Elsevier

Mayo Clinic Proceedings

Volume 81, Issue 9, September 2006, Pages 1159-1171
Mayo Clinic Proceedings

ORIGINAL ARTICLE
The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies

https://doi.org/10.4065/81.9.1159Get rights and content

OBJECTIVE

To better understand the absolute and relative risks of bloodstream infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults in which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI.

METHODS

English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremia [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream infection AND the specific type of intravascular device (eg, central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days.

RESULTS

Point incidence rates of IVD-related BSI were lowest with peripheral intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the intensive care unit. Surgically implanted long-term central venous devices—cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)—appear to have high rates of infection when risk is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodialysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

CONCLUSIONS

Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies in which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs in use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related infection have focused on short-term noncuffed CVCs used in intensive care units, infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

Section snippets

Sources of Data

English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremia [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream infection AND the specific type of intravascular device (eg, central venous port). Additional studies of relevance were identified by reviewing the citations of reviews of IVD-related BSI published since 1973.2, 3, 4, 5, 6, 7, 8, 9

RESULTS

Two hundred studies that prospectively examined the risk of IVD-related BSI with peripheral intravenous (IV) catheters and steel needles,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 midline catheters,33, 34, 35 arterial catheters for hemodynamic monitoring,36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 PA catheters,37, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61 PICCs,35, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75 nonmedicated CVCs,33, 37, 44, 45, 46, 49, 54, 63, 76, 77, 78

DISCUSSION

An analysis of this type is inherently limited by the heterogeneity of patient populations, protocols for catheter insertion and site care, and manufacturers' devices used in the studies analyzed. Moreover, the criteria used for defining IVD-related BSI varied across studies, although all the studies met published and widely accepted definitions of IVD-related BSI.10, 19, 20 Finally, because of differing degrees of severity of illness, a particular type of device may be associated with a higher

CONCLUSIONS

These data, based on prospective studies in which every IVD was analyzed for evidence of infection using microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by various types of IVDs in use at the present time. Expressing risk of IVD-related BSI per 1000 IVD-days allows for more meaningful estimates of risk than measuring BSIs per 100 IVDs. Since almost all the national effort to date to reduce

Acknowledgments

We are grateful to Richard Holcombe, PhD, for expert statistical guidance and assistance. This analysis of studies done in adults complements a similar analysis of studies done in children.222

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    Supported by an unrestricted gift for research from the Oscar Rennebohm Foundation of Madison, Wis.

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