Preventive Interventions for Central Venous Catheter Infections in Intensive Care Units: A Systematic Literature Review

Authors: Jakob Renko, Deja Praprotnik, Kristina Martinovič, Igor Karnjuš

Abstract:

Catheter-related bloodstream infections are a major burden for healthcare and patients. Although infections of this type cannot be completely avoided, they can be reduced by taking preventive measures. The aim of this study is to review and analyze the existing literature on preventive interventions to prevent central venous catheters (CVC) infections. A systematic literature review was carried out. The international databases CINAHL, Medline, PubMed, and Web of Science were searched using the search strategy: "catheter-related infections" AND "intensive care units" AND "prevention" AND "central venous catheter." Articles that met the inclusion and exclusion criteria were included in the study. The literature search flow is illustrated by the PRISMA diagram. The descriptive research method was used to analyze the data. Out of 554 search results, 22 surveys were included in the final analysis. We identified seven relevant preventive measures to prevent CVC infections: washing the whole body with chlorhexidine gluconate (CHG) solution, disinfecting the CVC entry site with CHG solution, use of CHG or silver dressings, alcohol protective caps, CVC care education, selecting appropriate catheter and multicomponent care bundles. Both single interventions and multicomponent care bundles have been shown to be currently effective measures to prevent CVC infections in adult patients in the ICU. None of the measures identified stood out in terms of their effectiveness. Prevention work to reduce CVC infections in the ICU is a complex process that requires the simultaneous consideration of several factors.

Keywords: Central venous access, critically ill patients, hospital-acquired complications, prevention.

References:

[1] Bell, T., & O’Grady, N. P. (2017). Prevention of central line-associated bloodstream infections. Infectious Disease Clinics of North America, 31(3), 551–559. https://doi.org/10.1016/j.idc.2017.05.007
[2] Timsit, J. F., Baleine, J., Bernard, L., Calvino Gunther, S., Darmon, M., Dellamonica, J., … Maxime, V. (2020). Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit. Annals of Intensive Care, 10(1), 118. https://doi.org/10.1186/s13613-020-00713-4
[3] Velasquez Reyes, D. C., Bloomer, M., & Morphet, J. (2017). Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review. Intensive & Critical Care Nursing, 43, 12–22. https://doi.org/10.1016/j.iccn.2017.05.006
[4] Aloush, S. (2018). Educating intensive care unit nurses to use central venous catheter infection prevention guidelines: Effectiveness of an educational course. Journal of Research in Nursing, 23(5), 406–413. https://doi.org/10.1177/1744987118762992
[5] Bakan, A. B., & Arli, S. K. (2021). Development of the peripheral and central venous catheter‐related bloodstream infection prevention knowledge and attitudes scale. Nursing in Critical Care, 26(1), 35–41. https://doi.org/10.1111/nicc.12422
[6] Al Qadire, M., & Hani, A. M. (2022). Nurses’ and physicians’ knowledge of guidelines for preventing catether related blood stream infections. Nursing in Critical Care, 27(4), 594–601. https://doi.org/10.1111/nicc.12577
[7] Hefner, J. L., Fareed, N., Walker, D. M., Huerta, T. R., & McAlearney, A. S. (2019). Central line infections in United States hospitals: An exploration of variation in central line device days and infection rates across hospitals that serve highly complex patient populations. American Journal of Infection Control, 47(8), 1032–1034. https://doi.org/10.1016/j.ajic.2018.12.001
[8] Buetti, N., & Timsit, J. F. (2019). Management and prevention of central venous catheter-related infections in the ICU. Seminars in Respiratory and Critical Care Medicine, 40(04), 508–523. https://doi.org/10.1055/s-0039-1693705
[9] Špoljarič, N., Kalač, A., Visočnik, D. (2017). Preventiva okužb, povezanih z žilnimi katetri. Zbornica zdravstvene in babiške nege Slovenije, 1–5. https://www.zbornica-zveza.si/wp-content/uploads/2019/10/%C5%BDilni-pristopi.pdf
[10] Burke, C., Jakub, K., & Kellar, I. (2021). Adherence to the central line bundle in intensive care: An integrative review. American Journal of Infection Control, 49(7), 937–956. https://doi.org/10.1016/j.ajic.2020.11.014
[11] Chi, X., Guo, J., Niu, X., He, R., Wu, L., & Xu, H. (2020). Prevention of central line-associated bloodstream infections: A survey of ICU nurses’ knowledge and practice in China. Antimicrobial Resistance and Infection Control, 9(1), 186. https://doi.org/10.1186/s13756-020-00833-3
[12] Barbosa Costa, C. A., Lopes Araújo, F., Leite Costa, A. C., Dos Reis Corrêa, A., Miyuki Kusahara, D., & Figueiredo Manzo, B. (2020). Central Venous Catheter bundle: Professional knowledge and behavior in adult Intensive Care Units. Revista Da Escola De Enfermagem Da U S P, 54, e03629. https://doi.org/10.1590/S1980-220X2019011203629
[13] Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., … PRISMA-P Group. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4, 1. https://doi.org/10.1186/2046-4053-4-1
[14] Zotero (2006). Retreived September 30, 2022 from https://www.zotero.org/download/
[15] Critical Appraisal Skills Programme (2021). CASP (cohort study, randomised controlled trials, systematic review) Checklist. Retreived November 4, 2022 from https://casp-uk.net/casp-tools-checklists/
[16] Polit, D. F., & Beck, C. T. (2020). Nursing research: Generating and assessing evidence for nursing practise (11th ed.). Wolters Kluwer Health.
[17] Eggimann, P., Pagani, J. L., Dupuis Lozeron, E., Ms, B. E., Thévenin, M. J., Joseph, C., … Que, Y. A. (2019). Sustained reduction of catheter-associated bloodstream infections with enhancement of catheter bundle by chlorhexidine dressings over 11 years. Intensive Care Medicine, 45(6), 823–833. https://doi.org/10.1007/s00134-019-05617-x
[18] Puig-Asensio, M., Marra, A. R., Childs, C. A., Kukla, M. E., Perencevich, E. N., & Schweizer, M. L. (2020). Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. Infection Control and Hospital Epidemiology, 41(12), 1388–1395. https://doi.org/10.1017/ice.2020.356
[19] Shi, Y., Yang, N., Zhang, L., Zhang, M., Pei, H. H., & Wang, H. (2019). Chlorhexidine disinfectant can reduce the risk of central venous catheter infection compared with povidone: A meta-analysis. American Journal of Infection Control, 47(10), 1255–1262. https://doi.org/10.1016/j.ajic.2019.02.024
[20] Inchingolo, R., Pasciuto, G., Magnini, D., Cavalletti, M., Scoppettuolo, G., Montemurro, G., … Richeldi, L. (2019). Educational interventions alone and combined with port protector reduce the rate of central venous catheter infection and colonization in respiratory semi-intensive care unit. BMC Infectious Diseases, 19(1), 215. https://doi.org/10.1186/s12879-019-3848-z
[21] Kaur, D., Jaspal, S., & Bajwa, S. S. (2020). The impact of open versus closed catheter access system of central venous catheter on infection prevention in critically ill patients: A comparative evaluation. Iranian Journal of Nursing and Midwifery Research, 25(6), 497–501. https://doi.org/10.4103/ijnmr.IJNMR_34_19
[22] Krikava, I., Kolar, M., Garajova, B., Balik, T., Sevcikova, A., Roschke, I., & Sevcik, P. (2020). The efficacy of a non-leaching antibacterial central venous catheter—A prospective, randomized, double-blind study. Biomedical Papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia, 164(2), 154–160. https://doi.org/10.5507/bp.2019.022
[23] Taşdelen Öğülmen, D., & Ateş, S. (2021). Use of alcohol containing caps for preventing bloodstream infections: A randomized controlled trial. The Journal of Vascular Access, 22(6), 920–925. https://doi.org/10.1177/1129729820952961
[24] Yasuda, H., Sanui, M., Abe, T., Shime, N., Komuro, T., Hatakeyama, J., … Japanese Society of Education for Physicians and Trainees in Intensive Care (JSEPTIC) Clinical Trial Group. (2017). Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled study. Critical Care (London, England), 21(1), 320. https://doi.org/10.1186/s13054-017-1890-z
[25] Wei, A. E., Markert, R. J., Connelly, C., & Polenakovik, H. (2021). Reduction of central line-associated bloodstream infections in a large acute care hospital in Midwest United States following implementation of a comprehensive central line insertion and maintenance bundle. Journal of Infection Prevention, 22(5), 186–193. https://doi.org/10.1177/17571774211012471
[26] Bae, S., Kim, Y., Chang, H. H., Kim, S., Kim, H. J., Jeon, H., … Kim, S. W. (2022). The effect of the multimodal intervention including an automatic notification of catheter days on reducing central line-related bloodstream infection: A retrospective, observational, quasi-experimental study. BMC Infectious Diseases, 22(1), 604. https://doi.org/10.1186/s12879-022-07588-9
[27] Duszyńska, W., Adamik, B., Lentka Bera, K., Kulpa, K., Nieckula Schwarz, A., Litwin, A., … Kübler, A. (2017). Effect of universal chlorhexidine decolonisation on the infection rate in intensive care patients. Anestezjologia Intensywna Terapia, 49(1), 28–33. https://doi.org/10.5603/AIT.2017.0007
[28] Karlnoski, R., Abboud, E. C., Thompson, P., Oxner, A. Z., Sinnott, J. T., & Marcet, J. E. (2019). Reduction in central line-associated bloodstream infections correlated with the introduction of a novel silver-plated dressing for central venous catheters and maintained for 6 years. Journal of Intensive Care Medicine, 34(7), 544–549. https://doi.org/10.1177/0885066617745034
[29] Khodare, A., Pindi, G., Joy, L., Khillan, V., & Kale, P. (2020). Incidence, microbiological profile, and impact of preventive measures on central line-associated bloodstream infection in liver care intensive care unit. Indian Journal of Critical Care Medicine, 24(1), 17–22. https://doi.org/10.5005/jp-journals-10071-23325
[30] Lai, C. C., Cia, C. T., Chiang, H. T., Kung, Y. C., Shi, Z. Y., Chuang, Y. C., … Infection Control Society of Taiwan. (2018). Implementation of a national bundle care program to reduce central line-associated bloodstream infections in intensive care units in Taiwan. Journal of Microbiology, Immunology, and Infection, 51(5), 666–671. https://doi.org/10.1016/j.jmii.2017.10.001
[31] Lin, M. R., Chang, P. J., Hsu, P. C., Lin, C. S., Chiu, C. H., & Chen, C. J. (2022). Comparison of efficacy of 2% chlorhexidine gluconate–alcohol and 10% povidone-iodine–alcohol against catheter-related bloodstream infections and bacterial colonization at central venous catheter insertion sites: A prospective, single-center, open-label, crossover study. Journal of Clinical Medicine, 11(8), 2242. https://doi.org/10.3390/jcm11082242
[32] Lv, Y., Huang, X., Lan, Y., Xia, Q., Chen, F., Wu, J., … Xiang, Q. (2022). Peripherally inserted central catheters have a protective role and the effect of fluctuation curve feature in the risk of bloodstream infection compared with central venous catheters: A propensity-adjusted analysis. BMC Infectious Diseases, 22(1), 289. https://doi.org/10.1186/s12879-022-07265-x
[33] Martino, A., Thompson, L., Mitchell, C., Trichel, R., Chappell, W., Miller, J., … Mann-Salinas, E. (2017). Efforts of a Unit Practice Council to implement practice change utilizing alcohol impregnated port protectors in a burn ICU. Burns: Journal of the International Society for Burn Injuries, 43(5), 956–964. https://doi.org/10.1016/j.burns.2017.01.010
[34] Musu, M., Finco, G., Mura, P., Landoni, G., Piazza, M. F., Messina, M., … Galletta, M. (2017). Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units. The Journal of Hospital Infection, 97(3), 275–281. https://doi.org/10.1016/j.jhin.2017.08.010
[35] Scheier, T., Saleschus, D., Dunic, M., Fröhlich, M. R., Schüpbach, R., Falk, C., … Schreiber, P. W. (2021). Implementation of daily chlorhexidine bathing in intensive care units for reduction of central line-associated bloodstream infections. The Journal of Hospital Infection, 110, 26–32. https://doi.org/10.1016/j.jhin.2021.01.007
[36] Shimoyama, Y., Umegaki, O., Agui, T., Kadono, N., Komasawa, N., & Minami, T. (2017). An educational program for decreasing catheter-related bloodstream infections in intensive care units: A pre- and post-intervention observational study. JA Clinical Reports, 3(1), 23. https://doi.org/10.1186/s40981-017-0095-4
[37] Wichmann, D., Belmar Campos, C. E., Ehrhardt, S., Kock, T., Weber, C., Rohde, H., & Kluge, S. (2018). Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients. BMC Infectious Diseases, 18(1), 267. https://doi.org/10.1186/s12879-018-3178-6
[38] Urbancic, K. F., Mårtensson, J., Glassford, N., Eyeington, C., Robbins, R., Ward, P. B., … Bellomo, R. (2018). Impact of unit-wide chlorhexidine bathing in intensive care on bloodstream infection and drug-resistant organism acquisition. Critical Care and Resuscitation: Journal of the Australasian Academy of Critical Care Medicine, 20(2), 109–116.
[39] Gupta, P., Thomas, M., Patel, A., George, R., Mathews, L., Alex, S., … El Hassan, M. (2021). Bundle approach used to achieve zero central line-associated bloodstream infections in an adult coronary intensive care unit. BMJ Open Quality, 10(1), e001200. https://doi.org/10.1136/bmjoq-2020-001200
[40] Jarding, E. K., & Flynn Makic, M. B. (2021). Central Line Care and Management: Adopting Evidence-Based Nursing Interventions. Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses, 36(4), 328–333. https://doi.org/10.1016/j.jopan.2020.10.010
[41] Karapanou, A., Vieru, A.-M., Sampanis, M. A., Pantazatou, A., Deliolanis, I., Daikos, G. L., & Samarkos, M. (2020). Failure of central venous catheter insertion and care bundles in a high central line–associated bloodstream infection rate, high bed occupancy hospital. American Journal of Infection Control, 48(7), 770–776. https://doi.org/10.1016/j.ajic.2019.11.018
[42] Klintworth, G., Stafford, J., O’Connor, M., Leong, T., Hamley, L., Watson, K., … Worth, L. J. (2014). Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central line–associated bloodstream infections. American Journal of Infection Control, 42(6), 685–687. https://doi.org/10.1016/j.ajic.2014.02.026
[43] Lee, K. H., Cho, N. H., Jeong, S. J., Kim, M. N., Han, S. H., & Song, Y. G. (2018). Effect of central line bundle compliance on central line-associated bloodstream infections. Yonsei Medical Journal, 59(3), 376–382. https://doi.org/10.3349/ymj.2018.59.3.376
[44] Pitiriga, V., Bakalis, J., Kampos, E., Kanellopoulos, P., Saroglou, G., & Tsakris, A. (2022). Duration of central venous catheter placement and central line-associated bloodstream infections after the adoption of prevention bundles: A two-year retrospective study. Antimicrobial Resistance & Infection Control, 11(1), 96. https://doi.org/10.1186/s13756-022-01131-w
[45] Inocencio de Quadros, A., Dorociaki Stocco, J. G., Cristoff, C., Bonfirm de Alcantara, C., Pimenta, A. M., & Saidelles Machado, B. G. (2022). Adherence to central venous catheter maintenance bundle in an intensive care unit. Revista Da Escola De Enfermagem Da U S P, 56, e20220077. https://doi.org/10.1590/1980-220X-REEUSP-2022-0077en
[46] Afonso, E., Blot, K., & Blot, S. (2016). Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: A systematic review and meta-analysis of randomised crossover trials. Eurosurveillance, 21(46). https://doi.org/10.2807/1560-7917.ES.2016.21.46.30400
[47] Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., … Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. The New England Journal of Medicine, 368(6), 533–542. https://doi.org/10.1056/NEJMoa1113849
[48] Frost, S. A., Alogso, M. C., Metcalfe, L., Lynch, J. M., Hunt, L., Sanghavi, R., … Hillman, K. M. (2016). Chlorhexidine bathing and health care-associated infections among adult intensive care patients: A systematic review and meta-analysis. Critical Care, 20(1), 379. https://doi.org/10.1186/s13054-016-1553-5
[49] Timsit, J. F., Mimoz, O., Mourvillier, B., Souweine, B., Garrouste Orgeas, M., Alfandari, S., … Lucet, J. C. (2012). Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. American Journal of Respiratory and Critical Care Medicine, 186(12), 1272–1278. https://doi.org/10.1164/rccm.201206-1038OC
[50] Yu, K., Lu, M., Meng, Y., Zhao, Y., & Li, Z. (2019). Chlorhexidine gluconate transparent dressing does not decrease central line‐associated bloodstream infection in critically ill patients: A randomized controlled trial. International Journal of Nursing Practice, 25(6). https://doi.org/10.1111/ijn.12776
[51] Flynn, J. M., Larsen, E. N., Keogh, S., Ullman, A. J., & Rickard, C. M. (2019). Methods for microbial needleless connector decontamination: A systematic review and meta-analysis. American Journal of Infection Control, 47(8), 956–962. https://doi.org/10.1016/j.ajic.2019.01.002
[52] Sweet, M. A., Cumpston, A., Briggs, F., Craig, M., & Hamadani, M. (2012). Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. American Journal of Infection Control, 40(10), 931–934. https://doi.org/10.1016/j.ajic.2012.01.025
[53] Tejada, S., Leal dos Santos, M., Peña López, Y., Blot, S., Alp, E., & Rello, J. (2022). Antiseptic barrier caps in central line-associated bloodstream infections: A systematic review and meta-analysis. European Journal of Internal Medicine, 99, 70–81. https://doi.org/10.1016/j.ejim.2022.01.040
[54] Wright, M. O., Tropp, J., Schora, D. M., Dillon Grant, M., Peterson, K., Boehm, S., … Peterson, L. R. (2013). Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. American Journal of Infection Control, 41(1), 33–38. https://doi.org/10.1016/j.ajic.2012.05.030
[55] Madden, W., Dockery, J., Smith, J., Bowman, W. B., & Macke, M. (2013). Alcohol impregnated caps: are they effective for preventing CLABSI? Biology of Blood and Marrow Transplantation, 19(2), S371. https://doi.org/10.1016/j.bbmt.2012.11.598
[56] Milstone, A. M., Rosenberg, C., Yenokyan, G., Koontz, D. W., Miller, M. R., & CCLIP Authorship Group. (2021). Alcohol-impregnated caps and ambulatory central-line-associated bloodstream infections (CLABSIs): A randomized clinical trial. Infection Control and Hospital Epidemiology, 42(4), 431–439. https://doi.org/10.1017/ice.2020.467
[57] Raad, I., Mohamed, J. A., Reitzel, R. A., Jiang, Y., Raad, S., Al Shuaibi, M., … Hachem, R. Y. (2012). Improved antibiotic-impregnated catheters with extended-spectrum activity against resistant bacteria and fungi. Antimicrobial Agents and Chemotherapy, 56(2), 935–941. https://doi.org/10.1128/AAC.05836-11
[58] Wang, H., Tong, H., Liu, H., Wang, Y., Wang, R., Gao, H., … Wang, C. (2018). Effectiveness of antimicrobial-coated central venous catheters for preventing catheter-related bloodstream infections with the implementation of bundles: A systematic review and network meta-analysis. Annals of Intensive Care, 8(1), 71. https://doi.org/10.1186/s13613-018-0416-4
[59] Ullman, A. J., Paterson, R. S., Schults, J. A., Kleidon, T. M., August, D., O’Malley, M., … Chopra, V. (2022). Do antimicrobial and antithrombogenic peripherally inserted central catheter (PICC) materials prevent catheter complications? An analysis of 42,562 hospitalized medical patients. Infection Control and Hospital Epidemiology, 43(4), 427–434. https://doi.org/10.1017/ice.2021.141