Wolf, H.H., Leithäuser, M., Maschmeyer, G., Salwender, H., Klein, U., Chaberny, I., Weissinger, F., . . . Infectious Diseases Working Party of the German Society of Hematology and Oncology. (2008). Central venous catheter-related infections in hematology and oncology: Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Annals of Hematology, 87, 863–876.

To identify risk factors for developing catheter-related infections (CRIs) and interventions to prevent CRIs in patients with central venous catheters (CVCs)

The guidelines were developed by reviewing studies to identify populations at risk and interventions effective in preventing CRIs. Key words searched included catheter-related infections, guidelines, neutropenia, antimicrobial treatment, infection prophylaxis, and biofilm.

Strict procedures for hygiene during insertion of CVCs are effective in avoiding infections. CVC insertion through the subclavian vein rather than the internal jugular is better for preventing infections, but other risks, including severe hemorrhage, need to be assessed.  

For dressing changes and insertion site prep, chlorhexidine solution is preferred over aqueous polyvidone-iodine solutions, and alcoholic chlorhexidine solution, alcoholic polyvidone solutions, or 70% propranolol are alternatives noted to be safe. One randomized, controlled study showed that using alcoholic chlorhexidine in sequence with aqueous polyvidone-iodine was superior to using them as single agents.

Routine catheter replacement, systemic prophylactic antibiotic therapy prior to catheter insertion, and applying antibiotic ointment to the catheter site all show no benefit in preventing infections. Sterile gauze dressing changes every two days and transparent film dressings changed weekly are recommended in the absence of inflammation or loss of dressing integrity, but more frequent dressing changes do not reduce CRIs.

Infusion tubing is recommended to be changed every 72 hours with the exception of systems used for lipid emulsions recommended to be changed every 24 hours. Transfusion tubing should include standard filters for red blood cells or platelets and German regulations are specific about filter changes every six hours, noting that replacing filters at earlier intervals does not lower infection rate. Only one randomized trial of patients with cancer with nontunneled minocycline/rifampin-coated CVCs reported a decrease in bloodstream infections that were catheter-related. Recent randomized studies do not show a correlation between CRIs and the number of catheter lumen, as reported by earlier nonrandomized studies recommending single-lumen catheters.

Recommendations include

• Adhering to hygiene principles when inserting CVCs and employing standardized aseptic placement, using subclavian vein versus internal jugular vein for vascular access, and using catheters impregnated with antiseptics like chlorhexidine/silver sulfadiazine or antibiotics including minocycline/rifampin have been effective in reduction of catheter colonization. 
• Educating nurses and physicians.
• Using ultrasound guidance during insertion. 

Routine replacement of catheters is not effective in reducing CRIs. Antibiotic ointment at insertion site or applied to nostrils is not recommended. Systemic antibiotics are not recommended prior to CVC insertion as prophylaxis.

• No conflict of interest concerns were addressed.

Age (pediatrics), grade of neutropenia, catheter type, disease diagnosis, nurse-to-patient ratio, administration of parental nutrition, and number of days the patient has the CVC may all contribute to the risk of developing CRIs. It was suggested in two studies that in the hematologic/oncologic population, subclinical thrombosis of the catheterized vein as seen on ultrasound could be a significant risk factor for developing CRIs. Although some of the studies show benefit of antibiotic flushes to reduce CRIs, there are no prospective randomized, double-blind studies involving adults or pediatric patients with hematologic or solid tumors to determine if this practice will result in development of resistant bacteria. Although recommendations were shown in text and table using the A–E, I–III grading and evidence, no definitions or key were presented in this article.