The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters
Short-term, noncuffed, percutaneously inserted central venous catheters (CVCs) are widely used and cause more than 250,000 bloodstream infections (BSIs) in hospitals each year in the United States. We report a prospective study undertaken to determine the pathogenesis of CVC-related BSI.
Design and setting
Prospective cohort study in a university hospital 24-bed medical-surgical intensive care unit.
Patients and participants
Patients participating in two randomized trials during 1998–2000—one studying the efficacy of a 1% chlorhexidine–75% alcohol solution for cutaneous antisepsis and the other a novel chlorhexidine-impregnated sponge dressing—formed the study population; CVC-related BSIs were considered to be extraluminally acquired if concordance was identified solely between isolates from catheter segments, skin, and blood cultures and intraluminally acquired if concordance was demonstrated only between hub or infusate and blood culture isolates, as confirmed by DNA subtyping of isolates from blood and catheter sites or infusate.
Of 1,263 catheters (6075 CVC days) prospectively studied, 35 (2.7%) caused BSI (5.9 per 1000 CVC days); 27 were caused by coagulase-negative staphylococci. Overall, 45% of infections were extraluminally acquired, 26% were intraluminally derived, and the mechanism of infection was indeterminate in 29%. In the pooled control groups of the two trials, 25 CVC-related BSIs occurred (7.0 per 1000 CVC days), of which 60% of infections were extraluminally acquired, 12% were intraluminally derived and 28% were indeterminate. In contrast, CVC-related BSIs in the treatment groups were most often intraluminally derived (60%, p=0.006).
Most catheter-related BSIs with short-term percutaneously inserted, noncuffed CVCs were extraluminally acquired and derived from the cutaneous microflora. Strategies achieving successful suppression of cutaneous colonization can substantially reduce the risk of catheter-related BSI with short-term CVCs.
KeywordsCatheter-related infection Central venous catheters Pathogenesis
- 1.Maki DG, Mermel LA (1998) Infections due to infusion therapy. In: Bennet JV, Brachman PS, editors. Hospital Infections. Lippincott-Raven, Philadelphia, pp 689–724Google Scholar
- 9.Maki DG (1988) Sources of infection with central venous catheters in an ICU: a prospective study. In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy, Los AngelesGoogle Scholar
- 16.Maki DG, Narans LL, Knasinski V, Kluger DM (2000) Prospective randomised, investigator-masked trial of a novel chlorhexidine-impregnated disk (Biopatch) on central venous and arterial catheters. In: Proceedings and Abstracts of the Fourth International Decennial Conference on Nosocomial and Healthcare-Associated Infections, AtlantaGoogle Scholar
- 17.Maki DG, Knasinski V, Narans LL, Gordon BJ (2001) A randomized trial of a novel 1% chlorhexidine-75% alcohol tincture versus 10% povidone-iodine for cutaneous disinfection with vascular catheters. In: Proceedings and Abstracts of the 31st Annual Society for Healthcare Epidemiology of America Meeting, TorontoGoogle Scholar
- 20.Balows LE, Hausler W, Shadomy H (1991). Manual of clinical microbiology, 5th edn. American Society for Microbiology, WashingtonGoogle Scholar
- 21.Alvarado CJ, Stolz SM, Maki DG (1991) Nosocomial infection from contaminated endoscopes: a flawed automated endoscope washer. An investigation using molecular epidemiology. Am J Med 91 [Suppl 3B]:S725–S805Google Scholar
- 23.Maki DG, Goldman DA, Rhame FS (1973) Infection control in intravenous therapy. Ann Intern Med 79:867–887Google Scholar
- 29.Mermel LA, McCormick RD, Springman SR, Maki DG (1991) The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med 91 [Suppl 3B]:1897–1205Google Scholar
- 32.Maki DG (1998) A prospective study of the pathogenesis of PICC-related BSI. In: Proceedings and Abstracts of the 38th Interscience Conference of Antimicrobial Agents and Chemotherapy, San DiegoGoogle Scholar
- 35.Garland JS, Alex CP, Mueller CD, Otten D, Shivpuri C, Harris MC, Naples M, Pellegrini J, Buck RK, McAuliffe TL, Goldmann DA, Maki DG (2001) A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 107:1431–1436PubMedGoogle Scholar
- 36.Safdar N, Kluger DM, Maki DG (2002) A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 81:466–479Google Scholar
- 40.Almirall J, Gonzalez J, Rello J, Campistol JM, Montoliu J, Puig de la Bellacasa J, Revert L, Gatell JM (1989) Infection of hemodialysis catheters: incidence and mechanisms. Am J Nephrol 9:454–459Google Scholar
- 41.Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H, Brun-Buisson C, Nitenberg G (2001) Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 286:700–707PubMedGoogle Scholar
- 43.Maki DG (1990) Marked differences in skin colonization of insertion sites for central venous, arterial, and peripheral IV catheters: the major reason for differing risks of catheter-related infection? In: Programs and Abstracts of the Third International Conference on Nosocomial Infections, AtlantaGoogle Scholar
- 45.Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B, Flynn L, Hayes S, Strong S, Cruz J, Bowton DL, Hulgan T, Haponik EF (2000) Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 132:641–648Google Scholar
- 47.Timsit JF, Bruneel F, Cheval C, Mamzer MF, Garrouste-Orgeas M, Wolff M, Misset B, Chevret S, Regnier B, Carlet J (1999) Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial. Ann Intern Med 130:729–735Google Scholar