Martinez, J.M., Leite, L., França, D., Capela, R., Viterbo, L., Varajão, N., . . . Santo, A. (2015). Bundle approach to reduce bloodstream infections in neutropenic hematologic patients with a long-term central venous catheter. Acta Medica Portuguesa, 28, 474–479. 

To use a bundle approach to reduce central line–associated bloodstream infections (CLABSI) in patients with hematologic malignancies and neutropenia with long-term central venous catheters (CVC)

Between 2010 and 2012, a bundle of interventions was introduced and outcomes were compared with the results from six months prior to the intervention. Interventions were the use of a different catheter (a neutral pressure mechanical valve connector versus a positive pressure mechanical valve connector), changing needless connectors twice weekly instead of weekly, and the replacement of a chlorhexidine solution to clean needless connectors rather than a solution with 70% alcohol. If blood cultures were obtained, patients were put on broad spectrum antibiotics. All patients were receiving prophylactic co-trimoxazole, itraconazole, and environmental neutropenic precautions.

• N = 116   
• AGE = older than 18 years
• MALES: Not provided  
• FEMALES: Not provided
• KEY DISEASE CHARACTERISTICS: Patients with acute leukemia, multiple myeloma, or non-Hodgkin lymphoma
• OTHER KEY SAMPLE CHARACTERISTICS: All had tunneled catheters

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Portugal

• PHASE OF CARE: Active antitumor treatment

• Prospective with historical cohort comparison

Blood cultures were obtained for the presence of a fever for more than one hour or other signs of infection from peripheral veins and CVC lines.

With the intervention, a 71% reduction in both CLABSIs (risk ratio [RR] = 0.29, p < 0.014) and overall bloodstream infections (RR = 0.28, p < 0.001) occurred. The reduction of gram-positive bacteria was most pronounced.

The institutional protocol changes related to catheter selection and IV access system care were associated with a reduction in CLABSIs.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Limited sample description.
• Outcomes measured at 72 hours only
• No information was provided regarding other aspects of care or techniques used in insertion.

The changes implemented here were associated with the reduced incidence of CLABSIs within 72 hours. The authors suggested that changing from a positive pressure valve catheter to a neutral pressure type catheter may have been most relevant, as positive pressure valves tend to develop a biofilm and cannot be cleaned well with routine flushing.