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Canada Communicable Disease Report

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

INFECTION CONTROL GUIDELINES

Preventing Infections Associated with Indwelling Intravascular Access Devices

Insertion Site Care, Including Dressing and Site Change Intervals

Heavy colonization of insertion sites is a well- documented risk factor for infections associated with indwelling devices(2,4). Site dressing is advocated to protect the open wound from contamination. One study found 10-fold more bacteria colonizing uncovered skin and 100-fold more bacteria colonizing skin occluded by an impermeable dressing compared with skin covered by any of several transparent semipermeable dressings or gauze(59). Few studies have specifically addressed the optimal frequency of dressing changes for catheters. However, several studies have addressed the issue of the type of dressing material and its influence on cutaneous flora(59-62).

Several studies have found increased bacterial colonization in warm, moist, occluded sites under transparent semipermeable (both conventional and the newer, highly permeable) dressings(61,63,64). However, these studies must be interpreted carefully with respect to potentially confounding variables such as dampness persisting under the dressing and differences in the relative permeability of the dressings(60,64). It should also be emphasized that a positive skin or cannula culture is a surrogate marker for clinical infection and that the risk of clinical infection is greater in patients with central as opposed to peripheral catheters. Some semipermeable transparent dressings have been associated with an increased risk of infection(60-62). Compared with simple gauze dressings, transparent semipermeable dressings are more expensive but permit easy inspection of the site, stabilize the catheter, may offer an advantage to patients who are mobile, and have been left in place for up to 7 days(2).

Antimicrobial ointments have been advocated for site care because of their theoretical advantage in suppressing microbial growth at the insertion site. There is no epidemiologic evidence to suggest that antimicrobial ointments are beneficial for short-term peripheral venous sites. Studies of long-term arterial or central line sites are confounded by changes in practice (e.g., decreasing use of cut-downs) and catheter materials, and have produced conflicting results. Increased cost and the potential to promote the emergence of drug-resistant organisms and colonization with yeasts are factors that also discourage the use of such ointments.

The cumulative incidence of infection rises with time. In a study of peripheral venous lines in adults, the risk associated with each additional 24-hour increment of use (incidence density) also increased with time, so risk can be reduced by replacing lines at new sites every 48-72 hours(65). A similar increase in incidence density has not been documented with peripheral venous or arterial lines in children(66-68) or with central venous lines(69,70). Therefore, it is not prudent to replace these lines on a routine basis. It has been suggested that pulmonary arterial lines in intensive care units be replaced every 4 days because of increased risk of infection(59), but one prospective study does not support this practice(70). Studies suggest that incidence density may rise during the first few days, but then declines and remains low. Unlike a study that used a historical comparison group(71), prospective studies show that routine cannula replacement over a guide wire fails to decrease the risk of infection(70,72,73).

RECOMMENDATIONS

All Lines

  1. Patients with intravascular devices should be evaluated at least daily for evidence of infectious complications. This evaluation may include gentle palpation of the insertion site through the intact dressing or direct observation, as appropriate for the type of device. (Category B; Grade III)
  2. If a patient has unexplained fever, or pain or tenderness at an insertion site, or if a patient cannot communicate, then the intravascular site should be inspected visually. (Category B; Grade III)

Peripheral Venous Lines

  1. Antimicrobial ointments are of no proven benefit and should not be applied at the time of dressing changes(2). (Category D; Grade II)
  2. A sterile gauze dressing should be used and, unless the dressing or the skin surrounding the entry site becomes wet or soiled, may be left in place until the catheter is removed. Alternatively, a transparent semipermeable dressing (low or high permeability) may be used since the risk of bacteremia is extremely low with peripheral IV lines(63). (Category A; Grade I)
  3. For adults in hospital settings, steel or plastic cannulae may be left in place for up to 72 hours(2,65). Unless there are signs of inflammation, peripheral venous lines in children need not necessarily be changed as long as they remain functional(66,67). (Category A; Grade II)
  4. There are insufficient data to make definitive recommendations for longer periods for lines used for intermittent infusion(74) or in home care settings(75). (Category C)

Arterial Lines

  1. There are insufficient data on which to base a recommendation concerning use of an antimicrobial ointment at the time of dressing changes. (Category C)

  2. A sterile gauze dressing should be used. A transparent semipermeable (low or high permeability) dressing may be considered for peripheral arterial lines, but gauze may be preferable for patients who are profoundly diaphoretic or who have very fragile skin. The dressing should be changed if skin at the entry site is wet; otherwise, an optimal interval for routine dressing changes is unknown. (Category B; Grade III)

  3. For adults, peripheral arterial catheters may be left in place for up to 6 days(76). Peripheral arterial catheters may be left in place for an even longer duration in pediatric patients(68). The upper limit for pediatrics is not yet established. (Category B; Grade II)

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

  1. Application of povidone-iodine ointment at the time of dressing changes(57) may be considered as a preventive measure. (Category B; Grade II)

  2. Sterile gauze dressings should be used for lines inserted at subclavian and internal jugular central sites(61). (Category A; Grade I)

  3. There are currently insufficient data to recommend the optimal choice of dressings for lines placed at other sites, including those for PICC (see Appendix III) and midline catheters. (Category C)

  4. By convention, gauze dressings have been changed every 2 to 3 days, but the optimal duration between dressing changes is unknown. Gauze dressings may be left in place for a longer duration but should be changed whenever they are soiled or wet. (Category C)

  5. Central venous lines used for total parenteral nutrition or long-term antimicrobial or antineoplastic chemotherapy and hemodialysis may be left in place as long as they remain functional, unless they appear to be a source of infection. (Category B; Grade III)

  6. A catheter should not be changed over a guide wire if infection is suspected. However, a change over a guide wire may be done in the case of malfunction(70). (Category B; Grade I)

  7. Pulmonary arterial catheters may be left in place for up to 4 days(58). If it is essential to continue pulmonary arterial catheter monitoring beyond the fourth day, there are four potential options (Category C):

    1. Leave the catheter in place, assuming that cumulative risk of infection will continue to multiply at a constant rate(70).

    2. Remove the catheter and place a new catheter at a new site, to gain another 4 days of presumed low risk(58).

    3. Replace the catheter over a guide wire and culture the old catheter. If the old catheter is shown to be infected, remove the new catheter from the infected site; if the old catheter is not infected, the new catheter may be left in place(58).

    4. Use catheters or catheter cuffs that incorporate antimicrobial compounds(29,30).

Totally Implantable Devices

  1. The needle may be removed at the end of each infusion or left in place as an intermittent heparinized lock. Needles should be changed frequently enough to prevent skin breakdown. This should be at least every 7 days(77). (Category B; Grade III)

  2. The needle should be secured and covered with a sterile dressing. There are insufficient data to recommend specific site care and dressing change protocols. (Category C)

Umbilical Lines

  1. The relation between duration of umbilical arterial and venous catheterization and catheter-related sepsis has not been established(78). No recommendation is made regarding time limits for umbilical lines. (Category C)

 

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