Original article
Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review

https://doi.org/10.1016/j.iccn.2017.05.006Get rights and content

Abstract

Background

In adult Intensive Care Units, the complexity of patient treatment requirements make the use of central venous lines essential. Despite the potential benefits central venous lines can have for patients, there is a high risk of bloodstream infection associated with these catheters.

Aim

Identify and critique the best available evidence regarding interventions to prevent central venous line associated bloodstream infections in adult intensive care unit patients other than anti-microbial catheters.

Methods

A systematic review of studies published from January 2007 to February 2016 was undertaken. A systematic search of seven databases was carried out: MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane Library; Scopus and Google Scholar. Studies were critically appraised by three independent reviewers prior to inclusion.

Results

Nineteen studies were included. A range of interventions were found to be used for the prevention or reduction of central venous line associated bloodstream infections. These interventions included dressings, closed infusion systems, aseptic skin preparation, central venous line bundles, quality improvement initiatives, education, an extra staff in the Intensive Care Unit and the participation in the ‘On the CUSP: Stop Blood Stream Infections' national programme.

Conclusions

Central venous line associated bloodstream infections can be reduced by a range of interventions including closed infusion systems, aseptic technique during insertion and management of the central venous line, early removal of central venous lines and appropriate site selection.

Introduction

Patients admitted to Intensive Care Units (ICUs) require specialised management of life threatening conditions. The complexity of the treatment and the procedures that patients in ICU may require, make central venous lines essential (College of Intensive Care Medicine of Australia and New Zealand [CICM], 2011). High volume intravenous fluids, parenteral nutrition, cardiovascular measurements, medication administration and blood infusions all require the use of central venous lines (Walder et al., 2002, World Health Organization, 2014). Despite their potential benefits, the risk of central venous line associated bloodstream infections (CLABSI) is high (Siempos et al., 2009). A CLABSI is a laboratory-confirmed bloodstream infection (BSI) in a patient who had a central venous line within the 48 hours prior to development of the BSI, not related to an infection at another site (Centre of Control and Disease Prevention, 2014; Fagan et al., 2013, Kallen et al., 2010, O’Grady et al., 2011, O’Grady et al., 2002).

A 2010 study conducted in the United States of America (USA) identified that about 41,000 patients developed CLABSI (Centre for Disease Control and Prevention, 2011; Virginia Department of Health, 2013). Around 18,000 of those affected were ICU patients, and one in four may die (Centre for Disease Control and Prevention, 2011; Virginia Department of Health, 2013). CLABSI is also associated with increased cost in patient care (Walder et al., 2002), estimated at USD$33,000 (Stevens et al., 2014).

Consequently, there is increased interest in ways to reduce and prevent CLABSI (Dumont and Nesselrodt, 2012, O’Grady et al., 2011). In 2008, a systematic review was undertaken evaluating strategies other than antimicrobial-coated catheters to reduce risk of CLABSI in the ICU (Ramritu et al., 2008b). In 2011, the Centre for Disease Control and prevention published updated guidelines for the prevention of intravascular catheter associated infections (O’Grady et al., 2011, O’Grady et al., 2002). Despite these guidelines, and advances in understanding related to infection patterns, pathogen agents, different pathogenesis, epidemiology and new diagnosis and prevention techniques in the last decade (Kim et al., 2011), no update of this systematic review has been undertaken.

The aim of this systematic review was to identify all existing interventions to prevent and/or reduce CLABSI in adults in ICU, other than antimicrobial-coated catheters. Literature published from 2007 was included, as that is when the previous systematic review was undertaken (Ramritu et al., 2008b).

Section snippets

Methods

This systematic review followed the Cochrane Effective Practice and Organisation of Care Review Group (EPOC) recommendations to assess quality in systematic reviews (Chandler et al., 2013). Randomised controlled trials and observational studies which investigated interventions for the prevention or reduction of CLABSI in adult ICU patients were included. The quality of evidence for each included study was determined based on the Grades of Recommendations, Assessment, Development and Evaluating

Search results

From the database searches, a total of 1500 studies were identified (Fig. 1).

Risk of bias in included studies

All the included randomised controlled studies had a low risk of bias (Kwakman et al., 2012, Marsteller et al., 2012, Mimoz et al., 2007, Pedrolo et al., 2014, Speroff et al., 2011, Timsit et al., 2012, Timsit et al., 2009, Yousefshahi et al., 2013) due to their random sequence generation, blinding of outcome assessment and intervention exposure measurement. Eleven studies had unclear risk of bias, because the

Discussion

From the nineteen studies included in this review, fifteen reported a positive impact in the reduction of CLABSI (Bonello et al., 2008, Cherifi et al., 2013, Maki et al., 2011, McLaws and Burrell, 2012, Mimoz et al., 2007, Parikh et al., 2012, Rangel-Frausto et al., 2010, Tang et al., 2014, Timsit et al., 2012, Timsit et al., 2009, Vilins et al., 2009, Yousefshahi et al., 2013). Open infusion containers, chlorhexidine dressings, aseptic interventions for central venous line maintenance

Limitations

This systematic review included only studies published in English. There was also a predominant heterogeneity in the interventions in the included studies. Consideration of the multiple confounders which could influence the outcomes of the studies should be taken into account.

Conclusion

This systematic review identified several interventions able to reduce or prevent CLABSI. Aseptic technique, which includes the application of skin antiseptic pre-central venous line insertion, and aseptic central venous line maintenance is essential. Closed infusion systems should be used at all times. Central venous line bundles, which promote appropriate insertion site selection, aseptic central venous line management and early removal; as well as increased intensivist staffing were both

Funding

The authors have no sources of funding to declare.

Ethical statement

Ethical statement not applicable the authors undertook a systematic review, no ethical statements to declare.

Conflict of interest

The authors have no conflict of interest to declare.

Acknowledgement

The researchers have no acknowledgements to make.

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