Catheter Site Dressing Regimens

Recommendations

Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site [2–5].

If the patient is diaphoretic or if the site is bleeding or oozing, use gauze dressing until this is resolved [2–5]. 

Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled [2, 3]. 

Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance [6, 7]. 

Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower) [8–10]. 

Replace dressings used on short-term CVC sites every 2 days for gauze dressings. 

Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing [6, 11]. 

Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. 

No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. 

Ensure that catheter site care is compatible with the catheter material [12, 13]. 

Use a sterile sleeve for all pulmonary artery catheters [1]. 

For patients aged 18 years and older: 

Chlorhexidine-impregnated dressings with an FDA-cleared label that specifies a clinical indication for reducing catheter-related bloodstream infection (CRBSI) or catheter associated blood stream infection (CABSI) are recommended to protect the insertion site of short-term, non-tunneled central venous catheters.

 For patients younger than 18 years: 

Chlorhexidine-impregnated dressings are NOT recommended to protect the site of short-term, non tunneled central venous catheters for premature neonates due to risk of serious adverse skin reactions.

No recommendation can be made about the use of chlorhexidine-impregnated dressings to protect the site of short-term, non-tunneled central venous catheters for pediatric patients less than 18 years old and non-premature neonates due to the lack of sufficient evidence from published, high-quality studies about efficacy and safety in this age group.

Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site [17–19]. 

Encourage patients to report any changes in their catheter site or any new discomfort to their provider. 

Background

Transparent, semi-permeable polyurethane dressings permit continuous visual inspection of the catheter site and require less frequent changes than do standard gauze and tape dressings. In the largest controlled trial of dressing regimens on peripheral catheters, the infectious morbidity associated with the use of transparent dressings on approximately 2,000 peripheral catheters was examined [20]. Data from this study suggest that the rate of colonization among catheters dressed with transparent dressings (5.7%) is comparable to that of those dressed with gauze (4.6%) and that no clinically substantial differences exist in the incidence of either catheter site colonization or phlebitis. Furthermore, these data suggest that transparent dressings can be safely left on peripheral venous catheters for the duration of catheter insertion without increasing the risk for thrombophlebitis [20]. 

A meta-analysis has assessed studies that compared the risk for CRBSIs using transparent dressings versus using gauze dressing [21]. The risk for CRBSIs did not differ between the groups. The choice of dressing can be a matter of preference. If blood is oozing from the catheter insertion site, gauze dressing is preferred. Another systemic review of randomized controlled trials comparing gauze and tape to transparent dressings found no significant differences between dressing types in CRBSIs, catheter tip colonization, or skin colonization [22].

 

Patient Cleansing 

Recommendation 

  1. Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI [23–25].

Background

Daily cleansing of ICU patients with a 2% chlorhexidine impregnated washcloth may be a simple, effective strategy to decrease the rate of primary BSIs. In a single center study of 836 ICU patients, patients receiving the chlorhexidine intervention were significantly less likely to acquire a primary BSI (4.1 vs 10.4 infections per 1,000 patient days; incidence difference, 6.3 [95% confidence interval, 1.2–11.0]) than those bathed with soap and water [23]. 

 

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  2. Maki DG, Stolz SS, Wheeler S, Mermel LA. A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management. Crit Care Med 1994; 22:1729–37.
  3. Bijma R, Girbes AR, Kleijer DJ, Zwaveling JH. Preventing central venous catheter-related infection in a surgical intensive-care unit. Infect Control Hosp Epidemiol 1999; 20:618–20.
  4. Madeo M, Martin CR, Turner C, Kirkby V, Thompson DR. A randomized trial comparing Arglaes (a transparent dressing containing silver ions) to Tegaderm (a transparent polyurethane dressing) for dressing peripheral arterial catheters and central vascular catheters. Intensive Crit Care Nurs 1998; 14:187–91.
  5. Rasero L, Degl’Innocenti M, Mocali M, et al. Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a randomized, multicenter study. The Italian Nurse Bone Marrow Transplant Group (GITMO). Haematologica 2000; 85:275–9.
  6. Zakrzewska-Bode A, Muytjens HL, Liem KD, Hoogkamp-Korstanje JA. Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters. J Hosp Infect 1995; 31:189–93.
  7. Flowers RH, Schwenzer KJ, Kopel RF, Fisch MJ, Tucker SI, Farr BM. Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection. A randomized, controlled trial. JAMA 1989; 261:878–83.
  8. Robbins J, Cromwell P, Korones DN. Swimming and central venous catheter-related infections in the child with cancer. J Pediatr Oncol Nurs 1999; 16:51–6.
  9. Howell PB, Walters PE, Donowitz GR, Farr BM. Risk factors for infection of adult patients with cancer who have tunnelled central venous catheters. Cancer 1995; 75:1367–75.
  10. Ivy DD, Calderbank M, Wagner BD, et al. Closed-hub systems with protected connections and the reduction of risk of catheter-related bloodstream infection in pediatric patients receiving intravenous prostanoid therapy for pulmonary hypertension. Infect Control Hosp Epidemiol 2009; 30:823–9.
  11. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009; 301:1231–41.
  12. Rao SP, Oreopoulos DG. Unusual complications of a polyurethane PD catheter. Perit Dial Int 1997; 17:410–2.
  13. Riu S, Ruiz CG, Martinez-Vea A, Peralta C, Oliver JA. Spontaneous rupture of polyurethane peritoneal catheter. A possible deleterious effect of mupirocin ointment. Nephrol Dial Transplant 1998; 13:1870–1.
  14. Garland JS, Alex CP, Mueller CD, et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001; 107:1431–6.
  15. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 2006; 58:281–7.
  16. Levy I, Katz J, Solter E, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J 2005; 24:676–9.
  17. Lorenzen AN, Itkin DJ. Surveillance of infection in home care. Am J Infect Control 1992; 20:326–9.
  18. White MC. Infections and infection risks in home care settings. Infect Control Hosp Epidemiol 1992; 13:535–9.
  19. White MC, Ragland KE. Surveillance of intravenous catheter-related infections among home care clients. Am J Infect Control 1994; 22:231–5.
  20. Maki DG, Ringer M. Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters. Gauze, a transparent polyurethane dressing, and an iodophor-transparent dressing. JAMA 1987; 258:2396–403.
  21. Hoffmann KK, Weber DJ, Samsa GP, Rutala WA. Transparent polyurethane film as an intravenous catheter dressing. A meta-analysis of the infection risks. JAMA 1992; 267:2072–6.
  22. Gillies D, O’Riordan E, Carr D, O’Brien I, Frost J, Gunning R. Central venous catheter dressings: a systematic review. J Adv Nurs 2003; 44:623–32.
  23. Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007; 167:2073–9.
  24. Munoz-Price LS, Hota B, Stemer A, Weinstein RA. Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute care hospital. Infect Control Hosp Epidemiol 2009; 30:1031–5.
  25. Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit. Infect Control Hosp Epidemiol 2009; 30:959–63.
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