Catheter Related Infxts JAN

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Catheter-related bloodstream infections in intensive care units:a systematic review with meta-analysis

Prabha Ramritu, Kate Halton, David Cook, Michael Whitby & Nicholas Graves

Accepted for publication 28 August 2007

Correspondence to N. Graves:

e-mail: [email protected]

Prabha Ramritu MN RN

Project Officer

The Centre for Healthcare Related Infection

Surveillance & Prevention, Princess

Alexandra Hospital, Brisbane, Qld, Australia

Kate Halton MSc

Project Officer




Institute of Biomedical and Health

Innovation, Brisbane, Qld, Australia

David Cook MBBS PhD

Medical Officer

Intensive Care Unit, Princess Alexandra

Hospital, Brisbane, Qld, Australia

Michael Whitby FRACP MPH

Director of Infectious Diseases




Nicholas Graves PhD

Senior Research Fellow in Health Economics




Institute of Biomedical and Health

Innovation, Brisbane, Qld, Australia

R A M RI T U P . , H A L T O N K . , C O O K D . , W H I T B Y M . & G R AV E S N . ( 2 0 08 )R A M RI T U P . , H A L T O N K . , C O O K D . , W H I T B Y M . & G R AV E S N . ( 2 0 08 ) Catheter-

related bloodstream infections in intensive care units: a systematic review with

meta-analysis. Journal of Advanced Nursing 62(1), 321

doi: 10.1111/j.1365-2648.2007.04564.x

AbstractTitle. Catheter-related bloodstream infections in intensive care units: a systematic

review with meta-analysis.Aim. This paper is a report of a systematic review and meta-analysis of strategies,

other than antimicrobial coated catheters, hypothesized to reduce risk of catheter-

related bloodstream infections and catheter colonization in the intensive care unit

setting.

Background. Catheter-related bloodstream infections occur at a rate of 5 per 1000

catheter days in the intensive care unit setting and cause substantial mortality and

excess cost. Reducing risk of catheter-related bloodstream infections among inten-

sive care unit patients will save costs, reduce length of stay, and improve outcomes.

Methods. A systematic review of studies published between January 1985 and

February 2007 was carried out using the keywords catheterization central venous

with combinations of infection*, prevention* and bloodstream*. All included

studies were screened by two reviewers, a validated data extraction instrument was

used and data collection was completed by two blinded independent reviewers. Risk

ratios for catheter-related bloodstream infections and catheter colonization were

estimated with 95% confidence intervals for each study. Results from studies of

similar interventions were pooled using meta-analyses.

Results. Twenty-three studies were included in the review. The strategies that

reduced catheter colonization included insertion of central venous catheters in the

subclavian vein rather than other sites, use of alternate skin disinfection solutions

before catheter insertion and use of Vitacuff in combination with polymyxin, neo-

mycin and bacitracin ointment. Strategies to reduce catheter-related bloodstream

infection included staff education multifaceted infection control programmes and

performance feedback.Conclusion. A range of interventions may reduce risks of catheter-related blood-

stream infection, in addition to antimicrobial catheters.

Keywords: bloodstream infection, central venous catheters, intensive care unit,

meta-analysis, nursing, prevention, systematic review

R E V I E W P A P E RJAN

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 3


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Introduction

Catheter-related bloodstream infections (CRBSI) occur at a

rate of 50 per 1000 catheter days in the intensive care unit

(ICU) setting (McLaws & Taylor 2003, Anonymous, 2004).

The mortality attributable to these infections may be as high

as 246% and length of stay is extended by between 7 and

191 days; the cost per case has been estimated to be

$US4888 (c. 2448) and 16,356 (c. 11,139) (Orsi et al.

2002, Rosenthal et al. 2003a). Reducing risk of CRBSI

among ICU patients will save costs, reduce length of stay and

improve mortality and morbidity.

The risk of CRBSI in the ICU setting depends on many

factors. Although many relate to patient diagnosis and

underlying health state, others are associated with discre-

tionary decisions made by healthcare professionals. Many

studies have focused on the use of anti-microbial catheters

to reduce rates in this clinical context and a number of

meta-analyses have been published that describe the effec-tiveness of different types of anti-microbial catheters for

the ICU setting (Veenstra et al. 1999, Marin et al. 2000,

Mermel 2000, Walder et al. 2002, Geffers et al. 2003).

However, a multitude of other interventions used at various

points in the catheter insertion and management pathway

are available. There are currently no systematic reviews

summarizing the evidence for these other interventions

specifically in relation to their effectiveness in the adult

ICU setting, or attempting to bring this information together

in one coherent summary (Halton & Graves 2007).

The review

Aim

The aim of the review was to evaluate strategies, other than

antimicrobial coated catheters, hypothesized to reduce risk of

CRBSI and catheter colonization in the ICU setting.

Design

A systematic review was conducted according to the methods

described by the Centre for Reviews and Dissemination,University of York (Centre for Reviews and Dissemination,

2001).

Search methods

Databases and search terms

A search was conducted of the following electronic data-

bases for research published between January 1985 and

February 2007: MEDLINE; Cumulative Index of Nursing

and Allied Health Literature (CINAHL); Current Contents;

Current Contents Connect; Australian Medical Index; Bio-

logical Abstracts; EMBASE; Science Citation; National

Library of Medicine; PubMed; Dissertation Abstracts;

Database of Review of Abstracts of Effectiveness; Cochrane

Library; Health Services Technology (National Health

Service, United Kingdom and United States of America);

National Clearing House (Agency for Healthcare Research

and Quality); Center for Disease Control guideline and

reports; Bandolier and Clinical Evidence (Wales BMJ

Publishing group). The broad MeSH search term, cathe-

terization central venous with combinations of keywords

infection*, prevention* and bloodstream* was used. The

reference lists of all relevant guidelines, systematic reviews,

and full articles of all studies included were hand-checked

for additional studies. Details of the inclusion and exclu-

sion criteria are presented in Table 1. Observational and

randomized controlled trial (RCT) designs were included.Studies were included if a definition of CRBSI was pro-

vided that required the isolation of the same organism from

the culture of a catheter segment and peripheral blood

cultures. Catheter colonization results were reported if the

study used a recognized definition of a positive catheter

colonization of either 15 colony forming units (CFU) by

semi-quantitative culture (Maki et al. 1977) or 103 CFU/

mL by quantitative technique from culture of the distal end

of the catheter (Brun-Buisson et al. 1987).

Table 1 Inclusion and exclusion criteria

Inclusion criteria

Full report of observational study or randomized controlled trial

Investigate short-term (


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Search outcome

Five hundred and sixty-nine abstracts were reviewed and 513

excluded. The remaining 56 articles were read in full and

judged explicitly against the inclusion criteria. Twenty-seven

were excluded and 29 met the inclusion criteria. Complete

data sets were obtained from twenty-three studies, published

between 1985 and February 2007: 13 RCTs, two trials and

nine observational cohort studies, see Table 2. Six were

excluded as part of the quality assessment exercise because

we could not obtain all the necessary data despite attempts to

contact the authors, see Table 3 for all exclusion criteria. The

process is illustrated by Figure 1.

Quality appraisal

Validated data extraction instruments for experimental and

observational studies chosen for clarity, comprehensiveness

and use in previous central venous catheter (CVC)-related

reviews [specifically the Evidence-based Practice Infection

Control (EPIC) project] were pilot tested and used (Prattet al. 2001). This instrument and the Scottish Intercollegiate

Guidelines Network (SIGN) checklist were used to assess

study quality (SIGN 2001). As in the EPIC project, studies

were grouped into three quality categories (Pratt et al. 2001):

category 1, well-designed study, findings can be generalized

to most hospitals; category 2, acceptable experimental study,

conclusions may be generalized and in absence of category 1

evidence, study accepted into review; category 3, study

methodology fatally flawed and rejected from review. Details

of the data extracted are provided in Appendix 1.

Data abstraction

All studies were screened by two reviewers using the abstract

or full paper. Data were extracted independently by two

reviewers (PR and either NG or DC or KH), blinded to the

author, date of publication and author affiliations, with

inconsistencies resolved by consultation. If required, corre-

sponding authors were contacted by e-mail, twice in 4 weeks,

to obtain missing information or clarify ambiguity.

Synthesis

For each study, the risk ratios (RR) with 95% confidence

intervals (CI) were calculated for the outcomes of CRBSI andcatheter colonization. A RR is a measure of relative risk

derived from two proportions. Relative risk is the risk of

developing a disease relative to exposure. Data from studies

investigating the same intervention were pooled. The DerSi-

monian & Laird method was used to calculate summary RR

with 95% CI for both outcomes via a random effects model

(Petitti 2000), normally distributed errors were assumed. This

method incorporates an assumption that the different studies

are estimating different, yet related, treatment effects. Sta-

tistical heterogeneity was assessed using the MantelHaenzel

test statistic. Studies brought together in any systematic

review will differ and these differences are known as statis-

tical heterogeneity. STATASTATA 9TM software package (StataCorp,

College Station, TX, USA) was used for all the statistical

analysis. No sensitivity or subgroup analysis was undertaken

due to the small number of studies anticipated to be available

for any one type of intervention.

Results

Study characteristics and a summary of results are presented

in Tables 3 and 4. Studies were grouped into eight categories:

site of CVC insertion; choice of skin disinfectant; catheter

replacement at a new site vs. exchange over a guidewire;

connectors and hubs; attachable cuffs; number of lumens on

the CVC; educational programme to increase healthcare

professional awareness of strategies to prevent infection; andcombined interventions. All 23 reported rates of CRBSI and

16 studies reported catheter colonization. The range of

definitions used in the studies are summarized in Table 5.

Site of insertion (two studies)

Short-term non-tunnelled CVC are inserted into the internal

jugular, subclavian, femoral or axillary veins and the risk of

CRBSI is believed to vary by site. One RCT (Merrer et al.,

2001) found a higher proportion of catheters inserted in the

femoral vein were colonized compared to the subclavian (RR

64; 95% CI: 19212; P < 0001) but there was no

difference in CRBSI rates (RR 2 02; 95% CI: 019221;

P = 06). A prospective comparative open study (Martin et al.

1998) found a similar colonization rate for internal jugular

vs. axillary vein (RR 106; 95% CI: 034332; P = 05) and

no significant difference in the CRBSI rate (RR 0 42; 95% CI:

004398; P = 041).

Skin disinfectant solutions (three studies)

The skin can be a source of CRBSI, with skin flora believed to

migrate along the subcutaneous insertion tract. The use ofskin disinfectants prior to insertion and ongoing management

of the catheter may be an important risk reducing strategy.

Three studies compared different types of skin disinfectants.

One RCT (Maki et al. 1991) compared 2% aqueous

chlorhexidine (Chl) gluconate to 10% povidone iodine (PI)

and 70% isopropyl alcohol. The 2% aqueous Chl solution

compared to 10% PI reduced colonization by 69% (RR 031;

95% CI: 017088; P = 001) but there was no statistically

JAN: REVIEW PAPER Catheter-related bloodstream infections in intensive care units



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Table2

Studycharacteristics

Strategy&Author

Year

Studydesign

Setting(no.

ICUs)

Interventions

Sample

size

Participants

Durationof

study(months)

Mean

age(years)

%

Males

Siteofinsertion

Merrer

2001

RCT

M,

S(8)

Subclavianvs.

femoral

136

134

59

7

61

9

6270

93

2

Martin

1998

OBS

Mixed(1)

Axillaryvs.

internaljugular

62

79

54

59

7975

24

Insertionsiteskindisinfectings

olution

Humar

2000

RCT

M/S;M,

NS(4)

10%

PIvs.

0

5%

Chl

117

125

62

2

58

3

615

625

12

Maki

1991

RCT

S(1)

10%PIvs.

70%

alcoholvs.

2%

Chl

77

32

67

53

53

51

NRNRNR

7

Parienti

2004

CORT

M

(2)

5%

PI/70%

ethanolvs.

10%

aqueousPI

106*

117

54

4

61

5

NRNR

12

Catheterreplacement

Bach

1992

RCT

CS(1)

Newsitevs.

guidewireexchange

80

79

68

64

6661

NR

Devices:connectors

Luna

2000

RCT

ICU(1)&surgicalunits

Standardhubvs.

SegurLock

27*

24*

NR

NR

NRNR

18

Leon

2003

RCT

M,

S(7)

Standardhubvs.

SegurLock

114

116

59

6

58

1

649

586

15

Lucet

2000

RCT

M,

S(3)

Hubprotectionboxandstandardhub

vs.

needle-lessclosedconnectorwithmultiflohub

37

40

NR

NR

NRNR

3

Yebenes

2004

RCT

Mixed(1)

Standard3-waystopcockvs.

disinfecta

ble

needle

freeconnector

139*

139*

58

7

55

3

755

705

NR

Devices:cuff

Flowers

1989

RCT

S(1)

Nocuff&PNBvs.

vitacuff&PNB

29*

26*

49

1

42

5

812

790

9

Hasaniya

1996

NRT

S(2)

Nocuffvs.

vitacuff

64

90

47

57

NRNR

13

Lumens

Gupta

1995

RCT

NR(1)

Singlevs.

double

25

25

NR

NR

NRNR

12

Gil

1989

OBS

M

(1)

Singlevs.

triple

63*

157*

NR

NR

NRNR

15

Hilton

1988

OBS

Mixed(4)

Singlevs.

triple

99*

309*

NR

NR

NRNR

6

Farkas

1992

RCT

M/S(1)

Singlevs.

triple

51

54

63

5

65

5

NRNR

22

P. Ramritu et al.

6 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd


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Table2

(Continued)

Strategy&Author

Year

Studydesign

Setting(no.

ICUs)

Interv

entions

Sample

size

Participants

Durationof

study(months)

Mean

age(years)

%

Males

Educationalprogramme

Warren

2003

OBS

M,S

(2)

Preintervention(nodetails)vs.

interventioneduc

ation,

posters,factsheetspostedinICU;10-pageself-study

modulecompleted

674

541

71

71

5252

29

Multipleinterventions

Bonawitz

1991

RCT

S(1)

Gp1

cuff&CVCremovedat3days

Gp2

cuff&CVCremovedat7days

Gp3

nocuff&CVCremovedat3days

Gp4

nocuff&CVCremovedat7days

40*

35*

45*

39*

NR

NR

NR

NR

NRNRNRNR

14

Cobb

1992

RCT

M,

S(2)

Gp1

CVCreplacedevery3days+insertionatnewsite

Gp2

CVCreplacedevery3days+exchangeoverguidewire

Gp3

CVCreplacedwhenclinically

indic

ated+insertionatnewsite

Gp4

CVCreplacedwhenclinically

indic

ated+exchangeoveraguidewire

35

40

41

44

57

59

55

59

685059 52

16

Civetta

1996

OBS

Trauma(1)

Phase

1:PIforskinpreparation

Ph2:

triplelumenChg/ssdCVCs

Phase

3chlorhexidineskincleanser,changeincriteria

forg

uidewireexchange;extensionofsafeperio

d

forc

atheterextensionfrom2to4days

147

34

156

NR

NR

NR

NRNRNR

15

Lobo

2005

OBS

M

(1)

Phase

1pretest,

observationofCVC

Phase

2effectofeducationprogram,

standardizedcathetercarepractices

Phase

3monthlyCRBSIratefeedback,

provision

ofCRBSI

preventionguidetoallmedicalresidents

316

190

266

NR

NR

NR

NRNR NR

23

Higuera

2005

OBS

M/SNS(2)

Phase

1activesurveillancewithoutprocesscontrol

Phase

2infectioncontroleducationprogram;process

controlofCVCcare;compliancewithinfection

controlpracticesandCVCcare

132

338

44

3

45

9

45

5

48

2

11

Rosenthal

2003

OBS

M/SC(4)

Phase

1surveillanceofCRBSIrates

Phase

2trainingandeducation

Phase

3performancefeedbackoncompliance

with

infectioncontrolprogrammeandCVCcare

NR

NR

NR

71

71

71

48

8

53

6

53

6

28

CRBSI,

catheter-relatedbloodstreaminfection;ICU,

intensivecareunit;C

VC,

centralvenouscatheter;NR,

notrepo

rted;RCT,

randomizedcontrolledtrial;O

BS:cohortobservational

study;CORT,

cross-overunit-randomizedtrial;NRT,

non-randomizedtrial;M,

medical;M/S,

medical/surgical;C,cardiac;S,surgical;CS,cardiacsurgical;NS,neuro-surgical.

*NumberofCVCsreportedon

ly.




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significant reduction for CRBSI (RR 023; 95% CI: 003

192; P = 014). Compared to the 70% alcohol solution the

2% Chl showed no statistically significant difference in

colonization (RR 038; 95% CI: 011133; P = 011) or

CRBSI rates (RR 024; 95% CI: 002254; P = 024).

Another RCT (Humar et al. 2000) compared 10% PI

solution with 05% tincture of Chl solution and found no

difference in rates of colonization or CRBSI (RR 0 8; 95% CI:

052126; P = 022; RR 107; 95% CI: 027417; P = 06

respectively). The third study (Parienti et al. 2004) used a

cross-over unit-randomized trial to compare 10% aqueous PI

solution with 5% PI in 70% ethanol based aqueous solution.

Colonization rates were significantly lower for alcoholic PI

(RR 038; 95% CI: 022 to 065; P < 0001) but there was

no significant difference in CRBSI rate (RR 03; 95% CI:

00324; P = 021).

Catheter replacement on new site vs. exchange over

guidewire (one study)

Catheters can be replaced by inserting a replacement

catheter in a new site, or by replacing the catheter over

a guide wire in the same insertion site. The one RCT

included in this review that looked at this intervention

found no significant difference in colonization rates withguidewire exchange relative to new site replacement (RR

037; 95% CI: 01135; P = 010) and no cases of CRBSI

were observed (Bach et al. 1992).

Use of devices: connectors (four studies)

Central venous catheter hubs may be a source of intralu-

minal catheter colonization and CRBSI due to frequent

manipulation and use of a PI connection shield might

reduce risk. Two RCTs (Lucet et al. 2000, Leon et al.

2003) compared the rate of CRBSI observed with use of a

Segur-Lock (Inibsa Laboratories, Barcelona, Spain) connec-

tor relative to that observed under use of a standard hub.

Luna (Luna et al. 2000) included patients from ICU and

surgical units and data from ICU participants only are

included in the analysis. The pooled findings of these two

studies indicated a non-significant reduction in risk of

CRBSI with Segur-Lock, see Figure 2 (RR 027; 95% CI:

007105). Lucet et al. (2000) compared antiseptic impreg-

nated hub protection boxes to needle-less closed connectors

in a RCT, and reported a non-significant difference in risk

of catheter colonization and CRBSI (RR 1 25; 95% CI:

0662

37; P = 0

3 and RR 0

96; 95% CI: 0

0614

99;

P = 074, respectively). The fourth RCT (Yebenes et al.

2004) compared a disinfectable needle-free connector to the

standard three-way stopcock. The rates of CRBSI and

catheter colonization were lower in the needle-free connec-

tor group, with this difference approaching statistical

significance for CRBSI (RR 014; 95% CI: 002114;

P = 003), but not for catheter colonization (RR 0 69; 95%

CI: 0316; P = 037).

Use of devices: cuffs (two studies)

A biodegradable collagen cuff impregnated with bacterici-

dal silver ions (Vitacuff; Vitaphore Corp, Menlo Park, CA,

USA) has been suggested to prevent CVC colonization from

skin organisms migrating along the subcutaneous tract.

One RCT (Flowers et al. 1989) and one non-randomized

trial (Hasaniya et al. 1996) investigated triple-lumen

catheters with an attachable cuff (Vitacuff) relative to

catheters with no cuff. In the RCT, colonization rates with

Table 3 Reasons for excluding studies following full review

Excluded papers Reasons for exclusion

Roberts & Cheung (1998) Definition of CRBSI was not clear.

Berenholtz et al. (2004) Insufficient information

on inclusion criteria

Carrer et al. (2005) Insufficient information


Coopersmith et al. (2002) Insufficient information


Warren et al. (2004) Insufficient information


Badley et al. (1996) Insufficient data on proven CRBSI

to calculate rate of CRBSI in the

three comparison groups

CRBSI, catheter-related bloodstream infection.

Search strategy

569 abstracts for review

513 rejected

27 excluded

(did not meet inclusion criteria)

6 excluded

(complete data sets not available)

56 articles for further review

29 included for full review

23 included

Figure 1 Search strategy and study selection.

P. Ramritu et al.



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Table4

Summaryresultsofincludedstudies(groupedtogetheraccording

topreventativestrategyexamined)

Preventativestrategy/Author

Year

Intervention

Proportionofcoloniza

tionRR(95%

CI)

ProportionofCRBS

IRR(95%

CI)

Siteofinsertion

Merrer

2001

Subclavianvs.

femoral

3/136

19/134

RR(usingfemoralsite

)6

4

(1

92

1

2,

P

1CVC

allowed

Multipleinterventions

Bonawitz

1991

SC;IJ

M

S,SG,

SGl

,C,

M

NS

Ga

uzepad

&

Opsite

2-3

Gps1&33

Gps2&47

Yes

Cobb

1992

SC,

IJ

3

M,

SG,SG

l,SD

10%PI

G,

AO

2

Gp13

Gp23

Gp36

Gp47

Yes

Civetta

1996

NR

3

M,C,S

G,SGl

Phase1:PI

Phase2:4%

chl

SG

/AO

PRN,

3

Phase

14

5

Phase

35

4

Yes

Lobo

2005

SCmostly

NS

SG,S

Gl,LD,

C,M

PI

G

PRN,

daily

NS

NS

Higuera

2005

NS

S

Fullbarrier

precaution

sometime

s

NS

G

NS

7

3*

NS

Rosenthal

2003

NS

S

NS

NS

G

NS

7

07*

NS

NS,notspecified;NR,

notrepo

rted;CVC,

centralvenouscatheter;A,

axillary;F.

femoral;IJ,

internaljugular;J,jugular;NR,

notreported;S,supraclavicular;SC,

subclavian;NC,

non-

coatedCVCs;Chg/ssd,

chlorhexidinegluconate/silversulfadiazinecoated

CVCs;M,

multiple;S,standard;SP,

standardpolyurethaneCVC;D,

drapes;LD,lar

gedrape;MBP,

maximal

barrierprecaution;SD,

steriledrape;LSD,

largesteriledrape;G.

gown;SG.

sterilegown;SGl,sterilegloves;Gl,gloves;M,

mask;C,

cap;Alc,

alcohol;AlcPI.alcoholicpovidoneiodine;Aq

PI,aqueouspovidoneiodine;AO

,antibiotic/antimicrobialointment;Chlg,chlorhexidinegluconate;Chl,chlorhexidine;I,iodinetincture;PI,povidoneiodine;SSD,s

tandardsteriledressing;

TSD,

transparentsteriledressing;TPU,

transparentpolyurethanedressing;

SG,

sterilegauze;G,

gauze;THD,

transparenthydrocolloiddressing;SPU,

standardpo

lyurethanedressing;AO,

antiseptic/antimicrobialointmentappliedoninsertionsite;PRN,

changed

asrequired;SP,

studysitepreference.

*Informationobtainedfromau

thorsviae-mail.




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error and bias can be minimized at all stages of the research.

Other limitations of the available evidence include the

inadequate power of many of the studies to detect a real

difference in CRBSI and colonization rates. Where possible

we combined evidence in meta-analyses, but the small

number of studies available for which we could pool datastill precluded the provision of statistical support for the

effectiveness of interventions. For example, colonization rates

were lower but did not reach significance at the 5% level for a

number of interventions such as 10% PI vs. 05% Chl

(Humar et al. 2000) and new site vs. guidewire exchange for

CVC replacement (Bach et al. 1992). We suggest future

studies be designed with a sample size large enough to detect

a real difference or to inform a subsequent meta-analysis.

The appraisal of evidence for reducing catheter coloniza-

tion and CRBSI is further complicated by the fact that a

number of different interventions are used concurrently inthe insertion and ongoing management of CVC. Unless all

studies investigating a particular intervention control for the

effect of these co-interventions it will be difficult to determine

the interventions that are most effective in reducing coloni-

zation and CRBSI, and if we can expect to achieve this effect

in other settings. As shown in Table 7, there was much

clinical heterogeneity in the studies and important confound-

ing data was often not provided for some co-interventions

such as site of insertion, use of barrier precautions and type

of disinfecting solution. Other problems arise from the

findings being influenced by the absence of a consistent

definition for CRBSI, see Table 5, and inconsistent catheter

management protocols across studies. In short, we still do

not have a full understanding of the most effective ways to

prevent CRBSI in the ICU context although this review and

others can help to indicate where some of the largest gaps in

our knowledge lie.

Conclusion

Interventions other than antimicrobial catheters may be

useful for reducing risks of CRBSI in the ICU setting.

Infection control is typically nurse-led within a wider multi-

disciplinary team and nurses play a key role in the care of ICU

patients, including assisting with the insertion and daily

management of CVCs. Nurse awareness and implementation

of appropriate risk reducing strategies is important. Thisreview is relevant to evidence-based nursing practice in many

international settings. It highlights the strength of evidence

underlying each intervention and the recent trend to use a

combination of most effective interventions to manage the

care of CVC. The strategies we recommend are relatively

low-cost, pose minimal risks for patients and constitute good

nursing practice. Finally, good decision-making requires that

the cost-effectiveness of all interventions be assessed and

compared, but understanding their effectiveness is an impor-

tant first step.

Acknowledgements

Financial support for the study was provided by the National

Health & Medical Research Council of Australia.

Author contributions

PR and NG were responsible for the study conception and

design and PR, DC and NG were responsible for the drafting

of the manuscript. PR, KH, DC and NG performed the data

collection and PR performed the searches and data analysis.

MW and NG obtained funding. PR, KH, DC and NG madecritical revisions to the paper. KH provided statistical advice.

DC, MW and NG supervised the study.

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Catheter-related bloodstream infection arising in the

intensive care unit setting is a serious clinical and

economic problem.

Antimicrobial catheters are effective at reducing risk of

catheter-related bloodstream infection in the intensive

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Less is known about the effectiveness of other risk

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What this paper adds

There is some evidence for strategies other than anti-

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This quality of this evidence is mixed and studies are

characterized by small samples. These interventions may be less costly and easier to

implement than widespread use of antimicrobial

catheters, but further work to model the cost-effec-

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Appendix 1

Details of data extracted.

Clinical data: experimental and observational studies

Study aim/objective

Definitions of study outcomes

Study design: type, appropriateness to aim

Study setting/characteristics of sample/inclusion criteria/sample size; study dates

Details of intervention type, regimen, co-interventions

Outcomes baseline measures, details of measurement, summary results

Duration of follow-up

Investigators conclusions, reviewer agreements and any reservations

Hand search of reference list

Data analysis

Preintervention comparability table

Similarity of subjects at start of study

Quality: experimental studies

Method of allocation, randomization; blinding

Sample size power calculation

Equal treatment of groups other than intervention

Bias due to drop out, characteristics and reasons for withdrawalsAppropriateness of statistical analysis, intention to treat or as treated

Dealing with confounding variables

Quality

Observational studies

Method of sample selection

Comparability of groups at baseline

Drop-out rate

Details of withdrawal

Appropriateness of statistical analysis

Summary of reviewers judgement for experimental and observational studies

Soundness of methodology design

Generalizability of findings

Clinical importance of outcomes

Harm/benefit analysisRisk of bias

Need for author contact for further information/ statistical assessment required

Acceptance of paper into review

Study grading for experimental studies

Category 1: study well designed experimental study; findings generalizable

Category 2: acceptable design, in absence of category 1, accept study into review

Category 3: methodologically fatally flawed, reject study.

Study grading for observational studies

Category 1: well designed observational study, findings generalizable

Category 2: acceptable design, in absence of category 1, accept study into review

Category 3: methodologically fatally flawed, reject study.

Sources: (Scottish Intercollegiate Guidelines Network 2001) & (Pratt et al. 2001).




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