Article of interest: Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection

Carratalà J. Role of antibiotic prophylaxis for the prevention of intravascular catheter-related infection. Clin Microbiol Infect. 2001;7 Suppl 4:83-90. Free full-text.

“A plausible explanation for the failure to reduce catheter-related bacteremia with this prophylactic approach probably lies in the mechanism by which catheter-related infection occurs. Thus, it is known that in long-term central venous catheters, bacteria are more likely to be introduced during and following catheter hub manipulation than via spread from the skin insertion site or from tunnel infection. On the other hand, the systemic administration of prophylactic glycopeptides may lead to the emergence of resistant organisms, and Centers for Disease Control and Prevention guidelines recommend against its use [55]. Therefore, the use of systemic glycopeptides to prevent intravascular catheter-related infections is not recommended.” (p. 85)

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Risk of bloodstream infections by intravascular device or insertion site

Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006 Sep;81(9):1159-71. Full-text for Emory users.

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 hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

Maki, et al. p. 1162

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.

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Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices

Wu S, Huang J, Jiang Z, et al. Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies. BMC Cancer. 2016 Sep 22;16(1):747. Free full-text.

Results: Twelve studies including 3905 patients published between 2008 and 2015, were included. Our meta-analysis showed that incidences of TIVAD-related infections (odds ratio [OR] 0.71, 95 % confidence interval [CI] 0.48-1.04, P = 0.081) and catheter-related thrombotic complications (OR 0.76, 95 % CI 0.38-1.51, P = 0.433) were not significantly different between the two groups. However, compared with SCV, IJV was associated with reduced risks of total major mechanical complications (OR 0.38, 95 % CI 0.24-0.61, P < 0.001). More specifically, catheter dislocation (OR 0.43, 95 % CI 0.22-0.84, P = 0.013) and malfunction (OR 0.42, 95 % CI 0.28-0.62, P < 0.001) were more prevalent in the SCV than in the IJV group; however, the risk of catheter fracture (OR 0.47, 95 % CI 0.21-1.05, P = 0.065) were not significantly different between the two groups. Sensitivity analyses using fixed-effects models showed a decreased risk of catheter fracture in the IJV group.

Conclusion: The IJV seems to be a safer alternative to the SCV with lower risks of total major mechanical complications, catheter dislocation, and malfunction. However, a large-scale and well-designed RCT comparing the complications of each access site is warranted before the IJV site can be unequivocally recommended as a first choice for percutaneous implantation of a TIVAD.

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Shoulder positioning for subclavian venous catheterization

Jeong HH, et al. A quantitative analysis of the relation between the clavicular tilt angle and subclavian central venous catheter misplacement. Clin Exp Emerg Med. 2014 Dec 31; 1(2):114-119.

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RESULTS: Among all central venous catheterizations (n=1,599), the subclavian route was used 981 times (61.4%). There were 51 misplacements of SCV catheters (5.2%) during the study period. There were no differences in the sex, age, blood pressure, and diagnosis between the two groups. The CTA values were 28.5°±7.3° and 22.6°±6.3° in the misplacement group and control group, respectively (95% confidence interval, 3.6 to 8.1; P<0.001).

CONCLUSION: In this study, the CTA was found to be 5.9° larger in the misplacement group than in the control group. Assuming that CTA indicates the shoulder position, our findings suggest that the chance of SCV catheter misplacement may be reduced by avoiding the shoulder elevated.

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The utility of Trendelenburg position on subclavian port placement

Kwon MY, Lee EK, Kang HJ, et al. The effects of the Trendelenburg position and intrathoracic pressure on the subclavian cross-sectional area and distance from the subclavian vein to pleura in anesthetized patients. Anesth Analg. 2013;117(1):114–118.

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“We evaluated the effects of increased intrathoracic pressure (20 cm H2O) or Trendelenburg position on the CSA and DSCV-pleura during SCV catheterization and general anesthesia, and determined whether their changes were clinically relevant (defined as [DELTA]CSA and [DELTA]DSCV-pleura >=15% vs S-0). Applying positive intrathoracic pressure alone or Trendelenburg position alone provided a statistically increased CSA of the SCV, but this increase did not meet our defined threshold for a relevant degree ([DELTA]CSA of >=15%). Only the combined application of these 2 maneuvers yielded a relevant increase in the CSA ([DELTA]CSA 23.2% vs S-0). No maneuvers provided a relevant change of DSCV-pleura ([DELTA]DSCV-pleura >=15%) despite their statistically significant changes in some conditions.” (Kwon, 2013, p. 116)

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