[Table of Contents]

Canada Communicable Disease Report - Supplement
Volume: 23S8
December 1997

INFECTION CONTROL GUIDELINES

Preventing Infections Associated with Indwelling Intravascular Access Devices

Insertion Site Selection and Preparation

It has previously been recommended that lower extremity insertion sites (see Appendix III) be avoided because the density of microbes (bioload [see Appendix III]) at sites below the groin was thought to compromise aseptic maintenance of sites and increase the risk of infection. This has not been confirmed in observational studies and in a prospective randomized study^(38,39). Pulmonary artery catheters inserted into an internal jugular vein were associated with higher risk of infection than those inserted into a subclavian or femoral vein in a number of observational studies, as well as in one of two prospective studies^(40-42). A second prospective study failed to show a difference in infection rate, possibly because of a small sample⁽⁴²⁾. Moisture and proximity to respiratory or tracheostomy secretions may explain elevated risk with internal jugular insertion. Consideration of comfort, security and maintenance of asepsis should guide site selection.

Hand washing remains a cornerstone of infection prevention and control. Although the efficacy of antiseptic formulations is superior to non-antiseptic detergents in laboratory tests, evidence of superiority in practice remains controversial: the quality and frequency of hand washing itself may be more important than choice of agent^(43,44). Two recent prospective studies have shown a reduction in infection rate in central catheters inserted with maximum barrier precautions versus those inserted with less stringent aseptic technique^(41,45). Cost-effectiveness was demonstrated in one study⁽⁴⁵⁾.

Preparation of central venous and arterial sites with aqueous 2% chlorhexidine gluconate has resulted in lower infection rates compared with site preparation with 10% povidone-iodine or 70% alcohol⁽⁴⁶⁾. A 0.5% chlorhexidine gluconate in 70% isopropyl alcohol was shown in laboratory models^(47,48) to be effective, and in a prospective non-randomized sequential study was superior to 10% povidone-iodine in preventing peripheral IV colonization in neonates⁽⁴⁹⁾. An observational study⁽⁵⁰⁾ of Broviac catheters used for total parenteral nutrition found that this preparation of chlorhexidine gluconate was associated with a lower catheter-related infection rate than 10% povidone-iodine. It is advisable to check the manufacturer's recommendations, as some products may be incompatible with alcohol preparations. Antimicrobial/antiseptic ointments have been advocated for site care because of their theoretical advantage in suppressing microbial growth at the insertion site wound. Application of antibiotic (see Appendix III) ointments has not been found to be effective in preventing infection of peripheral venous sites. These ointments may promote emergence of drug resistance and increase the frequency of fungal infections⁽²⁾, resulting in increased cost. Trials of topical antiseptic ointment (povidone-iodine) on central venous catheter sites have shown conflicting results. One study showed a fourfold reduction in catheter-related bacteremia⁽⁵¹⁾.

RECOMMENDATIONS

All Lines

1. Hands must be washed before intravascular devices are inserted or manipulated. The most important element is thorough hand washing; however, the optimal duration for hand washing is unknown. (Category B; Grade III)

2. The quality of hand washing may be more important than the choice of the agent^(43,44). However, it may be prudent to use an antiseptic formulation for hand washing prior to insertion of any intravascular device. (Category C)

3. Maximum aseptic barriers (long-sleeved sterile surgical gown, sterile gloves, mask, and large sterile drape) should be used for inserting all central catheters⁽⁴⁵⁾ and pulmonary arterial lines⁽⁴¹⁾. (Category A; Grade I)

4. Data are lacking regarding the degree to which aseptic barrier precautions should be used for midline and peripheral arterial lines. (Category C)

5. Insertion sites should be prepared with an antiseptic of proven efficacy. Chlorhexidine gluconate preparations (2% aqueous or 0.5% in 70% isopropyl or ethyl alcohol) may provide an advantage^(46,49,50). The efficacy of 0.5% alcoholic chlorhexidine gluconate preparations has not yet been confirmed by prospective randomized trials, but in vitro and observational studies suggest that they may be superior to iodophors^(49,50). Other suitable agents include 10% povidone-iodine, 1% tincture of iodine, and 70% isopropyl alcohol. It is advisable to check manufacturers' recommendations as some products may be incompatible with alcohol preparations. Regardless of which agent is applied, the skin should be prepared for at least 30 seconds (an optimal length of time is unknown) and allowed to dry. Benzalkonium chloride⁽⁵²⁾ or hexachlorophene should not be used as a preparation for an intravascular site. (Category A; Grade II)

6. Data are lacking to recommend for or against the removal of iodophor after application. Removal may reduce skin irritation but does terminate sustained release of iodine. Tincture of iodine should be removed. (Category C)

7. Acetone should not be used to "defat" the skin⁽⁵³⁾. (Category E; Grade II)

8. Insertion by surgical cutdown should be avoided⁽⁵⁴⁾. (Category E; Grade II)

9. The cannula should be secured to stabilize its position in an insertion site. There are no definitive data to suggest that using sterilized tape for this purpose reduces the risk of infection^(55,56). It is prudent to avoid gross contamination of tape and to store tape in a clean, dust-free environment. (Category B; Grade III)

Peripheral Venous Lines

1. Upper extremity sites may be preferable for convenience in adults. There is no evidence of any increased risk of infection in lower extremity sites. The hand, the dorsum of the foot or the scalp may be used in children. (Category B; Grade III)

2. Topical antimicrobial ointments should not be applied as a routine infection prevention measure⁽²⁾. (Category D; Grade II)

Arterial Lines

1. There are no data on which to base a recommendation concerning use of topical antimicrobial ointments. (Category C)

Central Venous Lines (including PICC, central hemodialysis lines and central pulmonary arterial catheters) and Midline Catheters

1. Povidone-iodine ointment may be applied as a measure to prevent infection⁽⁵⁷⁾. (Category B; Grade II)

2. There are insufficient data to make recommendations for midline catheters (see Appendix III). (Category C)

3. In adults, the subclavian site is preferable to the jugular site for insertion of central lines⁽⁵⁸⁾. (Category A; Grade I)

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