SSI

* In some countries, national guidelines or recommendations exist for infusion of blood or blood products including infusion times < 24 hours. Certain lipid products may require more frequent replacement [5].

General Comments

Unless signs of infection or irritation occur, peripheral venous catheters may be used as long as they are needed. (The CDC guidelines recommend changing peripheral venous catheters every 72-96 hours in adults.) Central catheters should not be replaced routinely [6].
The risk of infection in peripheral IV sites increases with length of time of catheterisation. Catheters should therefore be removed as soon as possible [7].
Infection rates are lowest with small needles. Teflon catheters are also associated with low rates, however are not necessary for short periods of infusion.
Well trained staff should set up and maintain infusions. Masks, caps and gowns are not necessary for insertion of peripheral lines. The use of non-sterile gloves and an apron or gown will protect the operator if profuse bleeding is likely.

Protocol for peripheral infusions

Place arm on clean towel.
Operator should use an alcohol rub or antiseptic detergent to disinfect hands. If antiseptic is not available, wash hands thoroughly for 20 seconds.
Dry hands thoroughly on a paper towel or clean linen towel, unless alcohol is used.
Avoid shaving skin site; clip hair instead, if necessary.
Disinfect skin site with 0.5% alcoholic chlorhexidine, 2% tincture of iodine, 10% alcoholic povidone-iodine, or 70% alcohol. Apply with rubbing for 30 seconds and allow to dry before inserting cannula.
Insert cannula into vein, preferably of upper limb, using no touch technique.
Apply sterile dressing (gauze or equivalent, or clear semi-permeable) and secure. Semi-permeable adhesive dressings are more expensive, but have the advantage of allowing inspection of the site without removal of the dressing [8].
Secure cannula to avoid movement and label with insertion date.
Assess the need for continuing catheterisation every 24 hours.
Inspect catheter daily and remove at first sign of infection.
Avoid cut downs, especially in the leg.
Cannulae and giving sets should be sterilised before use and preferably disposable.

If reuse is necessary, clean thoroughly and autoclave if possible.
If this is not possible, use boiling water (see Cleaning/disinfection section)
Chemical disinfection is undesirable but if reusable items are heat-labile, immerse in 0.5% sodium hypochlorite or other chlorine-releasing solution for 15 minutes after thorough cleaning. Use syringe and needle for cleaning interior of cannula. Ensure agent remains in contact with all surfaces of tubes and catheters. Hypochlorites are corrosive to metals and some plastics; thorough rinsing in sterile water is required after disinfection.

Additional guidelines for central catheters

Use maximum barrier precautions: sterile gloves, gowns, cap and mask for operator and a large sterile drape to cover the patient [2].
Change dressings regularly, at least once a week (individually determined, depending on the state of the patient) [9].

Minimal requirements

Do not insert catheters unnecessarily and minimise manipulations.
The operator should disinfect his or her hands before insertion of catheter and during maintenance procedures.
Thoroughly disinfect the skin site before insertion.
Use a no touch technique (i.e., gloved hands) during insertion, maintenance and removal of catheter.
Secure the IV line to prevent movement of the catheter.
Maintain a closed system.
Protect the insertion site with a sterile dressing.
Inspect the insertion site daily.
Remove the catheter as early as possible, and immediately if any signs of infection are present.

References

Gastmeier P, Weist K, Rueden H (1999) Catheter-associated primary bloodstream infections: epidemiology and preventive methods. Infection 27 Suppl 1: S1 – S6. Back to text
Raad II, Hohn DC, Gilbreath BJ, Suleiman N et al (1994) Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 15: 231 – 238. Back to text
Darouiche RO, Raad II (1997) Prevention of catheter-related infections: the skin. Nutrition 13: 26S – 29S. Back to text
Trautmann M, Zauser B, Wiedeck H, Buttenschon K, Marre R (1997) Bacterial colonization and endotoxin contamination of intravenous infusion fluids. J Hosp Inf 37: 225 – 236. Back to text
Guidelines for the Prevention of Intravascular Catheter-Related Infection s, 2002. MMWR 2002;51:1-26. Back to text
Cook D, Randolph A, Kernerman B, Cupido C et al (1997) Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 25: 1427 – 1424 Back to text
Bregenzer T, Conen D, Sakmann P, Widmer AF (1998) Is routine replacement of peripheral intravenous catheters neccessary? Arch Intern Med 158: 151 – 156 Back to text
Madeo M, Martin C, Nobbs A (1997) A randomized study comparing IV 3000 (transparent polyurethane dressing) to a dry gauze dressing for peripheral intravenous catheter sites. J Intraven Nurs 20: 253 – 256 Back to text
Powell CR, Traetow MJ, Fabri PJ, Kudsk KA, Ruberg RL (1985) Op-Site dressing study: a prospective randomized study evaluating povidone iodine ointment and extension set changes with 7 day Op-Site dressings applied to total parenteral nutrition subclavian sites. J Parenter Enteral Nutr 9: 443 - 446 Back to text

Suggestions for further reading:

Mermel LA, Farr BM, Sherertz RJ, Raad II et al (2001) Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis 32: 1249 - 1272.
Seifert H, Jansen B, Farr BM, eds (1997) Catheter-related infections. Marcel Dekker , New York .
Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. Journal of Hospital Infection 2001; 47(Suppl):S47-S67.



8. Prevention of Intravascular Device Associated Infection

Introduction Intravenous infusions are amongst the most common invasive procedures performed in hospitals and are administered either by the peripheral or central routes. Infections associated with these devices are common, and in many countries intravenous catheters are the most common source of nosocomial or hospital acquired bacteraemia. The principles used for prevention of infection are similar for both central and peripheral catheters. An intravenous catheter is a foreign body that produces a reaction in the host resulting in the formation of a film of fibrinous material on the inner and outer surfaces of the catheter. This biofilm may become colonised by micro-organisms which are protected from host defence mechanisms and the effect of antibiotics. Microbial contamination may cause local sepsis, or septic thrombophlebitis, or bacteraemia/septicaemia [1] . Infection control measures are designed to prevent micro-organisms from entering the equipment, the catheter insertion site, or the bloodstream (Figure 8.1). Because of the dangers of infection, catheters should not be inserted unnecessarily, and indications for insertion of catheters should be strict (e.g., severe dehydration, blood transfusion, and parenteral feeding). Use alternative routes where possible for hydration or parenteral therapy. If catheters need to be inserted, they should be removed as soon as possible and should not be left in ‘just in case they might be needed later. Good aseptic technique is required during insertion of the catheter and maintenance of the insertion site [2] . The site should be kept dry, free from contamination, secure, and comfortable for the patient. Sources and Routes of Transmission of infection Sources of contamination are either intrinsic (contamination before use), or extrinsic (contamination introduced during therapy). Most infections are acquired from the patient's own skin flora [3]. The organisms are usually coagulase-negative staphylococci or occasionally Staphylococcus aureus. Less frequently, Gram-negative bacilli or Candida albicans may be identified due to growth in the infusate. Skin organisms enter the catheter insertion site along the outside of the catheter. Occasionally organisms from the hands of staff or the patient's skin enter through the hub when the catheter is disconnected, or from the injection ports. The organisms grow in the biofilm on the catheter surfaces, usually the outer, and may be released in the bloodstream. Rarely, infection will arise from organisms growing in commercially prepared infusate due to faulty sterilisation or from contaminated added medicaments [4]. Finally, metastatic colonisation of the catheter tip may occur, seeded from a distant site of infection (e.g. wound, lung, or kidney). Source of infection and prevention

*Main source of infection*	*Prevention*
Infusion fluid	Ensure fluid is pyrogen free. Monitor sterilisation process. Avoid damage to container during storage. Inspect container for cracks, leaks, cloudiness, and particulate matter.
Addition of medicaments	Use aseptic precautions (hand disinfection, no touch technique). Add sterile medicaments. Carry out procedure preferably in the pharmacy. Use single-dose vials whenever possible. If multidose vials have to be used: Refrigerate after opening (if not otherwise recommended by manufacturer). Wipe diaphragm with 70% alcohol before inserting a cannula. Use a sterile device for access.
Container and water used	Ensure no contamination from warming fluid. Prefer dry warming systems.
Insertion of catheter	Thorough hand disinfection and use of sterile gloves by operator. Thoroughly disinfect the insertion site.
Catheter site	Cover with sterile dressing as soon as possible and remove if signs of infection occur. Inspect every 24 hours. Change dressing only when soiled, loosened or wet/damp, using good aseptic technique. Do not use antimicrobial ointments.
Injection ports	Clean with 70% alcohol and allow to dry before use. Close ports that are not needed with sterile stopcocks.
Changing of infusion set	Replace no more frequently than 72 hours (blood and lipids 24 hours*). Thorough hand disinfection by operator. Use good aseptic technique

* In some countries, national guidelines or recommendations exist for infusion of blood or blood products including infusion times < 24 hours. Certain lipid products may require more frequent replacement [5]. General Comments Unless signs of infection or irritation occur, peripheral venous catheters may be used as long as they are needed. (The CDC guidelines recommend changing peripheral venous catheters every 72-96 hours in adults.) Central catheters should not be replaced routinely [6]. The risk of infection in peripheral IV sites increases with length of time of catheterisation. Catheters should therefore be removed as soon as possible [7]. Infection rates are lowest with small needles. Teflon catheters are also associated with low rates, however are not necessary for short periods of infusion. Well trained staff should set up and maintain infusions. Masks, caps and gowns are not necessary for insertion of peripheral lines. The use of non-sterile gloves and an apron or gown will protect the operator if profuse bleeding is likely. Protocol for peripheral infusions Place arm on clean towel. Operator should use an alcohol rub or antiseptic detergent to disinfect hands. If antiseptic is not available, wash hands thoroughly for 20 seconds. Dry hands thoroughly on a paper towel or clean linen towel, unless alcohol is used. Avoid shaving skin site; clip hair instead, if necessary. Disinfect skin site with 0.5% alcoholic chlorhexidine, 2% tincture of iodine, 10% alcoholic povidone-iodine, or 70% alcohol. Apply with rubbing for 30 seconds and allow to dry before inserting cannula. Insert cannula into vein, preferably of upper limb, using no touch technique. Apply sterile dressing (gauze or equivalent, or clear semi-permeable) and secure. Semi-permeable adhesive dressings are more expensive, but have the advantage of allowing inspection of the site without removal of the dressing [8]. Secure cannula to avoid movement and label with insertion date. Assess the need for continuing catheterisation every 24 hours. Inspect catheter daily and remove at first sign of infection. Avoid cut downs, especially in the leg. Cannulae and giving sets should be sterilised before use and preferably disposable. If reuse is necessary, clean thoroughly and autoclave if possible. If this is not possible, use boiling water (see Cleaning/disinfection section) Chemical disinfection is undesirable but if reusable items are heat-labile, immerse in 0.5% sodium hypochlorite or other chlorine-releasing solution for 15 minutes after thorough cleaning. Use syringe and needle for cleaning interior of cannula. Ensure agent remains in contact with all surfaces of tubes and catheters. Hypochlorites are corrosive to metals and some plastics; thorough rinsing in sterile water is required after disinfection. Additional guidelines for central catheters Use maximum barrier precautions: sterile gloves, gowns, cap and mask for operator and a large sterile drape to cover the patient [2]. Change dressings regularly, at least once a week (individually determined, depending on the state of the patient) [9]. Minimal requirements Do not insert catheters unnecessarily and minimise manipulations. The operator should disinfect his or her hands before insertion of catheter and during maintenance procedures. Thoroughly disinfect the skin site before insertion. Use a no touch technique (i.e., gloved hands) during insertion, maintenance and removal of catheter. Secure the IV line to prevent movement of the catheter. Maintain a closed system. Protect the insertion site with a sterile dressing. Inspect the insertion site daily. Remove the catheter as early as possible, and immediately if any signs of infection are present. References Gastmeier P, Weist K, Rueden H (1999) Catheter-associated primary bloodstream infections: epidemiology and preventive methods. Infection 27 Suppl 1: S1 – S6. Back to text Raad II, Hohn DC, Gilbreath BJ, Suleiman N et al (1994) Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 15: 231 – 238. Back to text Darouiche RO, Raad II (1997) Prevention of catheter-related infections: the skin. Nutrition 13: 26S – 29S. Back to text Trautmann M, Zauser B, Wiedeck H, Buttenschon K, Marre R (1997) Bacterial colonization and endotoxin contamination of intravenous infusion fluids. J Hosp Inf 37: 225 – 236. Back to text Guidelines for the Prevention of Intravascular Catheter-Related Infection s, 2002. MMWR 2002;51:1-26. Back to text Cook D, Randolph A, Kernerman B, Cupido C et al (1997) Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 25: 1427 – 1424 Back to text Bregenzer T, Conen D, Sakmann P, Widmer AF (1998) Is routine replacement of peripheral intravenous catheters neccessary? Arch Intern Med 158: 151 – 156 Back to text Madeo M, Martin C, Nobbs A (1997) A randomized study comparing IV 3000 (transparent polyurethane dressing) to a dry gauze dressing for peripheral intravenous catheter sites. J Intraven Nurs 20: 253 – 256 Back to text Powell CR, Traetow MJ, Fabri PJ, Kudsk KA, Ruberg RL (1985) Op-Site dressing study: a prospective randomized study evaluating povidone iodine ointment and extension set changes with 7 day Op-Site dressings applied to total parenteral nutrition subclavian sites. J Parenter Enteral Nutr 9: 443 - 446 Back to text Suggestions for further reading: Mermel LA, Farr BM, Sherertz RJ, Raad II et al (2001) Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis 32: 1249 - 1272. Seifert H, Jansen B, Farr BM, eds (1997) Catheter-related infections. Marcel Dekker , New York . Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. Journal of Hospital Infection 2001; 47(Suppl):S47-S67.