Consistency between guidelines and reported practice for reducing the risk of catheter-related infection in British paediatric intensive care units
Optimal strategies for reducing catheter-related blood stream infection (CR-BSI) differ for adults and children. National guidelines do not make child-specific recommendations. We determined whether evidence explained the inconsistencies between guidelines and reported practice in paediatric intensive care units (PICUs).
We conducted a survey of eight interventions for reducing CR-BSI in all 25 British PICUs in 2009. Interventions were categorised as requiring child-specific evidence, generalisable to adults and children, or organisational recommendations.
Twenty-four of the 25 PICUs responded. For child-specific interventions, practice diverged from guidelines for “Insert into subclavian/jugular veins” (18 PICUs frequently used femoral veins, supported by observational evidence for increased safety in children). Practice reflected guidelines for “Use standard but consider antimicrobial-impregnated central venous catheters (CVCs) for high-risk patients” (14 used standard only, 3 used standard and antimicrobial-impregnated despite no randomised controlled trial (RCT) evidence for antimicrobial-impregnated CVCs in children, 7 used heparin-bonded for some or all children); “Use 2% chlorhexidine for skin preparation” (20 PICUs); “Avoid routine CVC replacement” (20 PICUs). For generalisable interventions, practice was consistent with guidelines for “Administration set replacement” (21 PICUs) but deviated for “Maintenance of CVC asepsis” (11 PICUs used alcohol due to inconclusive evidence for chlorhexidine). Practice diverged from guidelines for organisational interventions: “Train healthcare workers in CVC care” (9 PICUs); “Monitor blood stream infection (BSI) rates” (8 PICUs).
Guidelines should explicitly address paediatric practice and report the quality of evidence and strength of recommendations. Organisations should ensure doctors are trained in CVC insertion and invest in BSI monitoring, especially in PICUs. The type of CVC and insertion site are important gaps in evidence for children.
KeywordsCentral venous catheter (CVC) Infection Guidelines Paediatric
The authors wish to thank Roger Parslow and other members of the PICANet team for their support and the following intensivists for completing the survey form: James Fraser, Helen Fardy, Akash Deep, Duncan Macrae, Samir Latiff, Oliver Bagshaw, Iain MacIntosh, Martin Gray, Julie Freeman, Raghu Ramaiah, Mehrengise Cooper, Iain Johnstone, Ann Karimova, Samantha Jukes, Shane Tibby, Robert Yates, Andrew Magnay, John Roche, Andrew McIntyre, Steve Kerr, Josep Panisello, Jane Cassidy.
This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number 08/13/47). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.
- 1.Hockenhull J, Dwan K, Boland A, Smith G, Bagust A, Dündar Y, Gamble C, McLeod C, Walley T, Dickson R (2008) The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective agents in preventing bloodstream infections: a systematic review and economic evaluation. Health Technol Assess Rep 12:1–154Google Scholar
- 6.Brown R, Stechenberg B, Sands M, Hosmer D, Ryczak M (1987) Infections in a pediatric intensive care unit. Arch Pediatr Adolesc Med 141:267Google Scholar
- 7.Nosocomial Infection National Surveillance Service (2007) Surveillance of hospital-acquired bacteraemia in English hospitals, 1997–2002. Public Health Laboratory Service, LondonGoogle Scholar
- 10.Jeffries H, Mason W, Brewer M, Oakes K, Muñoz E, Gornick W, Flowers L, Mullen J, Gilliam C, Fustar S (2009) Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units: a performance improvement collaborative. Infect Control Hosp Epidemiol 30:645–651PubMedCrossRefGoogle Scholar
- 13.Department of Health (2005) Saving lives: a delivery programme to reduce healthcare associated infections including MRSA. Department of Health, LondonGoogle Scholar
- 17.O’Grady N, Alexander M, Dellinger E, Gerberding J, Heard S, Maki D, Masur H, McCormick R, Mermel L, Pearson M (2002) Guidelines for the prevention of intravascular catheter-related infections. Am Acad Pediatr Policy 110:e51–e74Google Scholar
- 18.Straus SE, Richardson WS, Glasziou P, Haynes RB (2005) Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone, EdinburghGoogle Scholar
- 19.Hamilton HC, Foxcroft D (2007) Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD004084.pub2
- 29.Garland J, Alex C, Mueller C, Otten D, Shivpuri C, Harris M, Naples M, Pellegrini J, Buck R, McAuliffe T (2001) A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 107:1431PubMedCrossRefGoogle Scholar
- 35.Gillies D, Wallen Margaret M, Morrison Anne L, Rankin K, Nagy Sue A, O’Riordan E (2005) Optimal timing for intravenous administration set replacement. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD003588.pub2
- 38.Centers for Disease Control (2000) Monitoring hospital-acquired infections to promote patient safety—United States, 1990–1999. MMWR Morb Mortal Wkly Rep 49:149–153Google Scholar
- 40.Zuschneid I, Schwab F, Geffers C, Rüden H, Gastmeier P (2003) Reducing central venous catheter-associated primary bloodstream infections in intensive care units is possible: data from the German nosocomial infection surveillance system. Infect Control Hosp Epidemiol 24:501–505PubMedCrossRefGoogle Scholar