Review: some interventions may reduce catheter-related bloodstream infections and colonisation in the ICU
Dr N Graves, Queensland University of Technology, Brisbane, Queensland, Australia;
How do various interventions compare for reducing catheter-related bloodstream infections (CRBSIs) and colonisation in the intensive care unit (ICU)?
Studies selected evaluated short-term (<21 d) non-tunnelled catheters and reported incidence of CRBSI in patients ⩾18 years of age in the ICU. Exclusion criteria included studies evaluating totally implantable or peripherally inserted central venous catheters or haemodialysis catheters, arterial venous catheters, and those conducted in diverse settings. Outcomes were CRBSI and colonisation.
Medline, CINAHL, EMBASE/Excerpta Medica, Current Contents, Cochrane Library, Health Services Technology, Centre for Disease Control guideline and reports, and 8 other databases were searched (from 1985 to Feb 2007) for observational studies or randomised controlled trials (RCTs) published in English. 14 RCTs (n = 2235, mean age 59 y based on 10 RCTs), 1 non-RCT, and 8 observational studies met the selection criteria. 7 RCTs reported randomisation method, 1 reported allocation concealment, and 4 had blinded outcome assessment.
Single RCTs showed that disinfectable needle-free connectors reduced risk of CRBSI compared with 3-way stopcock connectors (table); disinfecting skin with chlorhexidine gluconate, 2%, or povidone iodine (PI), 5%, plus ethanol, 70%, were more effective than PI, 10% alone, and use of Vitacuff was more effective than no cuff for reducing colonisation (table); femoral insertion had greater risk of colonisation than subclavian insertion (table).
Some interventions reduce risk of catheter-related bloodstream infections and colonisation in the intensive care unit.
Ramritu P, Halton K, Cook D, et al. Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis. J Adv Nurs 2008;62:3–21.
Source of funding: National Health and Medical Research Council of Australia.
The systematic review by Ramritu et al provides a sound evidence base for reducing risk of infection associated with insertion and management of central venous catheters. The review supports the effectiveness of strategies other than the widespread use of expensive antimicrobial catheters. It shows that specific single factor interventions, as well as more general strategies such as staff education, multifaceted infection control programmes, and performance feedback, are effective.
The explicit purpose of the review was to compare interventions, other than antimicrobial catheters, to reduce CRBSIs. The authors infer that antimicrobial catheters are more expensive than other interventions, although the costs of the interventions reviewed were not discussed. The cost issue remains inconclusive. The authors conclude that “interventions other than antimicrobial catheters may be useful in reducing risks.” What is still unclear is the extent to which use of antimicrobial catheters in addition to other interventions improve patient outcomes. This was not the focus of the review and limits the clinical applicability of the results.
The findings of the review have clear implications for nurses working in critical care settings. Specific interventions included site of catheter insertion, type of skin disinfectant, catheter replacement at a new site compared with catheter exchange at the same site, connecter and hub types, presence of attachable cuffs, number of catheter lumens, educational strategies, and mixed interventions. Some critical care nurses will say that the findings of this review are well-known and in practice. Nevertheless, the review provides a single information source, rather than current multiple sources, and advances the interventions and strategies from supposition and theory to a systematic foundation for practice. However, many questions remain about the best approach.