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  • Preventing infections associated with the use of central venous catheters

Systematic review

Preventing infections associated with the use of central venous catheters

Published Updated

This review summarizes research that give an overview of interventions that may reduce the risk of infections with the use of central venous catheters.

This review summarizes research that give an overview of interventions that may reduce the risk of infections with the use of central venous catheters.


About this publication

  • Year: 2015
  • Authors Holte HH, Underland V, Hafstad E.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-972-4

Key message

A central venous catheter is inserted into a large vein in the neck or groin to administer long-term intravenous medication or fluid nutrition. With use of a central venous catheter, the patients become susceptible to central line infections.

This review summarizes research that give an overview of interventions that may reduce the risk of infections with the use of central venous catheters.

Use of central venous catheters impregnated with antiseptic or antibiotic agents reduce the risk of catheter related bloodstream infections. All-cause mortality, adverse events, or catheter related topical infection are probably not affected.

We also identified other promising interventions; flushing and locking of long-term central venous catheter with a combined antibiotic and heparin solution for cancer patients, and use of antimicrobial ointment for patients with kidney failure.

This report does not evaluate long term effects of antiseptic or antibiotic agents. Antibiotic resistant bacteria is a problem, in Norway as well as internationally. This is important to keep in mind when applying these results.

Summary

Background

A central venous catheter (CVC) is inserted into a large vein in the neck, chest or groin to administer long-term intravenous medication or fluid nutrition, especially in chronically ill patients. Upon insertion, the skin barrier is broken, and the patients are susceptible to central line infections. A review of high quality systematic reviews can give an overview of interventions that reduce the risk of infection.

Most commonly, the central venous catheter is inserted into vena jugularis interna, vena subclavia or vena femoralis. Use of a central venous catheter is associated with increased risk of bloodstream infections compared to peripheral venous catheters.

Method

We searched for systematic reviews about prevention of infections when using central venous catheter, published in the Agency of Healthcare Research and Quality’s (AHRQ) report “Making Health Care Safer II” or in Cochrane Database of Systematic Reviews in 2010 or later.

We evaluated the systematic reviews identified in the Cochrane Library to be of high quality and to be newer than the AHRQ report.

We have included applicable Cochrane reviews and have done no further searches. We have extracted data about relevant interventions for preventing infections, and graded our confidence in the results using GRADE.

 

Results

We included ten systematic reviews. The studies included in these reviews were conducted in Australia, Austria, Belgium, Brazil, Canada, Chile, China, Denmark, France, Germany, Greece, Italy, Iran, Japan, Malaysia, Netherlands, Saudi Arabia, South Africa, Spain, Sweden, Taiwan, Tunisia, Turkey, UK and USA. The results show that:

  • Catheters impregnated with antiseptic or antibiotic agents compared to non-impregnated catheters in adults reduce the risk of catheter related bloodstream infections (Relative Risk (RR) 0.61; 95% Confidence Interval (CI) 0.51 to 0.73) and catheter colonization (RR 0.66; 95% CI 0.58 to 0.75). Probably there is a trend that all-cause mortality (RR 0.88; 95% CI 0.75 to 1.05), or catheter related topical infections (RR 0.84; 95% CI 0.66 to 1.07) are reduced. We are uncertain if adverse events (RR 1.09; 95% CI 0.94 to 1.27), clinically diagnosed sepsis (RR 1; 95% CI 0.88 to 1.13) are affected.
  • We are uncertain if the use of heparin instead of 0.9% sodium chloride will affect catheter-related sepsis (RR 1.02; 95% CI 0.34 to 3.03) or mortality (RR 0.77; 95% CI 0.45 to 1.32) in adults.
  • We are uncertain if the use of heparin-bonded catheters compared to non-heparin-bonded catheters in children result in a similar incidence of adverse events (RR 0.73; 95% CI 0.38 to 1.39), while catheter related bloodstream infections and central venous catheter-related colonization is reduced (RR 0.06; 95 % KI 0.01 to 0.41).
  • Flushing and locking of long-term central venous catheter with a combined antibiotic and heparin solution compared to use of only heparin solution for cancer patients may possibly reduce the risk of gram-positive catheter-related sepsis (RR 0.47; 95% CI 0.28 to 0.8).
  • Antimicrobial ointment compared with no ointment or placebo, might possibly reduce central venous catheter-infections (RR 0.33; 95% CI 0.18 to 0.61), catheter-re­lated bacteremia (RR 0.26 (95% CI 0.15 to 0.46)), infection-related mortality (RR 0.15; 95% CI 0.03 to 0.81) and premature removal due to infection (RR 0.35; 95% CI 0.25 to 0.5) for patient with kidney failure.
  • Subclavian access site compared with femoral access site for adults may possibly reduce catheter-related colonization (RR 6.43; 95% CI 1.95 to 21.21).

 

Our confidence in results from other comparisons is low. We are unable to conclude regarding the use of:

  • Lock treatment and systemic antibiotics compared to systemic antibiotics alone.
  • Urokinase (with or without heparin) in the lock compared to heparin alone.
  • Antibiotic and heparin in the lock compared to heparin alone.
  • Intravenous antibiotics prior to insertion of central venous catheter compared to no antibiotics first.
  • Transparent polyurethane dressings compared with gauze and tape.
  • Vena jugularis interna compared to vena subclavian.
  • Vena femoralis compared to vena jugularis interna.

 

Discussion

There are data supporting the effect of some interventions aimed at preventing infections when using central venous catheter. This documentation originates from a number of studies that are conducted in many different countries and there is good consistency in the results from the studies. This consistency strengthens our general confidence that these results are relevant and might be relevant to other countries and settings. This report does not evaluate long term effects of antiseptic or antibiotic agents. Antibiotic resistant bacteria is a problem, in Norway as well as internationally. This is important to keep in mind when applying these results.

 

Conclusion

The aim of this review was to identify the effect of various interventions to prevent infectious complications when using central venous catheter. We found that:

  • Catheters impregnating with antibiotic or antiseptic agents reduces the incidence of infections compared to no impregnation.

We also found several other interventions that appeared promising. Additionally we found several interventions that may possibly have similar effect. There is a need for more studies before conclusions about their effect can be reached.