrigation with chlorhexidine for the prevention of urinary infection after transurethral..., Ball [/bib_ref] [bib_ref] Controlled trial of intravesical noxythiolin in the prevention of infection following outA..., Jones [/bib_ref] [bib_ref] A randomized study on the effect of bladder irrigation with povidone-iodine before..., Schneeberger [/bib_ref] [bib_ref] Antibiotic irrigation and catheter-associated urinary-tract infections, Warren [/bib_ref] [bib_ref] Once-daily irrigation of long-term urethral catheters with normal saline. Lack of beneA..., Muncie [/bib_ref] [bib_ref] Assessment of the use of bladder washouts/instillations in patients with long-term indwelling..., Kennedy [/bib_ref] [bib_ref] Neomycin-polymyxin prophylaxis of urinary-tract infection associated with indwelling catheters, Cox [/bib_ref] [bib_ref] The use of bladder wash-outs to reduce urinary catheter encrustation, Getliffe [/bib_ref] Evidence from best practice supports these A ndings of no beneA cial effect, and indicates that the introduction of such bladder maintenance solutions may have local toxic effects and contribute to the development of resistant microorganisms. However, continuous or intermittent bladder irrigation may be required for other urological or catheter management indications. [bib_ref] Preventing catheter-related bacteriuria: should we? Can we? How?, Saint [/bib_ref] 

## Education of patients, relatives and healthcare workers
Given the frequency of urinary catheterisation in hospital patients and the associated risk of UTI, it is important that patients, their relatives and healthcare workers responsible for catheter insertion and management are educated about infection prevention. All those involved must be aware of the signs and symptoms of UTI and how to access expert help when difA culties arise. Healthcare professionals must be conA dent and proA cient in associated procedures.
We identiA ed two systematic reviews that reported evidence of the efA cacy of healthcare workers' education in reducing the risk of CAUTI within other system interventions. [bib_ref] Interventions to minimise the initial use of indwelling urinary catheters in acute..., Murphy [/bib_ref] Most of the studies included in these reviews provided lowgrade evidence from uncontrolled before-after studies where a combination of different system interventions focusing on reducing the use of urethral catheters and risk of CAUTI were introduced. The A rst systematic review [bib_ref] Interventions to minimise the initial use of indwelling urinary catheters in acute..., Murphy [/bib_ref] identiA ed one small controlled before-after study [bib_ref] Reduction of urinary tract infection and antibiotic use after surgery: a controlled,..., Stephan [/bib_ref] of an educational intervention with guideline change and posters that was associated with a reduction in use of urethral catheters [relative risk (RR) 0.86, 95% CI 0.68-1.10]. Another systematic review included one controlled before-after study that demonstrated a signiA cant (p<0.01) increase in adherence to a clinical guideline on the insertion and maintenance of urethral catheters in association with an education programme. [bib_ref] Evaluating the efA cacy of the infection control liaison nurse in the..., Ching [/bib_ref] A further study reported a reduction in CAUTI and an increase in adherence to protocols for hand hygiene and catheter care in association with an education programme. However, this study did not include a control group. 100 UC21 Healthcare workers should be trained and competent in the appropriate use, selection, insertion, maintenance and removal of short-term indwelling urethral catheters.

## Class d/gpp
UC22 Ensure patients, relatives and carers are given information regarding the reason for the catheter and the plan for review and removal. If discharged with a catheter, the patient should be given written information and shown how to:
- manage the catheter and drainage system; - minimise the risk of urinary tract infection; and - obtain additional supplies suitable for individual needs.

## Class d/gpp

## System interventions for reducing the risk of infection
A number of studies have reported the effect of quality improvement programmes on the risk of CAUTI.The components of these programmes include various combinations of clinical guidelines for catheter insertion and maintenance, education, audit and feedback of compliance with policy, physician/nurse reminder systems (to prompt removal if no longer necessary), automated or nurse-driven removal protocols [where the catheter is removed after a speciA ed period (e.g. 48-72 h) unless countermanded by the physician] and the use of bladder scanners to assess urinary retention and support appropriate catheterisation.We identiA ed three systematic reviews relevant to this question. [bib_ref] Interventions to minimise the initial use of indwelling urinary catheters in acute..., Murphy [/bib_ref] The A rst was a review of interventions to remind physicians/nurses to remove unnecessary catheters and the outcome on CAUTI, short-term indwelling urethral catheter use and catheter replacement. It included 14 studies (one RCT, one NRCT, three controlled before-after studies and nine uncontrolled before-after studies).Interventions included prewritten or computer-generated stop orders, nurse-generated daily bedside reminders to remove catheters, and daily use of a checklist or protocol to review need for the catheter. Some studies also implemented catheter placement restrictions and education. The meta-analysis suggested that the use of reminder or stop order systems reduced the rate of CAUTI by 52% (p<0.001) and the mean duration of catheterisation by 37%, with 2.61 fewer days of catheterisation in the intervention group compared with the control group, and no difference in re-catheterisation rates.
The second systematic review was a review of interventions to minimise the placement of urethral catheters in acute care patients. [bib_ref] Interventions to minimise the initial use of indwelling urinary catheters in acute..., Murphy [/bib_ref] It included one RCT, one NRCT and six uncontrolled before-after studies. Interventions included various combinations of clinician reminders, stop orders and indication checklists, use of bladder scanners and education. The authors concluded that the studies were too small and heterogeneous to draw a deA nitive conclusion about efA cacy in terms of reducing inappropriate catheter placement.
The third systematic review included three controlled before-after studies and seven uncontrolled before-after studies measuring interventions that increased adherence to catheter care protocols or reduced unnecessary catheter use.Interventions included reminders, stop orders, use of bladder scanners, education and catheterisation protocols with audit and feedback on performance. Physician/nurse reminders, particularly automatic stop orders, were found to reduce the duration of catheterisation, although there were insufA cient data to determine their effect on CAUTI.
Many studies in this area are uncontrolled before-after designs and therefore susceptible to bias in favour of the intervention. However, these interventions constitute best practice, and this evidence supports the use of systems to minimise the insertion of catheters and promote timely removal to reduce both the duration of catheterisation and the risk of CAUTI.

## H. p. loveday et al. / journal of hospital infection 86s1 (2014) s1-s70
S37 UC23 Use quality improvement systems to support the appropriate use and management of short-term urethral catheters and ensure their timely removal. These may include:
- protocols for catheter insertion;
- use of bladder ultrasound scanners to assess and manage urinary retention; - reminders to review the continuing use or prompt the removal of catheters; - audit and feedback of compliance with practice guidelines; and - continuing professional education.

## New recommendation class d/gpp
UC24 No patient should be discharged or transferred with a short-term indwelling urethral catheter without a plan documenting the: - reason for the catheter;
- clinical indications for continuing catheterisation; and - date for removal or review by an appropriate clinician overseeing their care.

## New recommendation class d/gpp

## Short-term indwelling urethral catheters -systematic review process
Systematic Review Questions 1. What are the clinical indications for the use of short-term urinary catheters?(*B) 2. What is the risk associated with short-term catheterisation in terms of bacteriuria, CAUTI, other morbidities and mortality? (B) 3. What is the effectiveness (in terms of patient acceptability and reduced risk of bacteriuria, CAUTI, other morbidities and mortality) and the cost-effectiveness of different types of short-term indwelling urinary catheters (material, coatings and design)? 4. What is the most effective catheter insertion technique in terms of patient acceptability and minimisation of urethral trauma, bacteriuria, CAUTI and other morbidities? 5. What is the most effective and cost-effective means of maintaining meatal hygiene and a closed drainage system? 6. What is the effectiveness of system interventions in reducing the use and duration of short-term urinary catheterisation to minimise the risk of bacteriuria, CAUTI, other morbidities and mortality? 7. What is the effectiveness of system interventions in improving healthcare workers' knowledge and behaviour relating to the insertion, maintenance and timely removal of indwelling urinary catheters to minimise the risk of bacteriuria, CAUTI, other morbidities and mortality?

# Search results
Total number of articles located = 7073

## Sift 1 criteria
Abstract indicates that the article: relates to infections associated with short-term indwelling urethral catheters; is written in English; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

## Articles retrieved
Total number of articles retrieved from Sift 1 = 54

## Sift 2 criteria
Full text conA rms that the article: relates to infections associated with short-term indwelling urethral catheters; is written in English; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasiexperimental), a systematic review or a meta-analysis including the above designs; and informs one or more of the review questions.

## Articles selected for appraisal
Total number of studies selected for appraisal during Sift 2 = 16

## Critical appraisal
All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

## Accepted and rejected evidence

## Guidelines for preventing infections associated with the use of intravascular access devices

# Introduction
This guidance is based on the best critically appraised evidence currently available. The type and class of supporting evidence explicitly linked to each recommendation is described. Evidence identiA ed in the HICPAC systematic review was used to support the recommendations in these guidelines. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] Some recommendations from the previous guidelines have been revised to improve clarity; where a new recommendation has been made, this is indicated in the text. These recommendations are not detailed procedural protocols, and need to be incorporated into local guidelines. None are regarded as optional.

## Background and context to the guidelines
Intravascular access devices, including peripheral, central venous and arterial catheters, are commonly used in the management of patients in acute and chronic care settings. CVCs are frequently used during clinical care and include peripherally inserted, non-tunnelled and tunnelled, and totally implantable CVCs [fig_ref] Table 3: Catheters used for venous and arterial access [/fig_ref]. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] The use of any of these catheters can result in bloodstream infection.
Catheter-related bloodstream infections (CR-BSI) associated with the insertion and maintenance of CVCs are potentially among the most dangerous complications associated with health care. [bib_ref] Four country healthcare associated infection prevalence survey 2006: overview of the results, Smyth [/bib_ref] [bib_ref] Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra..., Pittet [/bib_ref] In the most recent national prevalence survey, the Health Protection Agency reported that the prevalence of BSI was 0.5%, accounting for 7.3% of the HCAI detected; 64% of BSI occurred in patients with a vascular access device.A previous point prevalence survey reported that the prevalence of BSI was 0.85%, accounting for 7% of the HCAI detected; of these, 70% were primary CR-BSI. [bib_ref] Four country healthcare associated infection prevalence survey 2006: overview of the results, Smyth [/bib_ref] Peripheral venous catheters (PVCs) cause phlebitis in some patients, with studies indicating mean rates of 7-27%, [bib_ref] Is routine replacement of peripheral intravenous catheters necessary?, Bregenzer [/bib_ref] [bib_ref] Peripheral TeA on catheters: factors determining incidence of phlebitis and duration of..., Cornely [/bib_ref] [bib_ref] Phlebitis rate and time kinetics of short peripheral IV catheters, Grune [/bib_ref] [bib_ref] Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled..., Rickard [/bib_ref] but evidence suggests that these devices are less frequently associated with CR-BSI. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] [bib_ref] Is routine replacement of peripheral intravenous catheters necessary?, Bregenzer [/bib_ref] [bib_ref] Peripheral TeA on catheters: factors determining incidence of phlebitis and duration of..., Cornely [/bib_ref] [bib_ref] Phlebitis rate and time kinetics of short peripheral IV catheters, Grune [/bib_ref] [bib_ref] Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled..., Rickard [/bib_ref] [bib_ref] The risk of bloodstream infection in adults with different intravascular devices: a..., Maki [/bib_ref] CR-BSI involves the presence of systemic infection and evidence implicating the intravascular catheter as its source (i.e. the isolation of the same microorganism from blood cultures as that shown to be signiA cantly colonising the intravascular catheter). [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] [bib_ref] Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra..., Pittet [/bib_ref] Catheter colonisation refers to the growth of microorganisms on either the endoluminal or the external catheter surface beneath the skin in the absence of systemic infection. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] [bib_ref] Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra..., Pittet [/bib_ref] The microorganisms that colonise catheter hubs and the skin adjacent to the insertion site are the source of most CR-BSI. Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the microorganisms most frequently implicated in CR-BSI. Other microorganisms commonly involved include S. aureus, Candida species and enterococci. [bib_ref] Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a..., Wisplinghoff [/bib_ref] [bib_ref] National Nosocomial Infections Surveillance System. Overview of nosocomial infections caused by Gram-negative..., Gaynes [/bib_ref] [bib_ref] The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters, Safdar [/bib_ref] CR-BSI is generally caused either by skin microorganisms at the insertion site, which contaminate the catheter during insertion and migrate along the cutaneous catheter track after insertion, [bib_ref] SaraA n HW. A semiquantitative culture method for identifying intravenous-catheter-related infection, Maki [/bib_ref] [bib_ref] The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters:..., Mermel [/bib_ref] [bib_ref] Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization..., Raad [/bib_ref] or microorganisms from the hands of healthcare workers that contaminate and colonise the catheter hub during care interventions. [bib_ref] DNA A ngerprinting analysis of coagulase negative staphylococci implicated in catheter related..., Dobbins [/bib_ref] Less commonly, infusate contamination or seeding from a different site of infection in the body via the bloodstream is identiA ed as a cause of CR-BSI. 348,349

## What is the evidence for these guidelines?
These guidelines are based upon evidence-based guidelines for preventing intravascular device (IVD)-related infections, developed at the US Centers for Disease Control and Prevention by HICPAC and published in 2011. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] The AGREE II collaboration appraisal instrument was used by four appraisers to review the guidelines independently.The appraisal process resulted in the decision that the guideline development processes were valid and that the guidelines were evidence based, categorised to the strength of the evidence examined, reA ective of current concepts of best practice. The Guideline Development Advisory Group considered that they were the most authoritative reference guidelines currently available. Following the AGREE process, we systematically searched, retrieved and appraised additional evidence published since the search period identiA ed in the HICPAC technical report. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] Our search period for additional evidence spanned from 2009 to 2012.
These guidelines apply to caring for all adults and children over the age of 1 year in NHS acute care settings with a CVC or PVC that is being used for the administration of A uids, medications, blood components and/or parenteral nutrition. They should be used in conjunction with the recommendations for Standard Principles for Preventing HCAI, previously described in these guidelines.
These recommendations describe general principles of best practice that apply to all patients in hospital in whom an intravascular catheter is being used during an acute episode of treatment/care. They do not speciA cally address the more detailed, technical aspects of the care of infants under 1 year of age, or those children or adults receiving haemodialysis or chemotherapy who will generally have long-term intravascular catheters managed in renal dialysis or outpatient settings.
The recommendations are divided into nine distinct interventions: - education of healthcare workers and patients; - general asepsis; - selection of type of intravascular catheter; - selection of intravascular catheter insertion site; - MSB precautions during insertion; - cutaneous antisepsis; - catheter and catheter site care; - replacement strategies; and - general principles for catheter management.

## Education of healthcare workers and patients
To improve patient outcomes and reduce healthcare costs, it is essential that everyone involved in caring for patients with intravascular catheters is educated about infection prevention. Healthcare workers in hospitals need to be conA dent and proA cient in infection prevention practices, and to be aware of the signs and symptoms of clinical infection. Structured educational programmes that enable healthcare workers to provide, monitor and evaluate care and continually increase their competence are critical to the success of any strategy designed to reduce the risk of infection. Evidence reviewed by HICPAC demonstrates that the risk of infection declines following standardisation of the aseptic technique, [bib_ref] Effectiveness of surveillance of central catheter-related bloodstream infection in an ICU in..., Yoo [/bib_ref] [bib_ref] Effect of an education program on decreasing catheter-related bloodstream infections in the..., Coopersmith [/bib_ref] [bib_ref] Education of physiciansin-training can decrease the risk for vascular catheter infection, Sherertz [/bib_ref] [bib_ref] Impact of a prevention strategy targeted at vascularaccess care on incidence of..., Eggimann [/bib_ref] [bib_ref] Septic complications of total parenteral nutrition. A A ve year experience, Sanders [/bib_ref] [bib_ref] Catheter complications in total parenteral nutrition. A prospective study of 200 consecutive..., Ryan [/bib_ref] [bib_ref] Central venous catheter care in parenteral nutrition: a review, Murphy [/bib_ref] and increases when the maintenance of intravascular catheters is undertaken by inexperienced healthcare workers. [bib_ref] Impact of a prevention strategy targeted at vascularaccess care on incidence of..., Eggimann [/bib_ref] [bib_ref] Prospective study of catheter replacement and other risk factors for infection of..., Armstrong [/bib_ref] H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1-S70

## S39
We identiA ed two recent systematic reviews that assessed the effectiveness of education interventions in reducing CR-BSI. [bib_ref] What features of educational interventions lead to competence in aseptic insertion and..., Cherry [/bib_ref] [bib_ref] Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence..., Frampton [/bib_ref] The A rst concluded that current evidence comes predominantly from uncontrolled before-after studies that do not convincingly distinguish intervention effectiveness from secular trends. Clinical practices are addressed by a wide variety of educational strategies that do not draw upon pedagogic, theoretical or conceptual frameworks and consequently do not provide generalisable conclusions about the most effective approaches to education to improve practice. [bib_ref] Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence..., Frampton [/bib_ref] The second systematic review concluded A rst that educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit and feedback, and when availability of clinical equipment is consistent with the content of the education provided. Second, that educational interventions will have a greater impact if baseline compliance with best practice is low. Third, that repeated educational sessions, fed into daily practice, using practical participation, appear to have a small, additional effect on practice change compared with education alone. [bib_ref] What features of educational interventions lead to competence in aseptic insertion and..., Cherry [/bib_ref] Healthcare workers should be aware of the manufacturers' advice relating to the compatibility of individual devices with antiseptic solutions, dwell time and connections to ensure safe use.

## Ivad1 healthcare workers caring for patients
with intravascular catheters should be trained and assessed as competent in using and consistently adhering to practices for the prevention of catheter-related bloodstream infection.

## Class d/gpp
IVAD2 Healthcare workers should be aware of the manufacturer's advice relating to individual catheters, connection and administration set dwell time and compatibility with antiseptics and other A uids to ensure the safe use of devices.

## New recommendation class d/gpp
IVAD3 Before discharge from hospital, patients with intravascular catheters and their carers should be taught any techniques they may need to use to prevent infection and manage their device.

## Class d/gpp

## General asepsis
Hand decontamination and meticulous attention to the aseptic technique are essential during catheter insertion, manipulation, changing catheter site dressings and for accessing the system. Hands should be decontaminated using ABHR or liquid soap and water when hands are visibly soiled or potentially contaminated with organic material, such as blood and other body A uids.The aseptic technique should be used for the insertion and management of IVDs. Structured education should be provided to ensure that healthcare workers are trained and assessed as competent in performing the aseptic technique. Gloves should be worn for procedures involving contact with blood or body A uids. Sterile gloves must be worn for the insertion and dressing of CVCs. 334 IVAD4 Hands must be decontaminated, with an alcohol-based hand rub or by washing with liquid soap and water if soiled or potentially contaminated with blood or body A uids, before and after any contact with the intravascular catheter or insertion site.

## Class a
IVAD5 Use the aseptic technique for the insertion and care of an intravascular access device and when administering intravenous medication.

## Class b

## Selection of catheter type
The selection of the most appropriate intravascular catheter for each individual patient can reduce the risk of subsequent catheter-related infection.

# Catheter material
Intravascular catheter material may be an important determinant in the development of catheter-related infection. PolytetraA uroethylene (TeA on) and polyurethane catheters have been associated with fewer infections than catheters made of polyvinyl chloride or polyethylene. [bib_ref] Total parenteral nutrition-related infections: prospective epidemiologic study using semiquantitative methods, Snydman [/bib_ref] [bib_ref] Colonization of bacteria on polyvinyl chloride and TeA on intravascular catheters in..., Sheth [/bib_ref] [bib_ref] Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters...., Maki [/bib_ref] 

## Number of catheter lumens
Multi-lumen intravascular access devices may be used because they permit the concurrent administration of A uids and medications, parenteral nutrition and haemodynamic monitoring among critically ill patients.
Several RCTs and other studies suggest that multi-lumen catheters are associated with a higher risk of infection than single-lumen catheters. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] [bib_ref] Sepsis from triplevs single-lumen catheters during total parenteral nutrition in surgical or..., Pemberton [/bib_ref] [bib_ref] Prospective evaluation of single and triple lumen catheters in total parenteral nutrition, Mccarthy [/bib_ref] [bib_ref] Central catheter infections: single-versus triple-lumen catheters. InA uence of guide wires on..., Hilton [/bib_ref] [bib_ref] Infection rate for single lumen v triple lumen subclavian catheters, Yeung [/bib_ref] [bib_ref] Use of triple-lumen subclavian catheters for administration of total parenteral nutrition, Clark-Christoff [/bib_ref] [bib_ref] Increased infection rate in double-lumen versus single-lumen Hickman catheters in cancer patients, Early [/bib_ref] However, other studies examined by HICPAC failed to demonstrate a difference in the rates of CR-BSI. [bib_ref] Single-versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically..., Farkas [/bib_ref] [bib_ref] Triple-vs single-lumen central venous catheters. A prospective study in a critically ill..., Gil [/bib_ref] Multi-lumen catheter insertion sites may be particularly prone to infection because of increased trauma at the insertion site or because multiple ports increase the frequency of CVC manipulation. [bib_ref] Central catheter infections: single-versus triple-lumen catheters. InA uence of guide wires on..., Hilton [/bib_ref] [bib_ref] Infection rate for single lumen v triple lumen subclavian catheters, Yeung [/bib_ref] Patients with multi-lumen catheters tend to be more severely ill, although the increased risk of CR-BSI appears to be independent of underlying illness. 366

## A dedicated catheter lumen is needed for parenteral nutrition
A prospective epidemiological study in patients receiving parenteral nutrition concluded that either using a singlelumen catheter or a dedicated port in a multi-lumen catheter for parenteral nutrition would reduce the risk of CR-BSI. [bib_ref] Total parenteral nutrition-related infections: prospective epidemiologic study using semiquantitative methods, Snydman [/bib_ref] Neither we nor HICPAC identiA ed any additional evidence for this recommendation whilst updating our systematic review, and HICPAC considered this to be a unresolved issue. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] In a systematic review and quantitative meta-analysis focused on determining the risk of CR-BSI and catheter colonisation in multi-lumen catheters compared with single-lumen catheters, the reviewers reported that, although CR-BSI was more common in patients with multi-lumen catheters, when conA ned to highquality studies that control for patient differences, there is no signiA cant difference in rates of CR-BSI for the two types of catheter. This analysis suggests that multi-lumen catheters are not a signiA cant risk factor for increased CR-BSI or local catheter colonisation compared with single-lumen CVCs. [bib_ref] Rates of infection for single-lumen versus multilumen central venous catheters: a meta-analysis, Dezfulian [/bib_ref] A later systematic review and quantitative meta-analysis tested whether single-vs multi-lumen CVCs had an impact on catheter colonisation and CR-BSI. The study authors concluded that there is some evidence from A ve RCTs with data on 530 CVCs that for every 20 single-lumen catheters inserted, one CR-BSI (which would have occurred had multi-lumen catheters been used) would be avoided. [bib_ref] Colonization and bloodstream infection with single-versus multi-lumen central venous catheters: a quantitative..., Zurcher [/bib_ref] Neither we nor HICPAC identiA ed any additional evidence of acceptable quality whilst updating our systematic reviews. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] IVAD6 Use a catheter with the minimum number of ports or lumens essential for management of the patient.

## Class a
IVAD7 Preferably use a designated singlelumen catheter to administer lipidcontaining parenteral nutrition or other lipid-based solutions.

## Class d/gpp

## Tunnelled and totally implantable ports
Surgically implanted (tunnelled) devices (e.g. Hickman  catheters) are commonly used to provide vascular access to patients requiring long-term intravenous therapy. Alternatively, totally implantable intravascular access devices (e.g. Port-A-Cath  ) are also tunnelled under the skin, but have a subcutaneous port or reservoir with a self-sealing septum that is accessible by needle puncture through intact skin.

## S41
Multiple studies comparing the incidence of infection associated with long-term tunnelled CVCs and/or totally implantable IVDs with that from percutaneously (non-tunnelled) inserted catheters have been assessed by HICPAC. [bib_ref] Guideline for prevention of intravascular devicerelated infections. Hospital Infection Control Practices Advisory..., Pearson [/bib_ref] Although most studies reported a lower rate of infection in patients with tunnelled CVCs, [bib_ref] A prospective study of prolonged central venous access in leukemia, Abrahm [/bib_ref] [bib_ref] Broviac catheter-related bacteremia in oncology patients, Shapiro [/bib_ref] [bib_ref] Hickman catheter infections in patients with malignancies, Press [/bib_ref] [bib_ref] Problems associated with indwelling central venous catheters, Darbyshire [/bib_ref] [bib_ref] Complications of Hickman-Broviac catheters, Pessa [/bib_ref] [bib_ref] Management of Hickman catheter sepsis, Schuman [/bib_ref] [bib_ref] Catheter-related septicemia in patients receiving home parenteral nutrition, Rannem [/bib_ref] [bib_ref] Single-vs double-lumen central venous catheters in pediatric oncology patients, Shulman [/bib_ref] [bib_ref] Bacteraemia related to indwelling central venous catheters: prevention, diagnosis and treatment, Weightman [/bib_ref] some studies found no signiA cant difference in the rate of infection between tunnelled and nontunnelled catheters. [bib_ref] Low infection rate and long durability of nontunneled silastic catheters. A safe..., Raad [/bib_ref] [bib_ref] Lack of clinical beneA t from subcutaneous tunnel insertion of central venous..., Andrivet [/bib_ref] Additionally, most studies concluded that totally implantable devices had the lowest reported rates of CR-BSI compared with either tunnelled or non-tunnelled CVCs. [bib_ref] A totally implanted injection port system for blood sampling and chemotherapy administration, Gyves [/bib_ref] [bib_ref] Complications and management of implanted venous access catheters, Lokich [/bib_ref] [bib_ref] A totally implanted venous access system for the delivery of chemotherapy, Khoury [/bib_ref] [bib_ref] Implantable subcutaneous venous catheters, Mcdowell [/bib_ref] [bib_ref] Fifty-A ve patient years' experience with a totally implanted system for intravenous..., Brincker [/bib_ref] [bib_ref] Infection rates of Broviac-Hickman catheters and implantable venous devices, Wurzel [/bib_ref] [bib_ref] Complications from long-term indwelling central venous catheters in hematologic patients with special..., Kappers-Klunne [/bib_ref] [bib_ref] Classical external indwelling central venous catheter versus totally implanted venous access systems..., Carde [/bib_ref] [bib_ref] Comparison of infections in Hickman and implanted port catheters in adult solid..., Pegues [/bib_ref] [bib_ref] Experience with a totally implantable venous access device (Port-A-Cath) in patients with..., Van Der Pijl [/bib_ref] [bib_ref] Infectious morbidity associated with long-term use of venous access devices in patients..., Groeger [/bib_ref] However, although these devices are less disruptive for patients in terms of daily living, they have a number of disadvantages including the need for needle insertion resulting in increased discomfort. [bib_ref] Long-term central venous access, Galloway [/bib_ref] Additional evidence was obtained from studies of efA cacy of tunnelling to reduce catheter-related infections in patients with short-term CVCs. One RCT demonstrated that subcutaneous tunnelling of short-term CVCs inserted into the internal jugular vein reduced the risk for CR-BSI. [bib_ref] Effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill..., Timsit [/bib_ref] In a later RCT, the same investigators failed to show a statistically signiA cant difference in the risk for CR-BSI for subcutaneously tunnelled femoral vein catheters. [bib_ref] Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled..., Timsit [/bib_ref] An additional meta-analysis of RCTs was focused on the efA cacy of tunnelling short-term CVCs to prevent catheterrelated infections. [bib_ref] Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of..., Randolph [/bib_ref] Data synthesis demonstrated that tunnelling decreased catheter colonisation by 39% and decreased CR-BSI by 44% in comparison with non-tunnelled placement. The majority of the beneA t in the decreased rate of catheter sepsis came from one trial of CVCs inserted at the internal jugular site. The reduction in risk was not signiA cant when pooled with data from A ve subclavian catheter trials. Tunnelling was not associated with increased risk of mechanical complications from placement or technical difA culties during placement. This meta-analysis concluded that tunnelling decreased catheterrelated infections; however, a synthesis of the evidence in this meta-analysis does not support routine subcutaneous tunnelling of short-term subclavian venous catheters, and this cannot be recommended unless efA cacy is evaluated at different placement sites and relative to other interventions.
Peripherally inserted central catheters (PICCs) are increasingly used for medium term (6 weeks to 6 months) [bib_ref] Long-term central venous access, Galloway [/bib_ref] intravascular access, particularly in adults and children requiring antimicrobial treatment, chemotherapy and parenteral nutrition. Evidence examined by HICPAC suggested that PICCs are associated with a lower rate of infection than that associated with other non-tunnelled CVCs. [bib_ref] Low infection rate and long durability of nontunneled silastic catheters. A safe..., Raad [/bib_ref] [bib_ref] Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of..., Randolph [/bib_ref] Retrospective studies in outpatient settings indicate that rates of PICC-related bloodstream infection range from 0.4 to 0.8 per 1000 catheter-days. [bib_ref] Peripheral access options, Ryder [/bib_ref] [bib_ref] Long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in..., Bottino [/bib_ref] [bib_ref] Infectious complications among patients receiving home intravenous therapy with peripheral, central, or..., Graham [/bib_ref] [bib_ref] Peripherally inserted central venous catheters. Low-risk alternatives for ongoing venous access, Merrell [/bib_ref] [bib_ref] Survey of the use of peripherally inserted central venous catheters in children, Thiagarajan [/bib_ref] [bib_ref] Peripherally inserted central catheters in patients with AIDS are associated with a..., Skiest [/bib_ref] However, there is little recent robust evidence regarding comparison of rates of CR-BSI in PICCs vs other long-term central venous access devices. A prospective study [bib_ref] Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used..., Safdar [/bib_ref] that compared the use of inpatient PICCs indicated a similar rate of CR-BSI to non-tunnelled catheters placed in the internal jugular or subclavian veins and a higher rate than cuffed and tunnelled (CT) catheters (PICC 3.5 CR-BSI per 1000 catheter-days vs nontunnelled 2.7 CR-BSI per 1000 catheter-days vs cuffed and tunnelled 1.6 CR-BSI per 1000 catheter-days). A systematic review of 200 studies indicated that when used in inpatients, PICCs pose a slightly lower risk of CR-BSI than standard noncuffed and non-medicated CVCs placed in the subclavian or internal jugular vein (2.1 CR-BSI per 1000 catheter-days vs 2.7 CR-BSI per 1000 catheter-days). [bib_ref] The risk of bloodstream infection in adults with different intravascular devices: a..., Maki [/bib_ref] Neither we nor HICPAC identiA ed any additional evidence of acceptable quality whilst updating our systematic review. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] IVAD8 Use a tunnelled or implanted central venous access device with a subcutaneous port for patients in whom long-term vascular access is required.

## Class a
IVAD9 Use a peripherally inserted central catheter for patients in whom mediumterm intermittent access is required.

## New recommendation class d/gpp

## Antimicrobial impregnated catheters and cuffs
Some catheters and cuffs are marketed as anti-infective and are coated or impregnated with antimicrobial or antiseptic agents, e.g. chlorhexidine/silver sulfadiazine, minocycline/ rifampicin, platinum/silver, and ionic silver in subcutaneous collagen cuffs attached to CVC. Evidence reviewed by HICPAC [bib_ref] Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated..., Maki [/bib_ref] [bib_ref] Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention..., Logghe [/bib_ref] [bib_ref] InA uence of triple-lumen central venous catheters coated with chlorhexidine and silver..., Heard [/bib_ref] [bib_ref] A meta-analysis dealing with the effectiveness of chlorhexidine and silver-sufhadiazine impregnated central..., Haxhe [/bib_ref] [bib_ref] Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter, Oda [/bib_ref] [bib_ref] Cost-effectiveness of antiseptic-impregnated central venous catheters for the prevention of catheter-related bloodstream..., Veenstra [/bib_ref] [bib_ref] Central venous catheters coated with minocycline and rifampin for the prevention of..., Raad [/bib_ref] [bib_ref] Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: a continuous..., Collin [/bib_ref] [bib_ref] A Comparison of Two Antimicrobial-Impregnated Central Venous Catheters, Darouiche [/bib_ref] [bib_ref] EfA cacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection:..., Veenstra [/bib_ref] [bib_ref] Prevention of intravascular catheter-related infections, Mermel [/bib_ref] indicated that the use of antimicrobial or antisepticimpregnated CVC in adults whose catheter is expected to remain in place for more than A ve days could decrease the risk for CR-BSI. This may be cost-effective in high-risk patients (intensive care, burn and neutropenic patients) and in other patient populations in whom the rate of CR-BSI exceeds 3.3 per 1,000 catheter days even when there is a comprehensive strategy to reduce rates of CR-BSI. [bib_ref] Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated..., Maki [/bib_ref] A meta-analysis of 23 RCTs published between 1988-1999 included data on 4,660 catheters (2,319 anti-infective and 2,341 control). [bib_ref] Prevention of bloodstream infections with central venous catheters treated with antiinfective agents..., Walder [/bib_ref] Eleven of the trials in this meta-analysis were conducted in intensive care unit (ICU) settings; four among oncology patients, two among surgical patients; two among patients receiving total parenteral nutrition (TPN) and four among other patient populations. Study authors concluded that antibiotic and chlorhexidine-silver sulfadiazine coatings are anti-infective for short (approximately one week) insertion time. For longer insertion times, there was no data on antibiotic coating, and there is evidence of lack of effect for A rst generation chlorhexidine-silver sulfadiazine coating. For silver-impregnated collagen cuffs, there is evidence of lack of effect for both short-and long-term insertion.
Second generation chlorhexidine/silver sulfadiazine catheters with chlorhexidine coating on both the internal and external luminal surfaces are now available. The external surface of these catheters have three times the amount of chlorhexidine and extended release of the surface bound antiseptics than that in the A rst generation catheters (which are coated with chlorhexidine/silver sulfadiazine only on the external luminal surface). Early studies indicated that the prolonged anti-infective activity associated with the second generation catheters improved efA cacy in preventing infections. [bib_ref] Prolonged Antimicrobial Activity of a Catheter Containing Chlorhexidine-Silver Sulfadiazine Extends Protection against..., Bassetti [/bib_ref] A systematic review and economic evaluation in 2006 concluded that rates of CR-BSI were statistically signiA cantly reduced when an antimicrobial CVC was used. Studies in this review report the best effect when catheters were treated with minocycline/rifampin, or internally and externally treated with silver or chlorhexidine/silver sulfadiazine. A trend to statistical signiA cance was seen in catheters only extraluminally coated. Investigation of other antibiotic treated catheters is limited to single studies with non-signiA cant results. [bib_ref] The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective..., Hockenhull [/bib_ref] We identiA ed two additional systematic reviews and one RCT in our updated search. A recent Cochrane review of studies using impregnation, coating or bonding for reducing central venous catheter-related infections in adults included 56, predominantly unblinded studies, with low or unclear risk of bias. Patients with impregnated catheters had lower rates of CR-BSI (actual risk reduction of 2% (95% CI, 3% to 1%)), and catheter colonisation (actual risk reduction 10% (95% CI, 13% to 7%)). In terms of catheter colonisation sub-group analysis showed that impregnated catheters were more beneA cial in studies conducted in intensive care units (RR 0.68 (95% CI, 0.59 to 0.78)) than in studies conducted in haemo-oncology (RR 0.75 (95% CI, 0.51 to 1.11)) or in patients requiring long-term parenteral nutrition RR 0.99 (95% CI, 0.74 to 1.34)). However, sub-group analysis did not identify the same beneA t in terms of CR-BSI. There were no statistically signiA cant differences in the overall rates of bloodstream infections or mortality, although these outcomes were less often assessed than CR-BSI and catheter colonisation. [bib_ref] Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in..., Lai [/bib_ref] A collaborative network metaanalysis of CVC use in adults indicated that rifampicin-based impregnated CVC was the only type of impregnated/coated CVC that reduced catheter colonisation and CR-BSI compared with standard CVC. [bib_ref] Effectiveness of different central venous catheters for catheterrelated infections: a network meta-analysis, Wang [/bib_ref] In a single blind non-inferiority trial, authors concluded that CVC coated with 5-A uorouracil were non-inferior to chlorhexidine and silver sulfadiazine coated CVCs with respect to the incidence of catheter colonisation (2.9% vs. 5.3%, respectively). 422

## Be aware of patient sensitivity to chlorhexidine gluconate
Chlorhexidine is a potential allergenic antiseptic that is present in many products and is widely used in health care for skin antisepsis, insertion of urinary catheters or coating CVCs. [bib_ref] Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated..., Maki [/bib_ref] In susceptible individuals, initial contact will cause a minor hypersensitivity reaction that, although not severe, should not go undocumented as subsequent exposures to chlorhexidine may lead to anaphylaxis. [bib_ref] Immediate hypersensitivity to chlorhexidine is increasingly recognised in the United Kingdom, Nakonechna [/bib_ref] [bib_ref] Anaphylaxis to chlorhexidine-coated central venous catheters: a case series and review of..., Guleri [/bib_ref] The Medicines and Healthcare Products Regulatory Agency has alerted all healthcare providers in the UK to the risk of chlorhexidine allergyand requires them to have systems in place that ensure: - awareness of the potential for an anaphylactic reaction to chlorhexidine; - known allergies are recorded in patient notes; - labels and instructions for use are checked to establish if products contain chlorhexidine prior to use on patients with a known allergy; - if a patient experiences an unexplained reaction, checks are carried out to identify whether chlorhexidine was used or was impregnated in a medical device that was used; and - reporting of allergic reactions to products containing chlorhexidine to the Medicines and Healthcare Products Regulatory Agency.
IVAD10 Use an antimicrobial-impregnated central venous access device for adult patients whose central venous catheter is expected to remain in place for >5 days if catheter-related bloodstream infection rates remain above the locally agreed benchmark, despite the implementation of a comprehensive strategy to reduce catheter-related bloodstream infection.

## Class a

## Selection of catheter insertion site
The site at which a vascular access catheter is placed can inA uence the subsequent risk of CR-BSI because of variation in both the density of local skin A ora and the risk of thrombophlebitis. CVCs are generally inserted in the subclavian, jugular or femoral veins, or peripherally inserted into the superior vena cava by way of the major veins of the upper arm (i.e. the cephalic and basilar veins of the antecubital space). PVCs are normally inserted in the upper extremity, although alternatives, such as the foot and scalp, may be used in children and babies.

## Subclavian, jugular and femoral placements
HICPAC examined a number of studies that compared insertion sites and concluded that CVCs inserted into subclavian veins had a lower risk for catheter-related infection than those inserted into either jugular or femoral veins. [bib_ref] The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters:..., Mermel [/bib_ref] [bib_ref] InA uence of triple-lumen central venous catheters coated with chlorhexidine and silver..., Heard [/bib_ref] [bib_ref] Femoral vs jugular venous catheterization and risk of nosocomial events in adults..., Parienti [/bib_ref] [bib_ref] Impact of central venous catheter type and methods on catheter-related colonization and..., Moretti [/bib_ref] [bib_ref] To reduce catheterrelated bloodstream infections: is the subclavian route better than the..., Nagashima [/bib_ref] [bib_ref] Complications of central venous catheters: internal jugular versus subclavian access -a systematic..., Ruesch [/bib_ref] [bib_ref] Comparison between the jugular and subclavian vein as insertion site for central..., Sadoyama [/bib_ref] [bib_ref] Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter..., Richet [/bib_ref] [bib_ref] A review of risk factors for catheter-related bloodstream infection caused by percutaneously..., Safdar [/bib_ref] [bib_ref] Prospective study of arterial and central venous catheter colonization and of arterial-and..., Traore [/bib_ref] Guideline developers suggested that internal jugular insertion sites may pose a greater risk for infection because of their proximity to oropharyngeal secretions and because CVCs at this site are difA cult to immobilise. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] However, mechanical complications associated with catheterisation might be less common with internal jugular than with subclavian vein insertion.
Femoral catheters have been demonstrated to have relatively high colonisation rates compared with subclavian and internal jugular sites when used in adults, and current guidelines suggest that the femoral site should be avoided because it is associated with both a higher risk of deep vein thrombosis and catheter-related infection than internal jugular or subclavian catheters. [bib_ref] To reduce catheterrelated bloodstream infections: is the subclavian route better than the..., Nagashima [/bib_ref] [bib_ref] A review of risk factors for catheter-related bloodstream infection caused by percutaneously..., Safdar [/bib_ref] [bib_ref] Prospective study of arterial and central venous catheter colonization and of arterial-and..., Traore [/bib_ref] [bib_ref] Complications of femoral and subclavian venous catheterization in critically ill patients: a..., Merrer [/bib_ref] [bib_ref] Risk of infection due to central venous catheters: effect of site of..., Goetz [/bib_ref] [bib_ref] The incidence of infectious complications of central venous catheters at the subclavian,..., Deshpande [/bib_ref] One study also found that the risk of infection associated with catheters placed in the femoral vein is accentuated in obese patients. [bib_ref] A meta-analysis dealing with the effectiveness of chlorhexidine and silver-sufhadiazine impregnated central..., Haxhe [/bib_ref] Thus, in adult patients, a subclavian site is preferred for preventing infection, 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.
We identiA ed a systematic review and meta-analysis 438 in which investigators reviewed two RCTs, eight cohort studies and data from a national HCAI programme. These provided evidence that the selection of device insertion site is not a signiA cant factor for the prevention of CR-BSI. The metaanalysis demonstrated no difference in the risk of CR-BSI between the femoral, subclavian and internal jugular sites, S43 having removed two studies that were statistical outliers. The authors concluded that a pragmatic approach to site selection for central venous access, taking into account underlying disease (e.g. renal disease), the expertise and skill of the operator and the risks associated with placement, should be used. [bib_ref] The risk of catheter-related bloodstream infection with femoral venous catheters as compared..., Marik [/bib_ref] Two meta-analyses [bib_ref] Ultrasound guidance for placement of central venous catheters: a metaanalysis of the..., Randolph [/bib_ref] [bib_ref] Ultrasonic locating devices for central venous cannulation: meta-analysis, Hind [/bib_ref] indicate that the use of real-time two-dimensional ultrasound for the placement of CVCs substantially reduced mechanical complications compared with the standard landmark placement technique. Consequently, the use of ultrasound may indirectly reduce the risk of infection by facilitating mechanically uncomplicated subclavian placement. In the UK, NICE guidelines provide recommendations for two-dimensional ultrasound placement of CVCs. 441

## Upper arm placement
PICCs may be used as an alternative to subclavian or jugular vein catheterisation. These are inserted into the superior vena cava via the major veins of the upper arm above the antecubital fossa. HICPAC indicated that they are less expensive, associated with fewer mechanical complications (e.g. haemothorax, inA ltration and phlebitis) and easier to maintain than short peripheral venous catheters. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] In a prospective cohort study using data from two randomised trials and a systematic review to estimate rates of PICC-related bloodstream infection in hospitalised patients, the author concluded that PICCs used in high-risk hospitalised patients are associated with a rate of CR-BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (two to A ve per 1000 catheter-days). 441

## Peripheral venous catheters
To reduce the risk of CR-BSI and phlebitis, it is preferable to use an upper extremity site for inserting a PVC in adults and to replace a device inserted in a lower extremity to a site in the upper extremity as soon as possible. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] In paediatric patients, the upper or lower extremity and the scalp (in young infants) can be used for siting a PVC. [bib_ref] Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used..., Safdar [/bib_ref] [bib_ref] Infection control in intravenous therapy, Maki [/bib_ref] IVAD11 In selecting an appropriate intravascular insertion site, assess the risks for infection against the risks of mechanical complications and patient comfort.

## Class d/gpp
IVAD12 Use the upper extremity for nontunnelled catheter placement unless medically contraindicated.

## Class c

## Maximal sterile barrier precautions during catheter insertion

## Maximal sterile barrier precautions for the insertion of central venous catheters reduces the risk of infection
The importance of strict adherence to hand decontamination and the aseptic technique as the cornerstone for preventing catheter-related infection is widely accepted. Although this is considered adequate for preventing infections associated with the insertion of short peripheral venous catheters, it is recognised that central venous catheterisation carries a signiA cantly greater risk of infection.
Studies examined by HICPAC concluded that if MSB precautions were used consistently during CVC insertion, catheter contamination and subsequent catheter-related infections could be reduced signiA cantly. [bib_ref] The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters:..., Mermel [/bib_ref] [bib_ref] Education of physiciansin-training can decrease the risk for vascular catheter infection, Sherertz [/bib_ref] [bib_ref] Prevention of central venous catheter-related infections by using maximal sterile barrier precautions..., Raad [/bib_ref] [bib_ref] Effect of different sterile barrier precautions and central venous catheter dressing on..., Carrer [/bib_ref] A prospective randomised trial that tested the efA cacy of MSB precautions to reduce infections associated with long-term, non-tunnelled subclavian silicone catheters, compared with routine procedures, found that they decreased the risk of CR-BSI signiA cantly. [bib_ref] Prevention of central venous catheter-related infections by using maximal sterile barrier precautions..., Raad [/bib_ref] MSB precautions involve wearing sterile gloves and gown, cap and mask, and using a full-body sterile drape during insertion of the catheter. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] It has been generally assumed that CVCs inserted in the operating theatre pose a lower risk of infection than those inserted on inpatient wards or other patient care areas. [bib_ref] Guideline for prevention of intravascular devicerelated infections. Hospital Infection Control Practices Advisory..., Pearson [/bib_ref] However, data examined by HICPAC from two prospective studies suggest that the difference in risk of infection depended largely on the magnitude of barrier protection used during catheter insertion, rather than the surrounding environment (i.e. ward vs operating theatre). [bib_ref] The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters:..., Mermel [/bib_ref] [bib_ref] Prevention of central venous catheter-related infections by using maximal sterile barrier precautions..., Raad [/bib_ref] A systematic review of the value of MSB precautions to prevent CR-BSI deA ned the components as: the person inserting the catheter should wear a head cap, face mask, sterile body gown and sterile gloves, and use a full-size sterile drape. Their search identiA ed 95 papers discussing the prevention of CR-BSI. The majority of these were narrative reviews or consensus statements. Three primary research studies, differing in design, patient population and clinical settings, that compared infection outcomes using MSB precautions with less stringent barrier techniques, concluded that the use of MSB precautions resulted in a reduction in catheter-related infections. The authors concluded that using MSB precautions appears to decrease transmission of microorganisms, delay colonisation and reduce the rate of HCAI. They also suggested that biological plausibility and the available evidence support using MSB precautions during routine insertion of a CVC to minimise the risk of infection. They recommended that, given the lack of adverse patient reactions, the relatively low cost of MSB precautions and the high cost of CR-BSI, it is probable that MSB precautions will prove to be a cost-effective, or even a cost-saving, intervention. [bib_ref] Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic..., Hu [/bib_ref] Neither we nor HICPAC identiA ed any additional evidence of acceptable quality whilst updating our systematic review. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] IVAD13 Use maximal sterile barrier precautions for the insertion of central venous access devices.

## Cutaneous antisepsis

## Appropriate preparation of the insertion site will reduce the risk of catheter-related infection
Microorganisms that colonise catheter hubs and the skin surrounding the vascular catheter insertion site are the cause of most CR-BSI. [bib_ref] Prevention of intravascular catheter-related infections, Mermel [/bib_ref] [bib_ref] Catheter-related sepsis: an overview -Part 1, Fletcher [/bib_ref] As the risk of infection increases with the density of microorganisms around the insertion site, skin cleansing/antisepsis of the insertion site is one of the most important measures for preventing catheter-related infections. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] Since the early 1990s, research has focused on identifying the most effective antiseptic agent for skin preparation prior to the insertion of IVDs in order to prevent catheter-related infections, especially CR-BSI. In the UK, clinicians principally use alcohol, or either povidone iodine (PVI) or CHG, in various strengths, and the latter two as either aqueous or alcohol-based solutions.
A prospective randomised trial of agents used for cutaneous antisepsis demonstrated that 2% aqueous CHG was superior to either 10% PVI or 70% alcohol for the prevention of central venous and arterial catheter-related infections. [bib_ref] Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection..., Maki [/bib_ref] A further prospective, randomised trial demonstrated that a 4% alcoholbased solution of 0.25% CHG and 0.025% benzalkonium chloride was more effective for the prevention of central venous or arterial catheter colonisation and infection than 10% PVI. [bib_ref] Prospective, randomized trial of two antiseptic solutions for prevention of central venous..., Mimoz [/bib_ref] The use of 5% PVI solution in 70% ethanol has been shown to be associated with a substantial reduction in catheter-related colonisation and infection compared with 10% aqueous PVI. [bib_ref] Alcoholic povidone-iodine to prevent central venous catheter colonization: a randomized unit-crossover study, Parienti [/bib_ref] Clinicians may A nd this useful for those patients for whom alcoholic CHG is contraindicated.
A meta-analysis [bib_ref] Chlorhexidine compared with povidone-iodine solution for vascular cathetersite care: a meta-analysis, Chaiyakunapruk [/bib_ref] of studies that compared the risk for CR-BSI following insertion-site skin care with any type of CHG solution vs PVI solution indicated that the use of CHG rather than PVI can reduce the risk for CR-BSI by approximately 49% (RR 0.51, 95% CI 0.27-0.97) in hospitalised patients who require short-term catheterisation (i.e. for every 1000 catheter sites disinfected with CHG rather than PVI, 71 episodes of catheter colonisation and 11 episodes of CR-BSI would be prevented). In this analysis, several types of CHG solution were used in the individual trials, including 0.5% or 1% CHG alcohol solution and 0.5% or 2% CHG aqueous solution. All of these solutions provided a concentration of CHG that is higher than the minimal inhibitory concentration (MIC) for most nosocomial bacteria and yeasts. Subset analysis of aqueous and non-aqueous solutions showed similar effect sizes, but only the subset analysis of the A ve studies that used alcoholic CHG solution produced a signiA cant reduction in CR-BSI. As few studies used CHG aqueous solution, the lack of a signiA cant difference seen for this solution compared with PVI solution may be a result of inadequate statistical power. Additionally, an economic decision analysis based on available evidence from the same authors suggested that the use of CHG, rather than PVI, for skin care would result in a 1.6% decrease in the incidence of CR-BSI, a 0.23% decrease in mortality, and A nancial savings per catheter used. [bib_ref] Vascular catheter site care: the clinical and economic beneA ts of chlorhexidine..., Chaiyakunapruk [/bib_ref] Several studies were examined that focused on the application of antimicrobial ointments to the catheter site at the time of catheter insertion, or during routine dressing changes, to reduce microbial contamination of catheter insertion sites. [bib_ref] Prospective, randomized trial of two antiseptic solutions for prevention of central venous..., Mimoz [/bib_ref] Reported efA cacy of this practice for the prevention of catheter-related infections yielded contradictory A ndings. [bib_ref] Alcoholic povidone-iodine to prevent central venous catheter colonization: a randomized unit-crossover study, Parienti [/bib_ref] [bib_ref] Chlorhexidine compared with povidone-iodine solution for vascular cathetersite care: a meta-analysis, Chaiyakunapruk [/bib_ref] [bib_ref] Vascular catheter site care: the clinical and economic beneA ts of chlorhexidine..., Chaiyakunapruk [/bib_ref] [bib_ref] Guideline for use of topical antimicrobial agents, Larson [/bib_ref] [bib_ref] Catheter-related sepsis in long-term parenteral nutrition with Broviac catheters. An evaluation of..., Rannem [/bib_ref] [bib_ref] Colonization of central venous catheters, Prager [/bib_ref] [bib_ref] A clinical and bacteriologic study of infections associated with venous cutdowns, Moran [/bib_ref] [bib_ref] Application of antibiotic ointment to the site of venous catheterization -a controlled..., Norden [/bib_ref] [bib_ref] Risk of infection with intravenous indwelling catheters: effect of application of antibiotic..., Zinner [/bib_ref] There was also concern that the use of polyantibiotic ointments that were not fungicidal could signiA cantly increase the rate of colonisation of the catheter by Candida species. [bib_ref] The effects of antibiotic ointments and antiseptics on the skin A ora..., Jarrard [/bib_ref] [bib_ref] A comparative study of polyantibiotic and iodophor ointments in prevention of vascular..., Maki [/bib_ref] NICE 56 identiA ed three RCTs that compared the effectiveness of different antiseptic solutions for the insertion of PVCs in hospitalised patients. The evidence from these studies was considered to be of very low quality, and no conclusion could be drawn about the beneA ts of one particular antiseptic solution over another. However, while there is no evidence comparing different concentrations of CHG, the reviewers indicated that the trend in the evidence suggests that CHG in alcohol may be more effective than PVI in alcohol.
We identiA ed one recent systematic review of the clinical efA cacy and perceived role of CHG in skin antisepsis that included studies about intravascular access. [bib_ref] The forgotten role of alcohol: a systematic review and meta-analysis of the..., Maiwald [/bib_ref] The authors suggested a potential source of bias, as many studies have overlooked the importance of alcohol when assessing the efA cacy of CHG. The authors assessed the attribution of CHG in each study as correct, incorrect or intermediate. Studies were scored and analysis was performed separately to assess CHG efA ciency. The authors concluded that CHG is more efA cient than PVI or any other technique alone, but that the presence of alcohol provides additional beneA t. The authors suggested that vascular catheters require the immediate antiseptic activity provided by alcohol prior to insertion. They also require a long-lasting antiseptic, as they stay in place for prolonged periods of time.
IVAD14 Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry prior to the insertion of a central venous access device.

## Class a
IVAD15 Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry before inserting a peripheral vascular access device.

## New recommendation class d/gpp
IVAD16 Do not apply antimicrobial ointment routinely to the catheter placement site prior to insertion to prevent catheter-related bloodstream infection.

## Class d/gpp

## Catheter and catheter site care

## Infections can be minimised by good catheter and insertion site care
The safe maintenance of an intravascular catheter and appropriate care of the insertion site are essential components of a comprehensive strategy for preventing catheter-related infections. This includes good practice in caring for the patient's catheter hub and connection port, the use of an appropriate intravascular catheter site dressing regimen, and using A ush solutions to maintain the patency of the catheter.

## Choose the right dressing for insertion sites to minimise infection
Following placement of a PVC or CVC, a dressing is used to protect the insertion site. As occlusive dressings trap moisture on the skin and provide an ideal environment for the rapid growth of local microA ora, dressings for insertion sites must be permeable to water vapour. [bib_ref] Catheter-related sepsis: an overview -Part 1, Fletcher [/bib_ref] The two most common types of dressings used for insertion sites are sterile, transparent, semi-permeable polyurethane dressings coated with a layer of an acrylic adhesive ('transparent dressings') and gauze and tape dressings. Transparent dressings are permeable to water vapour and oxygen, and impermeable to microorganisms.
HICPAC reviewed the evidence related to which type of dressing provided the greatest protection against infection, including the largest controlled trial of dressing regimens on PVCs, 361 a meta-analysis comparing the risk of CR-BSI using transparent vs gauze dressings [bib_ref] Transparent polyurethane A lm as an intravenous catheter dressing. A metaanalysis of..., Hoffmann [/bib_ref] and a Cochrane review. [bib_ref] Gauze and tape and transparent polyurethane dressings for central venous catheters, Gillies [/bib_ref] All concluded that the choice of dressing can be a matter of preference, but if blood is leaking from the catheter insertion site, a gauze dressing might be preferred to absorb the A uid. We identiA ed an updated Cochrane review which concluded that bloodstream infection was higher in the transparent polyurethane group compared with the gauze and tape group. [bib_ref] Gauze and tape and transparent polyurethane dressings for central venous catheters, Webster [/bib_ref] The included trials were graded low quality due to the small sample size and risk of bias. There was additional low-quality evidence that demonstrated no difference between highly permeable polyurethane dressings and other polyurethane dressings in the prevention of CR-BSI.
HICPAC reviewed the evidence related to impregnated sponge dressings compared with standard dressings and found two RCTs in adults which demonstrated that chlorhexidineimpregnated sponge dressings were associated with a signiA cant reduction in CR-BSI. However, a meta-analysis that included eight RCTs found a reduction in exit site colonisation but no signiA cant reduction in CR-BSI. In paediatric patients, two small RCTs found a reduction in catheter colonisation but not CR-BSI, and evidence of localised contact dermatitis when used for infants of very low birth weight. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] We identiA ed one systematic review and meta-analysis, undertaken as part of a quality improvement collaborative, that synthesised the effects of the routine use of CHGimpregnated sponge dressings in reducing centrally inserted CR-BSI. [bib_ref] Using the collaborative evidence based practice model: a systematic review and uptake..., Chan [/bib_ref] Five studies were included in the analysis; two of the A ve studies were in patients in haemo/oncological ICUs, and the remaining three studies were in surgical and medical ICUs. Four of the A ve studies were sponsored by the manufacturer of the product. The reviewers concluded that CHG-impregnated sponge dressings are effective for the prevention of CR-BSI (OR 0.43, 95% CI 0.29-0.64) and catheter colonisation (OR 0.43, 95% CI 0.36-0.51).
We identiA ed an economic evaluation of the use of CHG sponge dressings and the non-inferiority of dressing changes at 3 and 7 days. [bib_ref] Economic evaluation of chlorhexidine-impregnated sponges for preventing catheterrelated infections in critically ill..., Schwebel [/bib_ref] The authors concluded that the major cost avoided by the use of CHG sponge dressings and 7-day dressing changes rather than 3-day dressing changes was the increased length of stay of 11 days associated with CR-BSI. Chlorhexidineimpregnated sponge dressings remained cost saving for any value where the cost per CR-BSI was >$4400 and the baseline rate of CR-BSI was >0.35%. [bib_ref] Economic evaluation of chlorhexidine-impregnated sponges for preventing catheterrelated infections in critically ill..., Schwebel [/bib_ref] We identiA ed a further RCT of CHG dressings compared with highly adhesive semi-permeable dressings or standard semi-permeable dressings for the prevention of CR-BSI in 1879 patients. [bib_ref] Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing..., Timsit [/bib_ref] In the CHG group, the major catheterrelated infection rate was 67% lower (0.7 vs 2.1 per 1000 catheter-days, HR 0.328, 95% CI 0.174-0.619, p=0.0006) and the CR-BSI rate was 60% lower (0.5 vs 1.3 per 1000 catheterdays, HR 0.402, 95% Cl 0.186-0.868, p=0.02) than with nonchlorhexidine dressings. Decreases were also noted in catheter colonisation and skin colonisation rates at catheter removal. Highly adhesive dressings decreased the detachment rate to 64.3% vs 71.9% (p<0.0001) and the number of dressings per catheter to two (one to four) vs three (one to A ve) (p<0.0001), but increased skin colonisation (p<0.0001) and catheter colonisation (HR 1.650, 95% Cl 1.21-2.26, p=0.0016) without inA uencing CR-BSI rates.
HICPAC identiA ed three studies that investigated the efA cacy of a 2% CHG-impregnated washcloth in reducing the risk of CR-BSI. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] These studies were included in a subsequent systematic review and meta-analysis on the efA cacy of either 2% CHG-impregnated cloths or 4% CHG solution for daily skin cleansing in adult acute care settings, mostly ICUs. [bib_ref] The efA cacy of daily bathing with chlorhexidine for reducing healthcareassociated bloodstream..., O&apos;horo [/bib_ref] Twelve studies were included: one RCT, one cluster NRCT and 10 controlled interrupted time series. Five studies that reported the insertion technique included the use of CHG. There was a high level of clinical heterogeneity and moderate statistical heterogeneity, which remained following a subgroup analysis by type of CHG formulation. The authors concluded that among ICU patients, daily CHG bathing with CHG liquid (OR 0.47, 95% CI 0.31-0.71) or cloths (OR 0.41, 95% CI 0.25-0.65) reduces the risk of CR-BSI. Similar beneA t is obtained regardless of whether CHG cloths or liquid preparation is used (OR 0.44, 95% CI 0.44-0.59). This review was not generalisable to paediatric care.
Whenever CHG is used for insertion site dressings or skin cleansing, systems should be in place to ensure that it is not used for patients with a history of chlorhexidine sensitivity. [bib_ref] InA uence of triple-lumen central venous catheters coated with chlorhexidine and silver..., Heard [/bib_ref] A single RCT compared the efA cacy of two commercially available alcohol-based antiseptic solutions for preparation and care of CVC insertion sites, with and without octenidine dihydrochloride. [bib_ref] Skin disinfection with octenidine dihydrochloride for central venous catheter site care: a..., Dettenkofer [/bib_ref] Data were collected from 2002 to 2005 and published in 2010. The authors concluded that octenidine in alcoholic solution is a better option than alcohol alone for the prevention of CVC-associated infections, and may be as effective as CHG in practice but a comparative trial is needed. IVAD17 Use a sterile, transparent, semipermeable polyurethane dressing to cover the intravascular insertion site.

## Class d/gpp
IVAD18 Transparent, semi-permeable polyurethane dressings should be changed every 7 days, or sooner, if they are no longer intact or if moisture collects under the dressing.

## Class d/gpp
IVAD19 Use a sterile gauze dressing if a patient has profuse perspiration or if the insertion site is bleeding or leaking, and change when inspection of the insertion site is necessary or when the dressing becomes damp, loosened or soiled. Replace with a transparent semi-permeable dressing as soon as possible.

## Class d/gpp
IVAD20 Consider the use of a chlorhexidineimpregnated sponge dressing in adult patients with a central venous catheter as a strategy to reduce catheterrelated bloodstream infection.

## New recommendation class b
IVAD21 Consider the use of daily cleansing with chlorhexidine daily in adult patients with a central venous catheter as a strategy to reduce catheter-related bloodstream infection.

## New recommendation class b
IVAD22 Dressings used on tunnelled or implanted catheter insertion sites should be replaced every 7 days until the insertion site has healed unless there is an indication to change them sooner. A dressing may no longer be required once the insertion site is healed.

## Class d/gpp

## Use an appropriate antiseptic agent for disinfecting the catheter insertion site during dressing changes
Research previously described in these guidelines has described the superior effectiveness of CHG to minimise the density of microorganisms around vascular catheter insertion sites. [bib_ref] Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection..., Maki [/bib_ref] [bib_ref] Prospective, randomized trial of two antiseptic solutions for prevention of central venous..., Mimoz [/bib_ref] [bib_ref] Chlorhexidine compared with povidone-iodine solution for vascular cathetersite care: a meta-analysis, Chaiyakunapruk [/bib_ref] Consequently, alcoholic CHG is now widely used in the UK for disinfecting the insertion site during dressing changes.
Studies focused on the use of antimicrobial ointment applied under the dressing to the catheter insertion site to prevent catheter-related infection do not clearly demonstrate efA cacy. [bib_ref] Colonization of central venous catheters, Prager [/bib_ref] [bib_ref] A comparative study of polyantibiotic and iodophor ointments in prevention of vascular..., Maki [/bib_ref] Most modern intravascular catheters and other catheter materials are not damaged by contact with alcohol. However, alcohol, and other organic solvents and oil-based ointments and creams, may damage some types of polyurethane and silicon catheter tubing (e.g. some catheters used in haemodialysis). The manufacturer's recommendations to only use disinfectants that are compatible with speciA c catheter materials must therefore be followed.
IVAD23 Use a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the central catheter insertion site during dressing changes, and allow to air dry.

## Class a
IVAD24 Use a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the peripheral venous catheter insertion site during dressing changes, and allow to air dry.

## New recommendation class d/gpp
IVAD25 Do not apply antimicrobial ointment to catheter insertion sites as part of routine catheter site care.

## Class d/gpp

## Catheter replacement strategies

## Replacing intravascular devices routinely does not prevent infection
Evidence indicates that the routine replacement of CVCs at scheduled time intervals does not reduce rates of CR-BSI. Three randomised trials investigated strategies for replacing CVCs routinely at either 7 days 469,470 or 3 days 471 compared with changing catheters when clinically indicated. Two studies were conducted in adult ICUs 469,471 and a third study was undertaken in a renal dialysis unit. [bib_ref] Changing subclavian haemodialysis cannulas to reduce infection, Uldall [/bib_ref] No difference in CR-BSI was observed in patients in the scheduled replacement groups compared with those replaced when clinically indicated.
Another suggested strategy for the prevention of CR-BSI is the routine scheduling of guidewire exchange of CVCs. A systematic review and meta-analysis 472 of 12 RCTs concluded that when compared with insertion at a new site, guidewire exchange was associated with a trend towards increased rates of catheter colonisation (RR 1.26, 95% CI 0.87-1.84), regardless of suspected CR-BSI at the time of replacement. Guidewire exchange was also associated with a trend towards increased rates of catheter exitsite infection (RR 1.52, 95% CI 0.34-6.73) and CR-BSI (RR 1.72, 95% CI 0.89-3.33), but also associated with fewer mechanical complications relative to insertion at a new site. [bib_ref] Central venous catheter replacement strategies: a systematic review of the literature, Cook [/bib_ref] Neither we nor HICPAC identiA ed any additional evidence for these recommendations whilst updating our systematic review. 334

## Peripheral vascular devices
We identiA ed one RCT that compared a routine 3-day re-siting of PVCs compared with a clinically indicated resiting. IVD-related complication rates were 68 per 1000 IVDdays (clinically indicated) and 66 per 1000 IVD-days (routine replacement) (p=0.86, hazard ratio 1.03, 95% CI 0.74-1.43). Re-siting a device on clinical indication would allow one in two patients to have a single cannula per course of intravenous treatment, as opposed to one in A ve patients managed with routine re-siting; overall complication rates appear similar. Clinically indicated re-siting would achieve savings in equipment, staff time and patient discomfort. [bib_ref] Routine resite of peripheral intravenous devices every 3 days did not reduce..., Rickard [/bib_ref] A recent update of a Cochrane review found no evidence to support changing catheters every 72-96 h. [bib_ref] Clinically-indicated replacement versus routine replacement of peripheral venous catheters, Webster [/bib_ref] 

## General principles for catheter management

## Aseptic technique is important when accessing the system
Evidence demonstrating that contamination of the catheter hub contributes to intraluminal microbial colonisation of catheters, particularly long-term catheters, was considered by HICPAC. [bib_ref] Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization..., Raad [/bib_ref] [bib_ref] Source and route of microbial colonisation of parenteral nutrition catheters, De Cicco [/bib_ref] [bib_ref] Catheter sepsis due to coagulase-negative staphylococci in patients on total parenteral nutrition, Capell [/bib_ref] [bib_ref] A prospective study of the catheter hub as the portal of entry..., Salzman [/bib_ref] [bib_ref] Adherence and growth of coagulase-negative staphylococci on surfaces of intravenous catheters, Peters [/bib_ref] [bib_ref] Pathogenesis of catheter sepsis: a prospective study with quantitative and semiquantitative cultures..., Linares [/bib_ref] [bib_ref] A randomized trial on the effect of tubing changes on hub contamination..., Sitges-Serra [/bib_ref] Catheter hubs are accessed more frequently when catheterisation is prolonged, and this increases the risk of CR-BSI originating from a colonised catheter hub rather than the insertion site. [bib_ref] Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization..., Raad [/bib_ref] Evidence from a prospective cohort study suggested that frequent catheter hub manipulation increases the risk for microbial contamination. [bib_ref] Contamination of stopcocks mounted in administration sets for central venous catheters with..., Weist [/bib_ref] Additional studies concurred and recommended that hubs and sampling ports should be disinfected using either povidone iodine or chlorhexidine before they are accessed. [bib_ref] Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated..., Maki [/bib_ref] [bib_ref] Use of disinfectants to reduce microbial contamination of hubs of vascular catheters, Salzman [/bib_ref] [bib_ref] Effectiveness of disinfectant techniques on intravenous tubing latex injection ports, Ruschman [/bib_ref] A randomised prospective clinical trial investigated the use of needleless connectors or standard caps attached to CVC luer connections. Results suggested that the use of needleless connectors may reduce the microbial contamination rate of CVC luers compared with standard caps. Furthermore, disinfection of needleless connectors with either chlorhexidine/alcohol or PVI signiA cantly reduced external microbial contamination. Both these strategies may reduce the risk of catheter-related infections acquired via the intraluminal route. [bib_ref] A randomized, prospective clinical trial to assess the potential infection risk associated..., Casey [/bib_ref] We found no RCT evidence comparing the efA cacy of different methods for the decontamination of ports and hubs prior to access. Expert opinion, based on consensus and evidence extrapolated from experimental studies of hub decontamination, [bib_ref] Scrub the hub': cleaning duration and reduction in bacterial load on central..., Simmons [/bib_ref] [bib_ref] Successful disinfection of needleless access ports: a matter of time and friction, Kaler [/bib_ref] and studies of skin decontamination prior to insertion and during dressing changes, suggests that injection ports or catheter hubs should be decontaminated for a minimum of 15 s using CHG in 70% alcohol before and after accessing the system. Although most intravascular catheters and catheter hub materials are now chemically compatible with alcohol or iodine, some may be incompatible and therefore the manufacturer's recommendations should be followed. IVAD30 A single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) should be used to decontaminate the access port or catheter hub. The hub should be cleaned for a minimum of 15 s and allowed to dry before accessing the system.

## Class d/gpp

## Using lock solutions to prevent infection
The procedure of A ushing and then leaving the lumen of a CVC A lled with an antibiotic solution is termed 'antibiotic lock prophylaxis' and has been described as a measure to prevent CR-BSI in haemodialysis or a patient who has a history of multiple CR-BSI despite optimal maximal adherence to the aseptic technique. Evidence reviewed by HICPAC 334 demonstrated the effectiveness of this type of prophylaxis. However, the majority of the studies were conducted in haemodialysis patients and therefore may not be generalisable.
We identiA ed a systematic review of RCTs which concluded that the scientiA c evidence for the effectiveness of the routine use of antibiotic-based lock solutions is weak, 487 thus supporting the HICPAC evidence. In addition, there is concern that the use of such solutions could lead to an increase in antimicrobialresistant microorganisms. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] An additional placebo-RCT of daily ethanol locks to prevent CR-BSI in patients with tunnelled catheters [bib_ref] Prevention of catheter-related bacteremia with a daily ethanol lock in patients with..., Slobbe [/bib_ref] found that the reduction in the incidence of endoluminal CR-BSI using preventive ethanol locks was non-signiA cant, although the low incidence of endoluminal CR-BSI precludes deA nite conclusions, and the low incidence of CR-BSI in the placebo arm meant the study was underpowered in retrospect. SigniA cantly more patients treated with ethanol locks discontinued their prophylactic treatment due to non-severe, ethanol-related adverse effects. IVAD31 Antimicrobial lock solutions should not be used routinely to prevent catheterrelated bloodstream infections.

## Class d/gpp

## Antibiotic prophylaxis does not prevent catheterrelated bloodstream infection
HICPAC identiA ed no studies which demonstrated that oral or parenteral antibacterial or antifungal drugs reduced the incidence of CR-BSI among adults. However, among lowbirthweight infants, two studies on vancomycin prophylaxis demonstrated a reduction in CR-BSI but no reduction in mortality. As the prophylactic use of vancomycin is an independent risk factor for the acquisition of VRE, it is likely that the risk of acquiring VRE outweighs the beneA t of using prophylactic vancomycin. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] Topical mupirocin is used to suppress S. aureus in nasal carriers. Some studies have shown that mupirocin applied nasally (or locally to the insertion site) results in reduced risk of CR-BSI. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] However, rates of mupriocin resistance of 12% have been reported in the UK,and its incompatibility with polyurethane catheters means that it should not be used routinely. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] Long-term tunnelled CVCs are frequently used for patients with cancer who require intravenous treatments. A Cochrane review published in 2003 concluded that prophylactic antibiotics or catheter A ushing with vancomycin and heparin may be of beneA t in reducing the risk of catheter-related infections in these high-risk cancer patients. [bib_ref] Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in..., Van De Wetering [/bib_ref] However, this practice should not be used routinely in order to minimise the development of antimicrobial resistance. 491 IVAD32 Do not routinely administer intranasal or systemic antimicrobials before insertion or during the use of an intravascular device to prevent catheter colonisation or bloodstream infection.

## Class a

## Maintaining device patency and preventing catheter thrombosis may help prevent infections
The placement of any CVC or pulmonary artery catheter leads to thrombus formation shortly after insertion, providing a focus for bacterial growth. [bib_ref] Heparin bonding reduces thrombogenicity of pulmonaryartery catheters, Hoar [/bib_ref] Catheters manufactured from silicone or polyethylene and placed in the subclavian vein are less frequently associated with thrombus formation. [bib_ref] Central venous access sites for the prevention of venous thrombosis, stenosis and..., Ge [/bib_ref] Between 35% and 65% of patients with long-term CVCs and PICCs develop a thrombosis of the large vessels, and patients are treated with prophylactic heparin to prevent the formation of both deep vein thrombosis and catheter thrombus. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] [bib_ref] The relationship between the thrombotic and infectious complications of central venous catheters, Raad [/bib_ref] [bib_ref] Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein:..., Chastre [/bib_ref] [bib_ref] Central vein thrombosis associated with intravenous feeding -a prospective study, Valerio [/bib_ref] [bib_ref] A cross-sectional study of catheter-related thrombosis in children receiving total parenteral nutrition..., Andrew [/bib_ref] [bib_ref] Catheter-related thrombosis in critically ill children: comparison of catheters with and without..., Krafte-Jacobs [/bib_ref] [bib_ref] A prospective study of femoral catheter-related thrombosis in children, Talbott [/bib_ref] The use of anticoagulants Heparin may be administered through several different routes. An early meta-analysis of RCTs compared the effectiveness of heparin administration via an infusion, subcutaneously or intermittent A ush for the prevention of thrombus formation and CR-BSI in patients with short-term CVCs. [bib_ref] BeneA t of heparin in central venous and pulmonary artery catheters: a..., Randolph [/bib_ref] Prophylactic heparin infusion was associated with a decrease in catheter thrombus formation, deep vein thrombosis, catheter colonisation and a trend towards reductions in CR-BSI, but this was not statistically H. P. Loveday et al. / Journal of Hospital Infection 86S1 (2014) S1-S70 S49 signiA cant. HICPAC identiA ed an additional prospective randomised trial that demonstrated a signiA cant decrease in the rate of CR-BSI in patients with non-tunnelled CVCs who received continuous heparin infusion. [bib_ref] Very low doses of warfarin can prevent thrombosis in central venous catheters...., Bern [/bib_ref] Heparin-bonded (HB) catheters have also been shown to reduce the risk of both thrombus formation and CR-BSI. [bib_ref] Randomized trial of prevention of catheter-related bloodstream infection by continuous infusion of..., Abdelkea [/bib_ref] [bib_ref] Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill..., Pierce [/bib_ref] [bib_ref] Surface heparinization of central venous catheters reduces microbial colonization in vitro and..., Appelgren [/bib_ref] [bib_ref] Use of heparincoated central venous lines to prevent catheter-related bloodstream infection, Abdelkea [/bib_ref] We identiA ed one systematic review of HB CVCs in children. [bib_ref] Heparin-bonded catheters for prolonging the patency of central venous catheters in children, Shah [/bib_ref] The reviewers identiA ed two RCTs of 287 children aged 1 day to 16 years who received either an HB catheter or a standard catheter. There was no signiA cant difference in the median duration of catheter patency in the two groups: 7 days in the HB catheter group and 6 days in the standard catheter group. The authors also reported a trend towards a reduction in the risk of catheter-related thrombosis and catheter occlusion in the HB group. The risks of catheter colonisation and catheterrelated infection were signiA cantly reduced in the treatment group, with a delay to infection in the HB catheter group. However, the reviewers considered the need for further studies to conA rm the efA cacy of HB catheters.
The use of warfarin has also been shown to reduce the risk of catheter-related thrombosis in some patient groups but not in others, and is generally not associated with a reduction in infection-related complications. 501,507-509

## Heparin vs normal saline intermittent a ushes
Systemic heparin, as either an infusion or A ush, has a number of side effects that contraindicate its routine use for maintaining the patency of CVCs and preventing thrombus formation; these include thrombocytopenia, allergic reactions and bleeding. [bib_ref] Thrombosis prophylaxis in patient populations with a central venous catheter: a systematic..., Klerk [/bib_ref] Normal saline is an alternative to the use of heparin A ush.
HICPAC refer to three systematic reviews, and meta-analysis of RCTs evaluating the effect of heparin on the duration of catheter patency and on the prevention of complications associated with the use of peripheral venous and arterial catheters concluded that heparin at doses of 10 U/mL for intermittent A ushing is no more beneA cial than A ushing with normal saline alone. [bib_ref] The heparin A ush syndrome: a cause of iatrogenic hemorrhage, Passannante [/bib_ref] [bib_ref] BeneA t of heparin in peripheral venous and arterial catheters: systematic review..., Randolph [/bib_ref] [bib_ref] A meta-analysis of effects of heparin A ush and saline A ush:..., Goode [/bib_ref] [bib_ref] Analysis of the research about heparinized versus nonheparinized intravascular lines, Peterson [/bib_ref] However, manufacturers of implanted ports or opened-ended catheter lumens may recommend heparin A ushes for maintaining CVCs that are accessed infrequently.
We identiA ed one systematic review and two RCTs that compared heparin with normal saline to maintain the patency of CVCs and PVCs, respectively. 515-517 A systematic review [bib_ref] Heparin A ushing and other interventions to maintain patency of central venous..., Mitchell [/bib_ref] of heparin A ushing and other interventions to maintain the patency of CVCs concluded that the evidence base for heparin A ushing and other interventions to prevent catheter occlusion is limited and published studies are of low quality. The reviewers concluded that there is no direct evidence of the effectiveness of heparin A ushes to prevent CR-BSI or other central line complications.
In a single-centre RCT 516 of newly placed multi-lumen CVCs in patients in medical ICUs and surgical/burn/trauma ICUs, normal saline and heparin A ush solutions were found to have similar rates of lumen non-patency. Given potential safety concerns with the use of heparin, normal saline may be the preferred A ushing solution for short-term use for CVC maintenance. Secondary outcomes for CR-BSI were non-signiA cant between groups.
A single-centre cluster RCT 517 of 214 medical patients found that twice-daily heparin (100 U/mL) A ushes for maintenance of PVCs was more effective than normal saline solution. The number of catheter-related phlebitis/occlusions and the number of catheters per patient was reduced; however, infection outcomes were not measured.
IVAD33 Do not use systemic anticoagulants routinely to prevent catheter-related bloodstream infection.

## Class d/gpp
IVAD34 Use sterile normal saline for injection to A ush and lock catheter lumens that are accessed frequently.

## Class a

## Safer sharps devices require vigilance
Needle-free infusion systems and connection devices have been widely introduced to reduce the incidence of sharps injuries and minimise the risk of transmission of bloodborne pathogens to healthcare workers. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] There is limited evidence that needleless devices or valves reduce the risk of catheter colonisation compared with standard devices. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] In addition, the design features of some of these devices pose a potential risk for contamination, and have been associated with reports of an increase in bloodstream infection rates. [bib_ref] Outbreak of bloodstream infection temporally associated with the use of an intravascular..., Rupp [/bib_ref] [bib_ref] Increased rate of catheter-related bloodstream infection associated with use of a needleless..., Salgado [/bib_ref] [bib_ref] Increased catheterrelated bloodstream infection rates after the introduction of a new mechanical..., Maragakis [/bib_ref] [bib_ref] Incidence of catheterrelated bloodstream infection among patients with a needleless, mechanical valve-based..., Field [/bib_ref] IVAD35 The introduction of new intravascular devices or components should be monitored for an increase in the occurrence of device-associated infection. If an increase in infection rates is suspected, this should be reported to the Medicines and Healthcare Products Regulatory Agency in the UK.

## Class d/gpp
IVAD36 When safer sharps devices are used, healthcare workers should ensure that all components of the system are compatible and secured to minimise leaks and breaks in the system.

## Class d/gpp

## Change intravenous administration sets appropriately
HICPAC reviewed three well-controlled studies on the optimal interval for the routine replacement of intravenous solution administration sets. [bib_ref] Guidelines for the prevention of intravascular catheter-related infections, O&apos;grady [/bib_ref] A Cochrane review 522 of 13 RCTs with 4783 patients concluded that there is no evidence that changing intravenous administration sets more often than every 96 h reduces the incidence of bloodstream infection. The reviewers were unable to conclude if changing administration sets less often than every 96 h affects the incidence of infection from the studies. There were no differences between participants with central vs peripheral catheters, nor between participants who did and did not receive parenteral nutrition, or between children and adults. Administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 h without increasing the incidence of infection. There is no evidence to suggest that administration sets which contain lipids should not be changed every 24 h as currently recommended.
IVAD37 Administration sets in continuous use do not need to be replaced more frequently than every 96 h, unless device-speciA c recommendations from the manufacturer indicate otherwise, they become disconnected or the intravascular access device is replaced.
Class A IVAD38 Administration sets for blood and blood components should be changed when the transfusion episode is complete or every 12 h (whichever is sooner).

## Class d/gpp
IVAD39 Administration sets used for lipidcontaining parenteral nutrition should be changed every 24 h.

## Class d/gpp

## System interventions to reduce catheter-related infection
Ensuring that patients receive care that is evidence based is an essential element of delivering high-quality health care. In 2005, the Department of Health issued a series of highimpact interventions that were derived from national and international evidence-based guidelines for the prevention of healthcare-associated infection and based on experience from the Institute of Healthcare Improvement 100,000 Lives Campaign focused on reducing patient harm.The high-impact interventions focused on increasing the reliability of care and ensuring that recommendations were implemented every time for every patient. The intervention for the prevention of infection associated with the use of IVDs included six key interventions often referred to as a 'care bundle', together with audit tools to measure adherence. These six practices included: - aseptic insertion of an appropriate device; - correct siting of the device; - effective cutaneous antisepsis; and for continuing care of the device: - hand decontamination and asepsis for any contact with the device; - daily observation of the insertion site; and - clean, intact dressing.
A small number of well-designed studies 353,524 have described the use of 'bundled' approaches to reducing CR-BSI, and have stimulated individual observational and quality improvement reports of the results of using key evidence-based practices for the prevention of CR-BSI. The most prominent of these was a study conducted in the ICU setting of 108 hospitals in the USA, which was then adopted by other countries including the UK. [bib_ref] An intervention to decrease catheter-related bloodstream infections in the ICU, Pronovost [/bib_ref] [bib_ref] Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units:..., Pronovost [/bib_ref] The authors reported the success of A ve evidence-based practices combined with system and organisational support, which resulted in a 66% decrease in CR-BSI 18 months after the inception of the programme (incidence rate ratio 0.62, 95% CI 0.47-0.81 to incidence rate ratio 0.34, 95% CI 0.23-0.50) and sustained reductions thereafter. [bib_ref] An intervention to decrease catheter-related bloodstream infections in the ICU, Pronovost [/bib_ref] The intervention comprised: hand hygiene using ABHR; MSB precautions for insertion; cutaneous antisepsis of the insertion site with 2% CHG; avoiding the femoral site; and removing CVCs as soon as they are no longer clinically indicated. In addition, system changes that prompted the clinician to 'do the right thing' included placing all the equipment needed in a cart for ease of access; the use of a checklist; authorising staff to halt procedures if best practice was not being followed; daily rounds to ensure the timely removal of CVCs; feedback of CR-BSI cases to clinical staff; and organisational support to purchase essential equipment and solutions prior to the start of the study.
Audit and feedback are an essential component of any quality improvement intervention as this promotes a continuous 'Hawthorne effect' and enables staff to maintain vigilance and sustain improvement. The use of dashboards and statistical process control charts alerts clinicians to variability outside control limits, and prompts scrutiny of practice and organisational systems, and remedial action to be taken. [bib_ref] Results of a multicentre randomised controlled trial of statistical process control charts..., Curran [/bib_ref] We identiA ed three additional studies that reported 'bundled interventions' to reduce CR-BSI. [bib_ref] A multifaceted intervention for quality improvement in a network of intensive care..., Scales [/bib_ref] [bib_ref] Effectiveness of stepwise interventions targeted to decrease central catheterassociated bloodstream infections, Munoz-Price [/bib_ref] [bib_ref] Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood..., Bion [/bib_ref] None were included in the systematic review as they failed to meet study quality criteria. The features of any quality improvement initiative need to be tailored to the local conditions and may include some or all of the following: - hand hygiene, aseptic insertion using MSB precautions (CVC), aseptic technique (PVC), cutaneous antisepsis using 2% CHG in alcohol unless contraindicated, appropriate siting of the CVC or PVC, and prompt removal when no longer indicated; - audit and feedback; - education and training; and - accessibility of equipment and appropriate system changes developed with clinical staff to make best practice the norm.
In one cost-effectiveness study, a Markov decision model was used to evaluate the cost-effectiveness of a care bundle to prevent CR-BSI. [bib_ref] Costeffectiveness of a central venous catheter care bundle, Halton [/bib_ref] The care bundle included in the model was based on the bundle advocated by the Institute for Health Improvement 100,000 Lives Campaign, 532 comprising optimal hand hygiene, chlorhexidine skin antisepsis, MSB precautions for catheter insertion and insertion equipment kit, optimal insertion site and prompt catheter removal. Costs included monitoring, education and clinical leadership activities. The authors estimated that the bundle would be cost-effective if the costs of implementation were less than AUS$94,559 (55,817) per ICU.

## Ivad40 use quality improvement interventions
to support the appropriate use and management of intravascular access devices (central and peripheral venous catheters) and ensure their timely removal. These may include:
- protocols for device insertion and maintenance; - reminders to review the continuing use or prompt the removal of intravascular devices; - audit and feedback of compliance with practice guidelines; and - continuing professional education.

## New recommendation

## Intravascular access devices -systematic review process
Systematic Review Questions 1. What types of CVCs (material, coating, antibiotic impregnation, cuffed, tunnelled, midline, PICC) and PVCs (material, coating, antibiotic impregnation) are most effective in reducing the risk of CR-BSI and related complications/adverse events including phlebitis, related mortality, catheter tip colonisation and premature line removal? 2. Which CVC/PVC insertion site is associated with the lowest risk of CR-BSI and related complications including phlebitis, related mortality, catheter tip colonisation and premature line removal? 3. What is the evidence that additional ports or lumens increase the risk of CR-BSI and related complications/adverse events including phlebitis, mortality, catheter tip colonisation and premature line removal? 4. Which infection prevention precautions used for inserting intravascular catheters are most effective in reducing the risk of CR-BSI and related complications/adverse events including phlebitis, catheter tip colonisation, premature line removal and mortality? 5. What levels of barrier precautions are most effective in reducing the risk of CR-BSI and related complications/adverse events including phlebitis, catheter tip colonisation, premature line removal and mortality? 6. What is the most effective skin antisepsis solution/antiseptic-impregnated product for decontamination of the skin prior to insertion of CVCs and PVCs to reduce the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 7. What is the effectiveness of antiseptics vs antiseptic-impregnated products (sponges or cloths) for decontaminating skin at the insertion site or surrounding area whilst a CVC or PVC is in situ in reducing the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 8. What is the evidence for the effectiveness of using antibiotics or antiseptics to lock, A ush or clean the catheter hub or entry ports of CVCs and PVCs in reducing the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 9. What is the effectiveness of low-dose systemic anticoagulation to reduce the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 10. Which dressing type is the most clinically effective in reducing the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality, and how frequently should dressings be changed? 11. What is the optimal frequency to change or re-site PVCs or midline catheters to reduce the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 12. What is the evidence for the effectiveness of replacing administration sets to reduce the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 13. What is the effectiveness of the prophylactic administration of systemic antimicrobials in reducing the incidence of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 14. What is the evidence that the needle-safe devices are associated with increased risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality? 15. What is the effectiveness of system interventions in reducing the risk of CR-BSI and related complications including phlebitis, catheter tip colonisation, premature line removal and mortality, and improving healthcare workers' knowledge and behaviour relating to the use of central venous access device (CVAD) and peripheral vascular device (PVD)?

## Databases and search terms

# Search results
Total number of articles located = 8053

## Sift 1 criteria
Abstract indicates that the article: relates to infections associated with intravascular access devices; is written in English; is primary research, a systematic review or a meta-analysis; and appears to inform one or more of the review questions.

## Articles retrieved
Total number of articles retrieved from Sift 1 = 96

## Sift 2 criteria
Full text conA rms that the article: relates to infections associated with intravascular access devices; is written in English; is primary research (randomised controlled trials, prospective cohort, interrupted time series, controlled before-after, quasi-experimental), a systematic review or a metaanalysis including the above designs; and informs one or more of the review questions.

## Articles selected for appraisal
Total number of studies selected for appraisal during Sift 2 = 30

## Critical appraisal
All articles that described primary research, a systematic review or a meta-analysis and met the Sift 2 criteria were independently critically appraised by two appraisers using SIGN and EPOC criteria. Consensus and grading was achieved through discussion.

## Accepted and rejected evidence
Total number of studies accepted after critical appraisal = 22 Total number of studies rejected after critical appraisal = 8
[fig] : Dr Debra Adams, NHS Trust Development Authority (DA) Ms Susan Bennett, Lay Member (SB) Dr Tim Boswell, Nottingham University Hospitals NHS Trust (TB) Ms Maria Cann, Lay Member (MC) Ms Tracey Cooper, South London NHS Trust (TC) Dr Peter Cowling, Northern Lincolnshire & Goole Hospitals NHS Trust Ms Judith Hudson, Association of Healthcare Cleaning Professionals Ms Theresa Neale, Urology Nurse Specialist, British Association of Urological Nurses (Consultant) Dr Jeff Phillips, Consultant Intensivist and Clinical Lead for Anaesthetics (Consultant) (JPh), Princess Alexandra Hospital Harlow Dr Jacqui Prieto, University of Southampton (Infection Prevention Adviser) Mr Julian Shah, Consultant Urologist (Consultant), King Edward VII Hospital, London Professor Mark Wilcox, Leeds Teaching Hospitals and University of Leeds Ms Carole Fry, Department of Health (Observer) Professor Brian I. Duerden CBE, Duerden Microbiology Consulting Ltd (Chair of Face-to-Face Meeting) Ms Meg Morse, Administrative OfA cer, University of West London [/fig]
[table] Table 1: Levels of evidence for intervention studies5 [/table]
[table] 1: What are the risk factors associated with sharps injuries in secondary health care? (*B) 2. What are the changes in legislation in relation to the use and disposal of sharps and the prevention of injuries in healthcare settings? (B) 3. What is the effectiveness and cost-effectiveness of using safety [/table]
[table] Table 3: Catheters used for venous and arterial access [/table]