How to reduce the risk of catheter-related infections as recommended by NHS England
In this series of posts, we will take a closer look at existing guidelines aimed to reduce the risk of catheter-related infections.
For simplicity we will use the epic3 guidelines by NHS England (revised and updated in 2014) — titled epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England.
Guidelines exist to provide comprehensive recommendations for preventing hospital-acquired infections in hospitals and other acute care settings based on the best currently available evidence. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection can be minimised.
Recommendations are classified from A — D where A has the highest level of supporting clinical evidence. In addition, a ‘Good Practice’ recommendation is also available; from clinicians and patient groups involved in the creation of the guidelines.
There are two main types of central venous catheters:
· Class II ‘Acute’ catheters for short-term acute applications (i.e. less than 30 days), including multi-lumen catheters used in intensive care units (ICUs)
· Class II ‘long-term’ catheters designed as permanent implants, such as implantable ports, peripherally inserted central catheters (PICCs) and cuffed catheters
As catheters can pose serious danger for patients acquiring infections in healthcare settings, there are some questions that healthcare workers would ask in order to prevent such infections.
Here we cover a few frequent enquiries:
1. How long can I safely leave my Class II catheter in situ?
Guideline IVAD2
· Healthcare workers should be aware of the manufacturer’s advice relating to individual catheters, connection and administration set dwell time, and compatibility with antiseptics and other fluids to ensure the safe use of devices.
> New recommendation Class D/GPP
Guideline IVAD10
· Use an antimicrobial-impregnated central venous access device for adult patients whose central venous catheter is expected to remain in place for more than 5 days if catheter-related bloodstream infection rates remain above the locally agreed benchmark, despite the implementation of a comprehensive strategy to reduce catheter-related bloodstream infection.
> Class A
Comment
·There are three types of catheter technologies available, designed for different dwell times. Plain polyurethane catheters have no protection from bacterial colonisation and therefore the risk increases over time. We would see these catheters used for low risk patients groups with a dwell time of ~ 48–72 hours.
· Typically, immune-compromised high-risk patients, who require central venous access for 5 days and over, will benefit mostly from a combined antibiotic and antifungal catheter protection. which protects both the internal and external catheter surfaces.
· Medium-risk patients where a dwell time is expected to be more than two but less than six days will benefit most from silver antimicrobial technologies, which have been shown to be effective at slowing the rate of catheter colonisation.
2. How many catheter lumens are safe?
Guideline IVAD6
· Use a catheter with the minimum number of ports or lumens essential for management of the patient.
> Class A
Comment
· Patients with complex infusion therapy requirements often with incompatible drugs and/or where a dedicated lumen is required will benefit most from the use of catheters with more lumens. Accordingly, if using a seven-lumen catheter reduces the risk of infusion error and aids patient management, then this is acceptable. However, if using a three, four or five-lumen catheter is more suitable, then choose a catheter with fewer lumens.
· In each case using one central venous catheter with multiple lumens is more preferable than using multiple catheters
3. Should I replace my catheter?
Guideline IVAD26
· Do not routinely replace central venous access devices to prevent catheter-related infection.
> Class A
Guideline IVAD27
· Do not use guidewire-assisted catheter exchange for patients with catheter related bloodstream infection.
> Class A
Comment
· Linking back to our first post in this series, we considered correct catheter technology selection as the primary tool to reduce the risk of catheter-related infection, based on dwell time.
· Guidewire exchange has been shown to transfer bacteria between catheters and should therefore be avoided
· In all cases correct catheter selection should prevent the need to replace the catheter during the patient’s ICU stay time.
4. Are antimicrobial locks effective?
Guideline IVAD31
· Antimicrobial lock solutions should not be used routinely to prevent catheter related bloodstream infections.
> Class D/GPP
Guideline IVAD32
· Do not routinely administer intranasal or systemic antimicrobials before insertion or during the use of an intravascular device to prevent catheter colonisation or bloodstream infection.
> Class A
Guideline VAD34
· Use sterile normal saline for injection to push and lock catheter lumens that are accessed frequently.
>Class A
Comment
· Biofilm forms quickly on both the internal and external surfaces of the catheter once they come into contact with blood and fluids. Biofilm forms a protective layer that both antra-lumen and systemic administration of antibiotics are unable to penetrate. Accordingly the current clinical evidence to support the use of an antimicrobials to prevent catheter colonisation is statistically poor.
· Based on the best currently available evidence appropriate catheter selection at the start of therapy remains the best form of protection against catheter related infection.
5. Does a big drape and procedure pack make a difference?
Guideline IVAD13
· Use maximal sterile barrier precautions for the insertion of central venous access devices.
>Class C
Comment
· This guideline is based on the initial research conducted by Peter Pronovost, first published in the 2006 New England Journal of Medicine. Where using a procedure pack incorporating full-barrier precautions during catheter insertion, significantly reduced the rate and frequency of catheter related infection
· Evidence indicates that a full body drape covering the patient from head to toe is a major factor in reducing catheter colonisation during insertion, together with an integrated procedure pack that avoids the addition of components into the sterile field.
Note: Supporting evidence is available on the epic3 guidelines, for details please email questions@vygon.com
David Wilkes
Principle International Business Development Manager, Vygon Critical Care
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