Disinfecting IV Catheter Caps

To evaluate the impact of the routine use of a passive disinfection cap for catheter hub decontamination

Prior to the use of disinfection caps, the organization followed Centers for Disease Control and Prevention (CDC) recommendations for catheter care and routinely used chlorhexidine-impregnated dressings. The intervention was the routine use of disinfection caps with each central venous catheter (CVC) access rather than manual scrubbing of catheter hubs. The caps were changed after each access or every seven days on high-risk units. After implementation on high-risk units for six months, disinfection caps were introduced for routine use in general oncology units. Central line–associated bloodstream infection (CLABSI) rates were compared across all phases, preimplementation to full implementation. Data were compared to that from clinical units that did not use disinfection caps.

• N = 691 patients with 806 CLABSI episodes. Total patients with central lines was not reported.
• AGE = Not provided
• MALES: Not provided, FEMALES: Not provided
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Not provided
• OTHER KEY SAMPLE CHARACTERISTICS: Not provided

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: New York

• Prospective observational

• Device utilization ratio—number of catheter days to patient days
• Standardized incidence ratio—ratio of observed infections to expected number of infections, assuming incidence rates were the same as those for the reference period

No significant decrease in CLABSI rates occurred when disinfection caps were used in high-risk units. CLABSI rates declined significantly when the caps were introduced among general oncology units that were at high-risk (p < 0.001); however, CLABSI rates did not change significantly within general oncology units that were not high-risk. The proportion of contaminated blood cultures from high-risk units declined after introducing the disinfection caps (p < 0.01). Substantial cost savings with reduction in CLABSI rates and contaminated specimens was estimated, assuming hospitalwide implementation results.

The use of catheter disinfection caps may help reduce CLABSI rates in high-risk patient groups and reduce the contamination of blood culture specimens obtained via catheters.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• No patient demographic information was provided, and whether patients were being actively treated in all areas was uknown; high-risk units included general medical-surgical intensive care, not oncology-specific populations
• No information was provided on other relevant practices, such as antibiotic prophylaxis.
• Whether all catheters were long-term indwelling catheters is unclear, particularly because general intensive care units were included.
• No information regarding other factors that could influence results
• Cost reduction estimates assumed hospitalwide implementation of disinfection caps; why this was done is unclear, because changes in CLABSI rates were seen only on high-risk units.

The findings suggest that the routine use of disinfection caps for CVCs may be helpful in reducing CLABSI rates among patients undergoing hematopoietic cell transplantation (HCT) and those with hematologic malignancies deemed to be at high-risk for infection. This is a relatively low-cost intervention that may be beneficial; however, this study does not provide strong evidence in support of this effect. Given the findings here, further research on the effects of this approach is warranted.

The objective of this study was to assess the effect of optimizing hub disinfection using alcohol-impregnated port protectors by measuring the rate of central line-associated bloodstream infections (CLABSIs) and contaminated blood cultures (CBCs) in adult oncologic patient population.

The intervention involved switching traditional catheter hub care using alcohol wipes to care using 70% isopropyl alcohol-impregnated port protectors and needless neutral-pressure connectors. The intervention period results were compared to those from historical controls. Data were collected for all types of central lines, including peripherally inserted tunneled catheters and implanted ports. Line insertion techniques followed best practices for draping, skin prep, etc. Port protectors are luer lock-style caps with provide cleaning as they are twisted on and off catheter hubs. A new protector is used each time the port is accessed. Compliance was assessed by weekly observations defined as percentage of patients with catheter protectors in place.

• The sample size was 1,272.
• The age range of participants was 19–92.
• Women made up 51% of the sample; men made up 49%.
• Key disease characteristics were blood and solid cancers.

A single-site inpatient setting in West Virginia

Active antitumor treatment

Observational trial with comparison to historical controls

Observational comparison. Researchers compared CLABSI and CBC rates before and after intervention.

There was a statistically significant decrease in CLABSI rates with the use of alcohol-impregnated port protectors  from 2.3 per 1,000 central line days to 0.3 per 1,000 central line days during the intervention period (RR = 0.14, 95% CI [0.02, 1.07], p = 0.03). The rate of contaminated blood cultures decreased from 2.5% to 0.2% (RR = 0.09, 95% CI [0.01, 0.65], p = 0.002).

The use of alcohol-impregnated port protectors may help to reduce CLABSI rates. Further evidence is needed to make strong conclusions.

• Baseline sample/group differences of import   
• Risk of bias (no control group) 
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias(sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results
• There is too much unexplained variability in this study to draw firm conclusions– types of disease and associated risk of infections are not described. 
• Varied types of catheters are included and considered together, although these are associated themselves with different risk of infection. 
• There is no information about total catheter dwell time, and whether these differed. 
• Although specific CLABSI rates may have differed, there is no information or analysis as to whether the rate of catheter removal and change differed. 
• Method of determination of compliance with specifics of use and hub changes is questionable–the fact that a hub is observed to be in place in a single point observation does not say anything about whether or not that is being changed as required for each hub access.

Suboptimal hub disinfection has a great effect on CLABSI rates. The use of alcohol-impregnated port protectors could help prevent CLABSI by eliminating this factor from the equation; however, effect sizes shown here are small. There are numerous limits to the evidence provided here which reduces the strength of the evidence and any conclusions that can be drawn; however, findings are promising. Additional well-designed studies are warranted. It would be useful to have associated cost benefit analysis, and studies comparing this approach to others to determine most cost-effective approaches to reduce CLABSI risk and rates.