Volume 12, Number 1, 2011
© Mary Ann Liebert, Inc.
001: 10.1 089/sur.2009.082
Prevention of Catheter-Related Blood Stream Infection:
Back to Basics?
Jill R. Cherry-Bukowiec.Krassimir Denchev/Sharon Dickinson?Carol E. Chenoweth," Christy Zalewski.'
Thomas J. Papadirnos,"Craig Meldrum," Kristen C. Sihler ' Melissa E. Brunsvold:
Pauline K. Park; and Lena M. Napolitano'
Background: Central venous catheter (CVC)-relatedinfections are a substantial problem in the intensive care unit
(lCU). Our infection control team initiated the routine use of antiseptic-coated (chlorhexidine-silver sulfadia-
zine; Chx-SS)CVCs in our adult lCUs to reduce catheter-associated (CA)and catheter-related (CR)blood stream
infection (BS1)as we implemented other educational and best practice standardization strategies. Prior ran-
domized studies documented that the use of Chx-SS catheters reduces microbial colonization of the catheter
compared with an uncoated standard (Std) CVC but does not reduce CR-BSI.We therefore implemented the
routine use of uncoated Std CVCs in our surgical ICU (SICU)and examined the impact of this change.
The use of uncoated Std CVCs does not increase CR-BSIrate in an SICU.
Methods: Prospective evaluation of universal use of uncoated Std CVCs, implemented November 2007 in the
SICU. The incidences of CA-BSIand CR-BSIwere compared during November 2006-0ctober 2007 (universal
use of Chx-SSCVCs) and November 2007-0ctober 2008 (universal use of Std CVCs)by t-test. The definitions of
the U.S. Centers for Disease Control and Prevention were used for CA-BSI and CR-BSI.Patient data were
collected via a dedicated Acute Physiology and Chronic Health Evaluation (APACHE) III coordinator for the
Results: Annual use of CVCs increased significantly in the last six years, from 3,543 (2001)to 5,799 (2006)total
days. The APACHE III scores on day 1 increased from a mean of 54.4 in 2004 to 55.6 in 2008 (p =0.0010;95%
confidence interval [CI]1.29-5.13).The mean age of the patients was unchanged over this period, ranging from
58.2 to 59.6 years. The Chx-SS catheters were implemented in the SICU in 2002. Data regarding the specific
incidence of CR-BSIwere collected beginning at the end of 2005, with mandatory catheter tip cultures when
CVCs were removed. Little difference was identified in the incidence of BSIbetween the interval with universal
Chx-SSuse and that with Std CVC use. (Total BSI0.7vs. 0.8per 1,000catheter days; CA-BSI0.5vs. 0.8per 1,000
catheter days; CR-BSI0.2vs. 0per 1,000catheter days.) No difference was seen in the causative pathogens ofCA-
Conclusion: Eliminating the universal use of Chx-SS-coated CVCs in an SICUwith a 10
of CR-BSlsdid not result in an increase in the rate of CR-BSls.This study documents the greater importance of
adherence to standardization of the processes of care related to CVC placement than of coated CVC use in the
reduction of CR-BSI.
. CENTRALVENOUSCATHETERS(CVCs) canbelife-savingfor
and nutrition,but theiruseisnot withoutrisk.Inparticular,
catheter-related(CR)infectionsare a significantsource of
morbidity and death in hospitalizedpatients [1).The U.S.
Departments of 1Acute Care Surgery and 2Anesthesiology, University of Michigan, Ann Arbor, Michigan.
3Surgical Intensive Care Unit, University of Michigan.
Departments of 4Internal Medicine, 5Infection Control, and 6ClinicalAffairs, University of Michigan.
7Department of Anesthesiology, The Ohio State University, Columb~s, Ohio.
an annual occurrence of more than 250,000CR-BSlsin the
United States alone .In addition to the lives lost as a result
of CR blood stream infection (BSI),the estimated financial
impact of even one BSIcan be substantial [3-6]. Because of
this, CR-BSIshave been deemed preventable and targeted for
eradication by influential medical bodies, including the CDC
, the Society for Healthcare Epidemiology of America
(SHEA) , the Infectious Diseases Society of America
(IDSA)[7,8], the 100,000Lives Campaign, and the 5 Million
Lives Campaign from the Institute for Healthcare Improve-
The CDC Guidelines for the Prevention of Intravascular
Catheter-Related Infections recommend preventive strategies
with strong supportive evidence, including: (1)Education and
training of healthcare providers; (2) use of full barrier pre-
cautions during CVCinsertion; (3) use of a 2% chlorhexidine
preparation for skin antisepsis; (4) no routine replacement of
CVCs; and (5) use of an antiseptic/antibiotic-impregnated
CVC in adults whose catheter is expected to remain in place
longer than fivedays if,after implementing a comprehensive
strategy to reduce the rate of CR-BSI,the infection rate re-
mains above the goal set by the individual institution on the
basis of benchmark rates and local factors. All of these pre-
ventive strategies are employed by critical care practitioners
in an attempt to achieve zero CR-BSlsin intensive care units
antiseptic-coated (chlorhexidine-silver sulfadiazine; Chx-SS)
CVCs have been studied extensively. Two meta-analyses
of randomized trials have established that antimicrobial!
antiseptic-coated CVCs reduce the incidence of microbial
colonization and CR-BSI,but the methodologic quality ofthe
studies generally was poor, putting the conclusions in doubt
.The minocycline/rifampin CVCs were associated with
CR-BSIreduction, but Chx-SSCVCs were not. Furthermore,
these studies were not done in settings where infection-
prevention bundles of care were established as routine prac-
tice. The investigators concluded that coated CVCs may be
useful if the incidence of CR-BSIis above institutional goals
despite full implementation of infection prevention interven-
However, few studies address the efficacy of antiseptic-
coated CVCs in K'Us with low CR-Bsr rates. Schuerer et al.
evaluated whether the use of Chx-SSCVCs would decrease
the CR-BSIrate in a surgical lCU (SlCU)with an already low
rate. They found no statistically significant decrease in CR-BSI
rates from beforeimplementation ofthe Chx-SSCVCs (3.3 per
1,000 catheter days) to after implementation (2.1 per 1,000
catheter days; p =0.16).
The routine use of Chx-SSCVCswas initiated in our SICU
as we implemented other educational and standardization
strategies to reduce CR-BSLOnce we achieved a low CR-BSl
rate, we began using uncoated Std CVCs instead of Chx-SS
CVCs and examined the impact of this unit-wide practice
(minocycline/ rifampin) and
Patients and Methods
The University of Michigan 20-bed SICU admits all non-
cardiothoracic critically ill surgical patients. The SlCU oper-
ates as a collaborative model in which a dedicated unit team
works closely with the admitting surgical team to facilitate
communication and coordinate all aspects of care. To mini-
mize duplication and optimize efficiency,only the SlCUteam
enters orders. Physician staffing includes an attending surgi-
caloranesthesiology intensivist and an in-house resident
team that consists of a surgical or anesthesiology critical care
fellow and resident staff assigned exclusively to the SICU.
All patients admitted to the SICUwere evaluated for BSls.
Only patients identified as having a BSI who underwent
placement ofa CVCby the SICUteam in the internal jugular,
subclavian, or femoral position were included in the analysis.
We used an interrupted time-series (quasi-experimental)
design to examine the outcomes of interest. In 2000, our
infection control team initiated the routine use of antiseptic-
coated triple-lumen CVCs (Chx-SS, first generation with
externalcoating[ARROW guard Blue®],transitionedtosecond-
generation coated internally and externally [ARROW guard
Blue PLUS ®; Arrow International, Inc, Reading PADin our
adult ICUs as we implemented other educational and stan-
dardization strategiesaimed atCR-BSIreduction (handhygiene
and antisepsis, dedicated catheter cart use, standardized
placement, chIorhexidine skin preparation, maximum sterile
barriers) (Fig.1).Placement,use, and care for CVCswere stan-
dardized by hospital policy (seebelow).Empowerment of any
member of the patient care team to stop line placement in the
event of contamination or failure of protocol adherence was
was performed during SlCUteam rounds starting in 2005.
The rate ofcatheter-associated (CA)-BSIdecreased steadily
until 2006,during which our rate was 0.9per 1,000CVCdays
and the rate of CR-BSIwas 0 per 1,000 CVC days. In No-
vember 2007, the SlCU team implemented use of standard
non-coated triple-lumen CVCs (same manufacturer) and
tracked our CA-BSIand CR-BSIrates over the following year.
Allpreventive efforts previously implemented regarding CA-
BSIprevention were continued. Although we did not track
compliance with hospital infection control policies, staff ed-
ucation and routine monitoring of hand washing were con-
tinued throughout the study period.
Standardization of eve placement and care
Placement and maintenance of CVCs is standardized by
the University Hospitals and Health Centers Infection Con-
trol Committee Policy:VI-58Central Lines: Temporary Central
and Arterial Vascular Access Catheters, Long-Term Central
Catheters: Tunneled and Ports, and Peripherally Placed
Central Catheters (PICC).Thehospital policy forUse and
Maintenance ofCVCCatheters was followed, which includes
washing hands before and after replacing, accessing, or re-
pairing the catheter, and before and after palpating or dress-
ing the catheter site; and use of clean gloves to remove old
dressings and either clean or s~erilegloves when placing a
fresh, sterile dressing; or using an aseptic "no-touch" tech-
nique to apply a sterile dressing to the catheter site. The in-
sertion site is evaluated every 24h, with every dressing
I change, andt=the patient complains of discomfort0' 'he
PREVENTION OF CATHETER-RELATEDBSI
-+- SICU BSI Rate
Linear (SICU BSI Rate)
Surgical intensive care unit blood-stream infection rate, 2000-2008.
site. The catheter site was cleansed during dressing changes
with a 2% chlorhexidine-70% isopropyl alcohol-based prep-
aration (70%isopropyl alcohol or iodophor solution if there
was a patient allergy). Catheter sites were kept clean with a
sterile, dry, gauze dressing taped in a manner to resist mois-
ture; alternatively, a highly permeable transparent dressing
dressings or any dressing constructed with gauze or other
opaque materials were changed at least every three days or
wheneverthey becomewet, loose,or soiledor when inspection
of the sitewas necessary.Highly permeable transparent dress-
ingswere changed at leastevery seven days and as necessary.
Catheter manipulations were kept to a minimum; when
necessary,they were performed using strict aseptic technique.
A needleless access system with a pierced injection port and
blunt cannula orlockingblunt cannula was used to maintain a
closed system. Accessports were changed every seven days.
A Luer-lok-type attachment was used for extension tubing.
All stopcocks were fitted with a pierced injection needleless
port at the time ofset-up. Accesspoints were disinfected with
alcoholjustbefore entry. Blooddraws through the CVCswere
kept to a minimum; .when required, blood specimens were
obtained using aseptic technique and clean gloves and the
tubing, stopcock, IVport, and the accessport attached to the
stopcock was flushed clean of any remaining blood after
the specimenwas removed. Theuse ofstopcockswas kept toa
minimum, and a fresh, sterile cap was used after each entry.
Stopcockswere flushed clean after blood drawing.
The SICUalso adheres to University policies for changing
the intravenous tubing and attached components (secondary
tubing, extension tubing, stopcocks, locking blunt cannu-
lae, pierced injection ports/ caps used on stopcocks, T-
connectors). These were changed according to the following
guidelines: Tubing for fluids, medications, hemodynamic
pressure monitoring, and parenteral nutrition without lipids
was changed every 96h: tubing for lipids and continuous
blood products was changed at least every 24hj and tubing
and components used for propofol administration were
changed at least every 12h.
The SlCUpolicy is not to remove or replace evcs inserted
outside the unit routinely if they were placed with aseptic
technique. If cves are placed in an emergency situation or
under non-sterile conditions, they are removed immediately.
It is our policy never to replace CVCsover a guidewire unless
it is impossible to place a new CVC elsewhere. The internal
jugular site is preferred forCVCplacement in the SlCU,with
real-time ultrasound guidance to avoid technical complica-
tions and to avoid subclavian vein stenosis in patients with
advanced renal disease.
Differentiation between CA-BSIand CR-BSIwas firstmade
in 2005,mandating catheter tip cultures and peripheral blood
cultures in all SIeU patients when CVCs were removed. A
CA-BSlwas defined as a positive blood culture in a patient
with a evc in place and no other apparent source ofinfection;
i.e.,the CVC is assumed to be the cause of the BS!.A CR-BSI
was defined as a positive blood culture in a patient with a
CVC in place, isolation of the same organism from a semi-
quantitative or quantitative culture ofa catheter segment and
from the blood of a patient with symptoms of BS!,and no
other apparent source of infection; i.e., the catheter is con-
firmed to be the cause of the BSI.Cultures from CVCs were
performed by the central microbiology laboratory using the
rollplate method, in which the cut end ofthe CVCcatheter is
rolled acrossan agar plate and thenumbers ofcolony-forming
units are counted after an incubation period . Blood
stream infections were monitored by the University infection
control team, and the data were evaluated monthly by the
faculty, staff, and administration at the SICU quality assur-
We used an unpaired t-test to compare the Acute Physiol-
ogy and Chronic Health EvaluJtion (APACHE) III score,
Acute Physi~l~gy Score (APS), ~nd a3e differences in the
SCIUfrom tlie year before intervention with those ofthe post-
i:hterventionIperiod. A 2x2 contingency table was analyzed
TABLE1. PATIENTDEMOGRAPffiCS' ANDCRlTICALCARECHARACTERlSTICS
No. of patients in surgical ICU
Mean patient age (years) (range)
Percent of patients aged 265 years
Mean APACHE III, rcu day 1 (range)
Mean Acute Physiology Score, lCU day 1 (range)
No. of patients on mechanical ventilation, lCU day 1
Admission therapy level (%)
, Active treatment
Low risk monitor
Mean length of stay (days)
Mean ventilator days
APACHE = Acute Physiology and Chronic Health Evaluation score; rcu = intensive care unit.
using the l test with Yates correction to compare total BSI,
CA-BSl, and CR-BSI rates from the pre-intervention
with those of the post-intervention
The number of SlCU admissions
1,340 to 1,491. The services admitting patients to the SIeu
General Surgery, Surgical Oncology, Urology, Obstetrics/
Gynecology, Orthopedics, Otolaryngology, Vascular Surgery,
Critical Care. Disease acuity, assessed
APACHEIII score , increased
intervention period (historical 58.2 in 2004) to 55.6 in the post-
intervention period (p =0.0010; 95% confidence interval [CI]
1.29-5.13).Similarly, the mean APS (16)increased from 42.3 to
45.3 (p = 0.0009;95% CI 1.22-4.74) during the same time. The
mean patient age remained the same at 57 years. There were
no differences in any other demographics
characteristics of the SlCU patients during the time periods
examined (Table 1).
annually ranged from
by the admission
from 52.5 in the pre-
or critical care
The total number of CVC days during the pre-intervention
period (November 2006-0ctober
triple-lumenCVCs were used exclusively was 5,580. The
mean number of catheter-days per patient was 5.79in the pre-
intervention period and 5.87 in the post-intervention
The total number of CA-BSls was three, a rate of 0.5 per 1,000
catheter-days. The total number of CR-BSls during the pre-
intervention period was one, a CR-BSI rate of 0.2 per 1,000
catheter-days (Table 2).
The total number of CVC days during the post-intervention
period (November 2007-0ctober
triple-lumen CVCs were in use was 5,244. The total number
of CA-BSls was four, a rate of 0.8 per 1,000 catheter-days.
The total numberof CR-BSls during the time period was
zero (Tables 2 and 3).
2007) when Chx-SS-coated
2008) when Std non-coated
No difference in the causative microbial pathogens for CA-
BSl or CR-BSI was noted between the pre-intervention
post-interventionperiods (Table 3). Note that most of these
TABLE2. CATHETER-AssOCIATED ANDCATHETER-RELATED BLOODSTREAM INFECTION RATESIN THESURGICAL
INTENSIVE CAREUNIT OVERTIME
BSI=blood stream infection; CA =catheter-associated; CR=catheter-related; Chx-SS=chlorhexidine-spver
catheter; N/ A= not available;Std= standard catheter.
'Rate =centralvenous catheter infectionsper 1,000catheter-days.
sulfadiazine central venous
TABLE 3. ORGANISMS CULTURED FROM CATHETER-AsSOCIATED
CENTRAL VENOUS CATHETER (CVC) POSITION, ANDDAYS FROM CATHETER INSERTION TOINFECTION
ANDCATHETER-RELATEDBLOOD STREAM INFECTIONS,
CA-BSI or CR-BSI
Vein usedDays from CVC insertion to BSI
Right internal jugular
Left internal jugular
Left internal jugular
VRE Left subclavian
CA = catheter-associated;
Enterococcus; VRE =vancomycin-resistant
CR = catheter- related; BSI= blood stream infection; CVC = central venous
line; VSE= vancomycin-sensitive
CA-BSlswere not confirmed as CR-BSls,and the microbial
pathogens identified probably were not the causative patho-
gens in the CR infections.
Relation of catheter location to infection
Catheter-associated BSls were commonly identified in
CVCspositioned in the internal jugular or femoral vein (Table
3). Subclavian CVC placement is not often performed in our
SlCU because the use of real-time ultrasound guidance is
employed regularly for safety concerns.
Ithas been estimated that CVCsaccount for approximately
90% of allblood stream infections [17,18], and more than five
million CVCs are inserted per year in the U.S. [19,20]. Anti-
microbial/ antiseptic-coated and -impregnated catheters have
been designed in an attempt to reduce CR-BS!.Multiple meta-
analyses have concluded that coated CVCs are associated
with reduction in the rates of BSI,but these studies were
performed in the era when CR-BSIrates were high [20-24].
A number of studies have documented that implementa-
tion of an education program and standardization of CVC
placement in addition to full application of the CDC guide-
lines for prevention of CA-BSIis associated with a signifi-
cant reduction in CA-BSI,without the use of antimicrobial!
institution study documented that the "recipe" for zero CR-
BSI included: (1) Standardized education of staff; (2) stan-
dardized placement of CVC; (3)having a CVC cart with all
necessary supplies; (4) daily inquiry regarding discontinua-
tion of CVC; (5) catheter-insertion checklist for assurance of
aseptic technique; and (6) empowering the team to halt the
procedure if aseptic technique rules are violated .A sim-
ilar intervention was implemented state-wide in Michigan
(108ICUs; 375,757 catheter days) without the use of antimi-
crobial! antiseptic-coated CVCs,and a significant reduction in
mean CA-BSl, from 7.7 to 1.4/1,000
documented, representing an overall 66% reduction .
After years of an aggressive education program,
plementation of the CDC guidelines, and use of Chx-SS-
coated CVCs,we reduced the incidence ofCA-BSlin the SlCU
to very low rates. We next examined whether Chx-SSCVCs
were an essential component of our CR-BSIinfection pre-
vention efforts. By replacing the Chx-SS CVCs with non-
coated Std CVCs, we introduced a single change in our
CR-BSIinfection prevention efforts that did not result in an
increase in either CA-BSIor CR-BS!.Our findings are similar
to those of Schuerer et al., who demonstrated that use ofChx-
SS-coatedcatheters in a SlCUwith an already low CA-BSlrate
failed to reduce the rate further .
We continue to use uncoated Std CVCs exclusivelyin the
SlCD.Importantly,neither the CA-BSlnor the CR-BSlrateinthe
SICUchangedsubstantially overthefollowingfivemonths (CA-
BSltotal one [0.5per 1,000catheter-days];CR-BSItotal zero.)
Catheter-associated BSl has been proposed to be and is
accepted as a "never" event; however, this is difficult to
achieve. Despite maximum multidisciplinary effortsto reduce
CA-BSIin a single ICU as a controlled environment, a per-
sistent zero rate of CA-BSIwas not achievable.
The interrupted time-series (quasi-experimental) design
used to examine the impact of this intervention (use of un-
coated Std eVCs) in the SICU does have severallirnitations.
Most notably, it was conducted in a single SlCU in a single
tertiary-care institution with all the inherent biases, and is
potentially subject to influence by changes in patient popu-
lations, ICU practices and policies, and other unrecognized
temporal biases. We did not collect data on the CVCs that
were not associated with BS!and therefore cannot make any
comments on the location, indwelling time, or specificpatient
characteristics associated with CVCs not linked to BS!.Ad-
ditionally, in the SlCU, CVCs are likely to be placed in a
specific subset of critically ill patients. The types of patients
and the reason for CVC placement were not tracked during
Despite these limitations, the findings of this analysis sup-
port the conclusion that aggressive education programs and
adherence to best-practice guidelines are powerful tools in the
prevention ofCA-BSIand CR-BS!.InlCUs where exceptionally
low CA-BSlrates already have been achieved, the universal
use of Chx-SS-coatedcatheters does not yield any additional
reduction. Giren the costof $50.00 to$100.00 more for aChx-SS
than an Std catheter, use of Std Cl
Cs in lCUs with a low CR-
~SIrate carrffs potential cost savi gs.
an SICD with a low number
rate of such infections.
of care related to CVC placement
design in reducing
of the universal use of Chx-55-coated
of CR-BSls did not increase the
and care than of catheter
of the processes
No conflicting financial interests exist.
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ML, et al. National
Dr. Jill R. Cherry-Bukowiec
University of Michigan
1500 E. Medical Center Dr., SPC 5033
Ann Arbor, MI 48109