International Federation of Infection Control
	Education Programme for Infection Control

Intravenous infusions

Intravenous infusions are one of the commonest invasive procedures in hospitals and are administered either by the peripheral or central routes. The principles of prevention of infection are similar, although these guidelines refer particularly to peripheral administration.

An intravenous catheter is a foreign body which produces a reaction in the host consisting of a film of a fibrinous material on the inner and outer surfaces of the catheter. This biofilm may become colonised by microorganisms and will protect them from host defence mechanisms. Microbial contamination may cause local sepsis or septic thrombophlebitis or bacteraemia/septicaemia.

Infection control measures are designed to prevent microorganisms from entering the equipment, the catheter insertion site or the bloodstream. (Fig. 2)

Indications for insertion of catheters should be strict e.g. severe dehydration, blood transfusion, parenteral feeding. Use alternative routes where possible for hydration or parenteral therapy.

Good asepsis is required during insertion of the catheter and maintenance of the insertion site. The site should be kept dry, safe from contamination, secure and comfortable for the patient.

Sources of contamination are either intrinsic, i.e. contamination before use, or extrinsic, i.e. contamination introduced during therapy.

Most infections are acquired from the patient's own skin flora. The organisms are usually coagulase-negative staphylococci or diphtheroids, occasionally S.aureus. Rarely Gram-negative bacilli growing in the infusate.

The 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 into the bloodstream. Rarely, infection will arise from organisms growing in the commercially prepared infusate due to faulty sterilisation or from contaminated added medicaments.

Sources 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 to infusion fluid	Aseptic precautions (wash hands, no touch technique) Add sterile medicament. Preferably carried out in pharmacy.
Container and water used	Ensure no contamination for warming fluid.
Insertion of catheter	Thorough handwashing by operator. Thorough disinfection of the skin site on patient.
Catheter site	Cover with sterile dressing as soon as possible and remove if signs of infection. Inspect every 24h Change dressing only when necessary and with good aseptic technique.
Injection ports	Clean with alcohol and allow to dry before use
Changing of infusion set	Thorough handwashing by operator. Good aseptic technique.

General comments

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Risk of infection in peripheral IV sites increases with length of time of catheterisation.

Catheters should therefore be removed as soon as possible.

Infection rates are lowest with small needles. Teflon catheters are also associated with low rates, but are not necessary for short periods of infusion e.g. 24 h postoperative.

Well-trained staff should set up and maintain infusions. Masks, caps and gowns are not necessary. Sterile gloves are only required when setting up a central line. 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 wash hands thoroughly with soap and running water for 15-20 seconds. (an antiseptic-detergent or alcohol rub is preferred if available)

·         Dry hands thoroughly on a paper towel or clean linen towel, unless alcohol is used.

·         Avoid shaving skin site, clip hair instead

·         Disinfect skin site with 0.5% alcoholic chlorhexidine, or 10% alcoholic povidone-iodine if not available, use 70% ethanol or isopropanol.

·         Apply with rubbing for 30 secs. 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 have the advantage of allowing inspection of the site without removal of dressing but are more expensive and some are associated with higher infection rates.

·         Secure cannula to avoid movement and label with insertion date.

·         Assess the need for continuing catheterisation every 24h.

·         Remove catheter at first sign of infection or at 72h if another suitable site is available.

·         Change giving set after 72h or immediately after giving blood or lipids if advised by the manufacturer of the lipids.

·         Avoid cut downs especially in leg

·         Cannulae and giving sets should be sterilised before use and preferably should be disposable.

·         If reuse is necessary, wash thoroughly and autoclave if possible.

·         If not possible, use boiling water. Chemical disinfection is undesirable but if reusable items are heat-labile, immerse in 0.5% sodium hypochlorite or other chlorine-producing solution for 15 min 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.

Minimal requirements

·         Thorough handwashing by operator before insertion of catheter and during maintenance procedures.

·         Thorough disinfection of skin of insertion site

·         No touch technique during insertion, maintenance and removal of catheter

·         Secure the iv line to prevent movement of catheter

·         Maintain the closed system

·         Protect the insertion site with a sterile dressing

·         Inspect insertion site daily and remove catheter as early as possible and if any signs of infection.