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Background: Central venous catheter-related infections are a significant medical problem. Improved preventive measures are needed.Objective: To ascertain 1) effectiveness of a second-generation antiseptic-coated catheter in the prevention of microbial colonization and infection; 2) safety and tolerability of this device; 3) microbiology of infected catheters; and 4) propensity for the development of antiseptic resistance.Design: Multicenter, randomized, double-blind, controlled trial.Setting: 9 university-affiliated medical centers.Patients: 780 patients in intensive care units who required central venous catheterization.Intervention: Patients received either a standard catheter or a catheter coated with chlorhexidine and silver sulfadiazine.Measurements: The authors assessed catheter colonization and catheter-related infection, characterized microbes by molecular typing, and determined their susceptibility to antiseptics. Patient tolerance of the catheter was monitored.Results: Patients with the 2 types of catheters had similar demographic features, clinical interventions, laboratory values, and risk factors for infection. Antiseptic catheters were less likely to be colonized at the time of removal compared with control catheters (13.3 vs. 24.1 colonized catheters per 1000 catheter-days; P < 0.01). The center-stratified Cox regression hazard ratio for colonization controlling for sampling design and potentially confounding variables was 0.45 (95% CI, 0.25 to 0.78). The rate of definitive catheter-related bloodstream infection was 1.24 per 1000 catheter-days (CI, 0.26 to 3.62 per 1000 catheter-days) for the control group versus 0.42 per 1000 catheter-days (CI, 0.01 to 2.34 per 1000 catheter-days) for the antiseptic catheter group (P = 0.6). Coagulase-negative staphylococci and other gram-positive organisms were the most frequent microbes to colonize catheters. Noninfectious adverse events were similar in both groups. Antiseptic susceptibility was similar for microbes recovered from either group.Limitations: The antiseptic catheter was not compared with an antibiotic-coated catheter, and no conclusion can be made regarding its effect on bloodstream infection.Conclusions: The second-generation chlorhexidine-silver sulfadiazine catheter is well tolerated. Antiseptic coating appears to reduce microbial colonization of the catheter compared with an uncoated catheter. [ABSTRACT FROM AUTHOR]

Objective: To assess the risk associated with midline catheter use in hospitalized patients.Design: Prospective, consecutive enrollment.Setting: A 719-bed university-affiliated hospital.Patients: Patients were enrolled if they were likely to require at least 7 days of intravascular catheterization while hospitalized.Measurements: Patients were monitored for adverse reactions. Catheter segment, insertion site, hub, infusate, and blood cultures were assessed.Results: From February 1993 through June 1994, 251 Landmark midline catheters were inserted in 238 patients. One hundred forty catheter cultures were obtained from 130 patients who remained hospitalized for the duration of catheterization. For these 130 patients, the mean duration of catheterization was 9 days, the incidence of catheter colonization was 5.0 per 1000 catheter days, and the incidence of catheter-related bloodstream infection was 0.8 per 1000 catheter days. During the study period, two severe, unexpected adverse reactions occurred that may have been associated with the use of Landmark midline catheters; no such reactions were associated with the insertion of 58,580 Teflon peripheral catheters (P < 0.00001; exact 95% lower bound of the odds ratio, 68.9). Fifty-three similar reactions associated with Landmark midline catheters, including two deaths, have been reported to the Food and Drug Administration through June 1994.Conclusion: The risk for midline catheter-related infection is low. However, Landmark midline catheters are associated with life-threatening adverse reactions that are probably attributable to the catheter material itself. [ABSTRACT FROM AUTHOR]

Background: Bloodstream infection related to short-term use of noncuffed central venous catheters is a common and serious problem. Technologic innovations to reduce the risk for these infections are needed.Objective: To determine 1) the efficacy of a novel antiseptic catheter in preventing central venous catheter-related infection, 2) patient tolerance of this catheter, and 3) the sources of bloodstream infection originating from noncuffed, multilumen central venous catheters.Design: Randomized, controlled clinical trial.Setting: Medical-surgical intensive care unit of a 450-bed university hospital.Participants: 158 adults scheduled to receive a central venous catheter; 403 catheters were studied.Intervention: Participants received either a standard triple-lumen polyurethane catheter or a catheter that was indistinguishable from the standard catheter and was impregnated with chlorhexidine and silver sulfadiazine.Measurements: Catheters were studied for colonization and catheter-related bloodstream infection at removal; local and systemic effects of catheters were assessed. The origin of each catheter-associated bloodstream infection was sought by culturing all potential sources (skin, catheter segments, hubs, and infusate) and confirmed by restriction-fragment DNA subtyping.Results: Antiseptic catheters were less likely to be colonized at removal than control catheters (13.5 compared with 24.1 colonized catheters per 100 catheters; relative risk, 0.56 [95% CI, 0.36 to 0.89]; P = 0.005) and were nearly fivefold less likely to produce bloodstream infection (1.0 compared with 4.7 infections per 100 catheters; 1.6 compared with 7.6 infections per 1000 catheter-days; relative risk, 0.21 [CI, 0.03 to 0.95]; P = 0.03). In the control group, 8 catheter-related bloodstream infections were caused by Staphylococcus aureus, gram-negative bacilli, enterococci, or Candida species; no infections with these organisms occurred in the antiseptic catheter group (P = 0.003). No adverse effects from the antiseptic catheter were seen, and none of the 122 isolates obtained from infected catheters in either group showed in vitro resistance to chlorhexidine-silver sulfadiazine. Cost-benefit analysis indicated that the antiseptic catheter should prove cost-beneficial if an institution's rate of catheter-related bacteremia with noncuffed central venous catheters is at least 3 infections per 1000 catheter-days).Conclusions: The chlorhexidine-silver sulfadiazine catheter is well tolerated, reduces the incidence of catheter-related infection, extends the time that noncuffed central venous catheters can be safely left in place for the short term, and should allow cost savings. [ABSTRACT FROM AUTHOR]

Purpose: To review the literature on prevention of intravascular catheter-related infections., Data Sources: The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. Primary authors were contacted directly if data were incomplete., Study Selection: Studies met the following criteria unless otherwise stated: Trials were prospective and randomized; catheters were inserted into new sites, not into old sites over guidewires; catheter cultures were done by using semi-quantitative or quantitative methods; and, for prospective studies, catheter-related bloodstream infection was confirmed by microbial growth from percutaneously drawn blood cultures that matched catheter cultures., Data Extraction: Data on population, methods, preventive strategy, and outcome (measured as catheter-related bloodstream infections) were gathered. The quality of the data was graded by using preestablished criteria., Data Synthesis: The recommended preventive strategies with the strongest supportive evidence are full barrier precautions during central venous catheter insertion; subcutaneous tunneling short-term catheters inserted in the internal jugular or femoral veins when catheters are not used for drawing blood; contamination shields for pulmonary artery catheters; povidone-iodine ointment applied to insertion sites of hemodialysis catheters; specialized nursing teams caring for patients with short-term peripheral venous catheters, especially at institutions with a high incidence of catheter-related infection; no routine replacement of central venous catheters; antiseptic chamberfilled hub or hub-protective antiseptic sponge for central venous catheters; and use of chlorhexidine-silver sulfadiazine-impregnated or minocycline-rifampin-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies that do not incorporate antimicrobial agents (for example, maximal barrier precautions)., Conclusions: Simple interventions can reduce the risk for serious catheter-related infection. Adequately powered randomized trials are needed.

The yield of blood cultures depends on the volume of blood cultured. We recently discovered that 15% of blood-culture specimens from adults in our hospital were being collected in 3.5-mL pediatric tubes and that another 5%, drawn in 10-mL adult tubes, contained less than 5 mL of blood. A comparison of 829 matched pairs of standard-volume (mean, 8.7 mL) and low-volume (mean, 2.7 mL) blood cultures showed that standard-volume cultures had a substantially higher detection rate for bloodstream infection than did low-volume cultures (92% compared with 69%; difference, 23% [95% CI, 9% to 37%]; P < 0.001). Our data, together with an analysis of previous studies, show that the yield of blood cultures in adults increases approximately 3% per millilitre of blood cultured. A survey of 158 U.S. clinical microbiology laboratory directors in the American Society of Clinical Pathologists showed that only 20% of 71 responding laboratories record the volume of blood submitted for culture and that the practice of culturing suboptimal volumes of blood from adults is widespread. Clinical laboratories should routinely monitor the volume of blood cultured as a quality-assurance measure. Blood-culture specimens from adults should not be drawn using small pediatric tubes.