What’s New in the 2011 Guideline for
Preventing Catheter Related BSI?
Naomi P. O’Grady, MD
Critical Care Medicine Department
National Institutes of Health
I have no disclosures.
Objectives
Highlight some areas of controversy, including
catheter site selection, antimicrobial locks, and
chlorhexidine impregnated sponge dressings
 Discuss the recommendations in the updated
guideline
 Outline some of the data to support the new
recommendations

Clinical Infectious Diseases 2011; 52(9) e162-e193
Site Selection
Old Recommendation

Use a subclavian site (rather than a jugular
or a femoral site) in adult patients to
minimize infection risk for non-tunneled
CVC placement
Site Selection
Rather than focus on one specific site to select,
we now focus on one specific site to avoid.
 Avoid the femoral vein for central venous access
in adults
 Femoral site associated with greater risk of
infection and DVT

Merrer; JAMA, 2001
Parienti; JAMA, 2008
JAMA, 2001; 286:700-07
Catheter Complications
Randomized patients to femoral (145) vs
subclavian (144)
 8 ICU’s; 3 years
 Mechanical complications similar in both groups
 Infection and thrombosis higher in femoral group

Catheter Complications
Catheter Complications
* Thrombotic complications were 21% in femoral group
and 1.9% in subclavian group ( p<0.001) with 2 PE’s
JAMA 2008
Femoral vs Jugular Catheterization
375 patients in each arm over a 3 year period
 Primary endpoint was colonization on removal
 Insertion complications, CR-BSI, and thrombosis
were secondary endpoints

Mechanical Complications
Jugular catheters: longer insertion times, more
failed attempts and more crossover
 Arterial punctures no different (5.1% vs 3.6%),
although hematoma formation higher in jugular
 2 patients required intubation in jugular group
 1 patient required vascular surgery for carotid
artery insertion
 1 patient with acute leg ischemia required limb
amputation

Infectious Complications
JAMA 2008
Controversy. . .
JAMA 2008
Skin Antisepsis
Old Recommendation
Disinfect clean skin with an appropriate
antiseptic. A chlorhexidine-based
preparation with >2% is preferred.
Alternatively, tincture of iodine, an
iodophor, or 70% alcohol could be
used.
New Recommendation
Disinfect clean skin with an appropriate
antiseptic. A chlorhexidine-based
preparation with >0.5% is preferred.
Alternatively, tincture of iodine, an
iodophor, or 70% alcohol could be
used.
Chlorhexidine significantly reduces risk of colonization and BSI
Annals of Internal Medicine 2002
Catheter Site Dressing Regimens
Old Recommendation:
No recommendation
Efficacy of Chlorhexidine Impregnated
Sponges for Prevention of Intravascular
Catheter Related Infections
Chlorhexidine
Sponge
N = 665
Catheter Colonization
Blood Stream Infection
Control
N = 736
RR
109 (16%)
216 (29%)
0.62 (0.49-0.78)
8 (1.2%)
24 (3.3%)
0.38 (0.16-0.29)
ICAAC 2000
Timsit JF et al. JAMA 2009
Chlorhexidine sponge dressings reduce
risk of infection and colonization
2 x 2 factorial RCT to evaluate chx dressing vs
standard and to evaluate 3 day vs 7 day dressing
changes
 1653 patients
 3778 catheters
 28,931 catheter days

Chlorhexidine sponge dressings reduce risk of infection and colonization
Timsit JF et al. JAMA 2009
Catheter Site
Dressing Regimens
Use a chlorhexidine sponge dressing in
adult patients with short-term catheters
to reduce the incidence of infection
catheter-related infection.
Antimicrobial Lock Solutions
Use prophylactic antimicrobial lock
solution in patients with long term
catheters who have a history of multiple
CRBSI despite optimal maximal adherence
to aseptic technique.
Catheter Locks
Technique by which an antimicrobial solution is
used to fill a catheter lumen and then allowed to
dwell for a period of time while the catheter is idle.
 Antibiotics of various concentrations that have
been used either alone (when directed at a specific
organism) or in combination (to achieve broad
empiric coverage)
 Formulations made in-house
 Studies are limited; populations are hemodialysis,
neonates, patients with neutropenia

Needleless Connectors
Mechanical Valve
Split Septum
Recommendation
When needleless systems are used, a split septum
valve may be preferred over a mechanical valve
due to increased risk of infection with some
mechanical valves. Category II
Bundles and Checklists
Eliminating Catheter Related Infections
Crit Care Med; October 2004
Eliminating Catheter Related Infections
Educational intervention to increase provider
awareness
 Created CVC insertion cart
 Asking providers daily if the CVC is needed
 Checklist at bedside for nurses
 Empowering nurses to stop the procedure
 Did not include tunneled of PA catheters

Eliminating Catheter Related Infections
Implemented simple strategies
 No impregnated catheters
 Reduced infection rate from 11.3/1000 catheter
days to 0/1000 catheter days during study period
 Performance sustained
 Jan-April 2003 only 2 infections (0.54/1000 catheter
days)

Eliminating Catheter Related Infections
Eliminating Catheter Related Infections
Excluded PICCS
 Implemented teaching program
 CVC carts
 Checklist for compliance with handwashing and
barrier precautions

Eliminating Catheter Related Infections
Antibiotic/Antiseptic Catheters
Antibiotic/Antiseptic Catheters
Use an antimicrobial or antiseptic-impregnated CVC
in adults whose catheter is expected to remain in
place >5 days if, after implementing a comprehensive
strategy to reduce rates of CR-BSI, the rate has not
sufficiently decreased. The comprehensive strategy
should include the following 3 components:
educating persons who insert and maintain
catheters, use of maximal barrier precautions, and a
0.5% chlorhexidine preparation for skin antisepsis
during central venous catheter insertion.
Efficacy of Chlorhexidine-Silver Sulfadiazine
Catheters for Prevention of Catheter Colonization
Heard, 1998
Maki, 1997
van Heerden, 1997
George, 1999
Bach, 1996
Collin, 1999
-0.2
0
0.2
Odds ratio, 95% CI
0.4
0.6
0.8
1
Decreasing risk
1.2
Increasing risk
Proportion of Catheters
without Infection
Risk of Bloodstream Infections Using Two
Types of Impregnated Catheters
Catheter
M/R
C/SS
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.1
0.0
0
No. at Risk
365
382
Minocycline-rifampin
catheters
Chlorhexidine-silver
sulfadiazine catheters
5
10
15
20
30
25
Duration of Catheterization (Days)
214
246
93
96
48
39
20
18
9
5
4
2
Darouiche
NEJM 1999
Eliminating Catheter Related Infections
Annals of Internal Med 2005
Eliminating Catheter Related Infections
Summary






Educate healthcare workers and provide training
for the insertion and maintenance of catheters
Use chlorhexidine preferentially for skin
antisepsis
Use maximal barrier precautions
Use a chlorhexidine sponge dressing in adults
with short-term catheters
Use an antibiotic/antiseptic catheters if CRI rates
have not sufficiently declined
Use a bundled strategy for simplicity
Conclusions
Prevention strategies have measurable impact
 Multiple interventions may be needed
 Performance improvement programs will be
focused on moving toward elimination of CABSIs rather than “benchmark goals”
 Focus of prevention moving away from
insertion phase and into maintenance phase

Thank you.