Likely to Be Effective

Antimicrobial Coated CVC Catheters in Adults

for Prevention of Infection: General

IV catheters that are coated or impregnated with agents such as chlorhexidine, rifampin, silver sulfadiazine, or other antimicrobial agents have been examined for effectiveness in preventing central line-associated infections. This approach has been used with nontunneled, short-term catheters in adults and children, and in the general and HCT patient populations. Findings differ between use in adults and children.

Research Evidence Summaries

Chemaly, R.F., Sharma, P.S., Youssef, S., Gerber, D., Hwu, P., Hanmod, S.S., . . . Raad, I.I. (2010). The efficacy of catheters coated with minocycline and rifampin in the prevention of catheter-related bacteremia in cancer patients receiving high-dose interleukin-2. International Journal of Infectious Diseases, 14, e548–e552.

Study Purpose

The purpose of this study was to evaluate effects of antibiotic-coated central venous catheters as compared to non-coated central venous catheters on the development of catheter-associated blood stream infection.

Intervention Characteristics/Basic Study Process

Data was retrospectively analyzed from December 1, 2003 through August 31, 2006 at an inpatient center for patients treated with interleukin-2. Prior to December 2004, non-coated tunneled catheters (NC-C)  were used in these patients; antibiotic-coated catheters were used after December 2004. The coated catheters contained minocycline and rifampin (M/R-C) in their coating. All patients received antibiotic prophylaxis. Cases of catheter-related infection were retrospectively analyzed and compared between the two groups. Catheter insertion and line care remained the same for both groups independent of the type of catheter inserted.

Sample Characteristics

  • The study reviewed 78 and 107 episodes of catheter use.
  • The age range of studied participants was 26–66 years.
  • Sixty-one percent of reviewed participants were diagnosed with melanoma and renal cell carcinoma.
  • Non-coated catheters were used in 77 episodes, and M/R-C-coated catheters were used in 30 episodes. All patients received IV nafcillin (67%), clindamycin (15%), or levofloxacin (13%) during high-dose interleukin-2 for 48 hours afterwards.

Setting

A single-site inpatient setting.

Phase of Care and Clinical Applications

Active treatment

Study Design

Retrospective descriptive

Measurement Instruments/Methods

  • Catheter colonization was defined as the isolation of 15 colony-forming units (CFU) of any microorganism from a catheter tip or subcutaneous segment; or any organism from a blood culture drawn through the catheter during routine surveillance in the absence of fever.
  • Local catheter-related infection was defined as exit site infection as demonstrated by purulent drainage from the catheter site.
  • Probable catheter-related bacteremia (CRB) was defined as the presence of an indwelling central venous catheter (CVC) with at least one positive blood culture from the peripheral vein, with clinical manifestations of infection.
  • Definite CRB was defined as the presence of an indwelling CVC with at least one positive blood culture from the peripheral vein, manifestations of infection, and no apparent source for the blood stream infection except the catheter. Response to treatment was defined as the resolution of all clinical and microbiological manifestations of catheter-related infection, and failure to treatment was defined as persistence of the clinical signs and symptoms of the infection and positive microbiological data.
     

Results

A total of nine episodes of CRB were identified (six were probable and three definite), all in patients with NC-C (M/R-C 0% versus NC-C 12%; p = 0.06). In three of the nine episodes of bacteremia, the blood cultures grew more than one pathogen and in all nine cases, the prophylactic antibiotic had no activity against the pathogen. The causative pathogens for CRB included methicillin-resistant, coagulase-negative infections. There was one episode of probable catheter-related candidemia (Candidaparapsilosis) in a patient with a coated catheter, while two episodes of catheter colonization secondary to coagulase-negative Staphylococci occurred in two patients who had no signs or symptoms of infection.

Conclusions

Based on the data presented, there is potential benefit to an antibiotic-coated catheter compared with a non-coated catheter.

Limitations

  • Small sample (less than 100 participants)
  • Only 30 cases with coated catheters
  • Retrospective design

Nursing Implications

No recommendations can be made on the basis of this study alone. Antibiotic-coated, short-term CVCs may be helpful in preventing catheter-associated bloodstream infections.

Print

Schierholz, J.M., Nagelschmidt, K., Nagelschmidt, M., Lefering, R., Yucel, N., & Beuth, J. (2010). Antimicrobial central venous catheters in oncology: Efficacy of a rifampicin-miconazole-releasing catheter. Anticancer Research, 30, 1353–1358.

Study Purpose

The purpose of the study was to determine if central venous catheters (CVCs) impregnated with rifampicin and miconazole would decrease growth of bacteria and lead to a decline in catheter-related bloodstream infections as well as the complications associated with them.

Intervention Characteristics/Basic Study Process

Hospitalized adults (aged 18–80 years) who required a CVC for at least two days and were undergoing their first venous catheterization were included in this study. A triple lumen polyurethane CVC supersaturated with rifampicin andmiconazole was compared with the standard version. A segment of the catheter was cultured to evaluate catheter colonization. Catheter colonization was defined as growth of 15 or more colony-forming units detected on a catheter segment by the semi-quantitative roll-plate technique. Catheter-related local infection was defined as a colonized catheter accompanied by at least one of the following criteria: redness, induration/swelling, purulent secretion, and/or pain.

Sample Characteristics

  • The total sample included 223 participants.
  • The mean age was 61 years (range = 21–80)
  • Male participants made up 69% of the sample; female participants made up 31%.
  • Participants were hospitalized surgical patients requiring a CVC (84 patients [38%] with oncological diagnoses.
  • Overall catheter indwelling time was 6.7 days (SD = 3.2) in the control group and 7.5 days (SD = 4.7) in the intervention group. However, long-term indwelling  (more than seven days) was significantly higher in the intervention group (10.8 days [SD = 4.9], median = 9 days, n = 46) than in the control group (9.2 days [SD = 2.9], median = 8 years, n = 48) (p = 0.029).

Setting

Single inpatient setting in Germany.

Phase of Care and Clinical Applications

Active treatment

Study Design

Prospective-controlled, non-blinded, randomized clinical trial.

Measurement Instruments/Methods

  • Microbiologic evaluation
  • Swab samples taken from the catheter connectors (hub) and the skin at the site of catheter insertion
  • Cultures of  the IV part of the catheter.
  • After removal of the catheter, ex vivo activity of the antimicrobial catheters was measured as the mean diameter of inhibition towards Staphylococcus epidermidis RP62A.

Results

Compared to the standard device, modified CVCs showed significantly lower catheter colonization as well as catheter-related infection during short-term (less than seven days, p = 0.001), as well as during long-term (seven days or more, p = 0.001). In the control group,38 (36.3%) of the 105 standard CVCs were colonized. In the intervention group, 6 of 118 loaded CVCs were colonized (5.1%). The colonization rate in the oncology subgroup did not differ greatly from the rate of the patients without cancer (39% versus 34.4%, p = 0.629); however, the catheter-related infection rate was significantly higher in patients with cancer. The catheter-related infection rate of oncologic patients was reduced from 26.8% to 2.3% using the loaded CVC, indicating its pronounced efficacy in preventing catheter-related infection in patients with cancer (p < 0.001). The main covariate for catheter colonization was colonization of the skin at the catheter site (p = 0.001), underscoring the importance of hygienic site care.

Conclusions

Use of an impregnated antimicrobial catheter in patients with cancer has the potential to decrease the risk of catheter-related bloodstream infections and the associated complications.

Limitations

  • Only 38% of the patients in this study had an oncologic diagnosis (n = 84)
  • All of the patients were surgical patients.

Nursing Implications

CVCs impregnated with rifampicin and miconazole may decrease the risk of catheter-related infections and appear to exert their antimicrobial effect for more than four weeks. Additional study is needed to evaluate these catheters in a general oncology population with a larger sample. Skin colonization was associated with increased risk of catheter colonization, emphasizing the importance of meticulous site care.

Print

Guideline / Expert Opinion

National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Prevention and treatment of cancer-related infections [v.2.2011]. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/infections.pdf

Purpose & Patient Population

To provide guidance for clinical practices for the prevention and treatment of infection in patients with cancer.

Type of Resource/Evidence-Based Process

This resource is a consensus-based guideline.

Phase of Care and Clinical Applications

Patients were undergoing the active antitumor treatment phase of care.

Guidelines & Recommendations

The guideline

  • Recommends the consideration of general antibacterial prophylaxis in patients at intermediate and high risk for infection, consideration of antifungal prophylaxis during neutropenia and for anticipated mucosits, and antiviral prophylaxis for intermediate- and high-risk patients.
  • Provides suggestions for specific agents for prophylaxis and treatment in various clinical scenarios.
  • Outlines treatment and diagnostic/assessment approaches for neutropenic fever and specific clinical presentations.
  • Notes that chlorhexidine and sliver sulfadiazine-coated short-term central catheters have been shown to decrease the incidence of catheter colonization and bloodstream infections, but not in patients with hematologic malignancies requiring indwelling catheters for approximately 20 days.
  • Notes that vaccination recommendations for transplantation recipients and their household members should be performed.
  • Recommends the pneumococcal vaccine in asplenic patients.

The National Comprehensive Cancer Network (NCCN) does not currently endorse the use of a vancomycin lock solution for long-term vascular access devices due to concerns about the emergence of bacterial resistance if widely used. Influenza vaccination with a vaccine that does not use live attenuated organisms can be safely given, and the guideline recommends administration at least two weeks before receiving cytotoxic therapy.

Limitations

This study lacked high-quality evidence, with most recommendations being based on consensus.

Nursing Implications

This guideline provided comprehensive references to assess patient risk of infection and expert recommendations regarding interventions aimed at the prevention and treatment of infection in patients with cancer. The guideline does not discuss long-term survivorship issues in this area.

Print

O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P., Garland, J., Heard, S.O., . . . Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011). Guidelines for the prevention of intravascular catheter-related infections, 2011. Retrieved from http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Purpose & Patient Population

To provide evidence-based recommendations for the prevention of intravascular catheter-related infections for healthcare personnel who insert and care for intravascular catheters and for those responsible for surveillance and infection control in hospital, outpatient, and home health settings. Patients addressed in the guidelines were adult and pediatric patients with intravascular catheters.

Type of Resource/Evidence-Based Process

The resource is comprised of evidence-based guidelines. For the development process, evidence was categorized as category 1A to category 2 based on strength of recommendation and support from clinical or epidemiological studies.

Phase of Care and Clinical Applications

  • Patients were undergoing multiple phases of care.
  • The study has clinical applicability for pediatrics. 

Results Provided in the Reference

The results were not summarized.

Guidelines & Recommendations

The guidelines provided extensive recommendations regarding the education and training of staff; selection of catheters and sites, including avoidance of the femoral vein for central venous access and use of the central venous catheter with the minimum number of ports needed; hand hygiene; use of maximal sterile barrier precautions for insertion; skin preparation with alcohol, iodine, or chlorhexidine; use of standard catheter site dressing regimens; specific aspects of care for umbilical and dialysis catheters; and use of piggybacks, stopcocks, and catheter flushing. Guideline recommendations include a bundling of multiple recommendations: antimicrobial-impregnated catheters and cuffs are recommended in patients with long-term use if the organizational central line-associated blood stream infection (CLABSI) rate is not decreasing despite the implementation of comprehensive strategies for improvement. Lower-level (category II) recommendations include the use of prophylactic antimicrobial lock solutions in patients with long-term catheters who have a history of CLABSIs despite optimal aseptic technique as well as daily cleansing of patients in the intensive care unit with 2% chlorhexidine-impregnated washcloths. Recommends changing IV administration sets no more often than every 96 hours unless used for blood products. For needleless components, recommends changing according to administration set timing as above, and states no benefit to changing more than every 72 hours.

Nursing Implications

Provides extensive recommendations for management of all types of intravenous catheters and system components. Nurses should refer to the full set of guidelines for all specific aspects of care.

Print

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.

Purpose & Patient Population

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

 

Type of Resource/Evidence-Based Process

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.

Results Provided in the Reference

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.

Guidelines & Recommendations

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.

Limitations

  • No conflict of interest concerns were addressed.

Nursing Implications

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.

Print