Replacement of Infusion Equipment

Replacement of Peripheral and Midline Catheters 

Recommendations 

There is no need to replace peripheral catheters more frequently than every 72–96 hours to reduce risk of infection and phlebitis in adults [36, 140, 141]. 

No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated [142–144]. 

Replace peripheral catheters in children only when clinically indicated [32, 33].

Replace midline catheters only when there is a specific indication. 

Background

Scheduled replacement of intravascular catheters has been proposed as a method to prevent phlebitis and catheter-related infections. Studies of short peripheral venous catheters indicate that the incidence of thrombophlebitis and bacterial colonization of catheters increases when catheters are left in place >72 hours [258]. However, rates of phlebitis are not substantially different in peripheral catheters left in place 72 hours compared with 96 hours [141]. Because phlebitis and catheter colonization have been associated with an increased risk for catheter-related infection, short peripheral catheter sites commonly are replaced at 72–96 hour intervals to reduce both the risk for infection and patient discomfort associated with phlebitis.

Some studies have suggested that planned removal at 72 hours vs. removing as needed resulted in similar rates of phlebitis and catheter failure [142–144]. However, these studies did not address the issue of CRBSI, and the risk of CRBSIs with this strategy is not well studied.

Midline catheters are associated with lower rates of phlebitis than short peripheral catheters and with lower rates of infection than CVCs [322–324]. In one prospective study of 140 midline catheters, their use was associated with a BSI rate of 0.8 per 1,000 catheter days [324]. No specific risk factors, including duration of catheterization, were associated with infection. Midline catheters were in place a median of 7 days, but for as long as 49 days. Although the findings of this study suggested that midline catheters could be changed only when there is a specific indication, no prospective, randomized studies have assessed the benefit of routine replacement as a strategy to prevent CRBSI associated with midline catheters. 

 

Replacement of CVCs, Including PICCs and Hemodialysis Catheters  

Recommendations

Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. 

Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. 

Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection. 

Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. 

Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. 

Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. 

Background

Catheter replacement at scheduled time intervals as a method to reduce CRBSI has not lowered rates. Two trials have assessed a strategy of changing the catheter every 7 days compared with a strategy of changing catheters as needed [165, 325]. One of these studies involved 112 surgical ICU patients needing CVCs, pulmonary artery catheters, or peripheral arterial catheters [165], whereas the other study involved only subclavian hemodialysis catheters [325]. In both studies, no difference in CRBSI was observed in patients undergoing scheduled catheter replacement every 7 days compared with patients whose catheters were replaced as needed. 

Scheduled guidewire exchange of CVCs is another proposed strategy for preventing CRBSI. The results of a meta-analysis of 12 randomized, controlled trials assessing CVC management failed to demonstrate any reduction of CRBSI rates through routine replacement of CVCs by guidewire exchange compared with catheter replacement on an as needed basis [326]. Thus, routine replacement of CVCs is not necessary for catheters that are functioning and have no evidence of causing local or systemic complications. 

Catheter replacement over a guidewire has become an accepted technique for replacing a malfunctioning catheter or exchanging a pulmonary artery catheter for a CVC when invasive monitoring no longer is needed. Catheter insertion over a guidewire is associated with less discomfort and a significantly lower rate of mechanical complications than are those percutaneously inserted at a new site [327]. In addition, this technique provides a means of preserving limited venous access in some patients. Replacement of temporary catheters over a guidewire in the presence of bacteremia is not an acceptable replacement strategy because the source of infection is usually colonization of the skin tract from the insertion site to the vein [37, 327]. However, in selected patients with tunneled hemodialysis catheters and bacteremia, catheter exchange over a guidewire, in combination with antibiotic therapy, is an alternative as a salvage strategy in patients with limited venous access [328–331]. 

Because of the increased difficulty obtaining vascular access in children, attention should be given to the frequency with which catheters are replaced in these patients. In a study in which survival analysis techniques were used to examine the relation between the duration of central venous catheterization and complications in pediatric ICU patients, all of the patients studied (n = 397) remained uninfected for a median of 23.7 days [250]. In addition, no relation was found between duration of catheterization and the daily probability of infection (r = 0.21; P > .1), suggesting that routine replacement of CVCs likely does not reduce the incidence of catheter-related infection [250]. 

Vascular access sites can be even more limited among neonates. Four randomized trials (n = 368) summarized in a recent Cochrane Database Systemic Review compared the effects of giving parenteral nutrition through percutaneous central venous catheters vs. peripheral intravenous catheters. Fewer painful procedures (venipunctures) were required in neonates randomized to percutaneously placed CVCs, and there was no evidence for increased risk of BSIs [332]. CVC occlusion due to thrombus formation is one of the most common reasons for CVC

removal in neonates. Various methods have been tried to prevent catheter occlusion. Recently, a randomized trial (n = 201) evaluated whether a continuous heparin infusion (0.5 units/kg/hour) could effectively prolong the duration of catheterization when compared with a placebo infusion. The rate of catheter occlusion requiring catheter removal was lower in the heparin group (6% vs. 31%, P = .001: NNT = 4). Rates of CRBSI were similar, although the study was not powered to evaluate CRBSI rate differences. Heparin associated antibody levels were not routinely measured [333]. 

Hemodialysis Catheters. The use of catheters for hemodialysis is the most common factor contributing to bacteremia in dialysis patients [334, 335]. The relative risk for bacteremia in patients with dialysis catheters is sevenfold the risk for patients with arteriovenous (AV) fistulas [336]. AV fistulas and grafts are preferred over hemodialysis catheters in patients with chronic renal failure, due to their lower associated risk of infection. If temporary access is needed for dialysis, a tunneled cuffed catheter is preferable to a non-cuffed catheter, even in the ICU setting, if the catheter is expected to stay in place for >3weeks [59]. 

Pulmonary Artery Catheters. Pulmonary artery catheters are inserted through a Teflon® introducer and typically remain in place an average of 3 days. The majority of pulmonary artery catheters are heparin bonded, which reduces not only catheter thrombosis but also microbial adherence to the catheter [307]. Meta-analysis indicates that the CRBSI rate associated with pulmonary artery catheterization is 3.7 per 1,000 catheter days and somewhat higher than the rate observed for unmedicated and non-tunnelled CVCs (2.7 per 1,000 catheter days)[6, 45]. 

Data from prospective studies indicate that the risk of significant catheter colonization and CRBSI increases the longer the catheter remains in place. In general, the risk of significant catheter colonization increases after 4 days of catheterization [75, 337, 338], whereas the risk of CRBSI increases beyond 5-7 days of catheterization [75, 84, 166]. Efforts must be made to differentiate between infection related to the introducer and that related to the pulmonary artery catheter. Significant colonization of the introducer occurs earlier than that of the pulmonary artery catheter [337, 339]. However, no studies indicate that catheter replacement at scheduled time intervals is an effective method to reduce risk of CRBSI [165, 327, 339]. In patients who continue to require hemodynamic monitoring, pulmonary artery catheters do not need to be changed more frequently than every 7 days [339]. No specific recommendation can be made regarding routine replacement of catheters that need to be in place for >7 days. 

Pulmonary artery catheters are usually packaged with a thin plastic sleeve that prevents touch contamination when placed over the catheter. In a study of 166 catheters, patients who were randomly assigned to have their catheters self-contained within this sleeve had a reduced risk for CRBSI compared with those who had a pulmonary artery catheter placed without the sleeve (P = .002) [81]. 

 

Umbilical Catheters 

Recommendations 

Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency in the lower extremities, or thrombosis are present [145]. 

Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present [145]. 

No recommendation can be made regarding attempts to salvage an umbilical catheter by administering antibiotic treatment through the catheter. 

Cleanse the umbilical insertion site with an antiseptic before catheter insertion. Avoid tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine containing products (e.g., povidone iodine) can be used [146– 150]. 

Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance [88, 89].

Add low-doses of heparin (0.25–1.0 U/ml) to the fluid infused through umbilical arterial catheters [151–153]. 

Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Optimally, umbilical artery catheters should not be left in place >5 days [145, 154]. 

Umbilical venous catheters should be removed as soon as possible when no longer needed, but can be used up to 14 days if managed aseptically [155, 156]. 

An umbilical catheter may be replaced if it is malfunctioning, and there is no other indication for catheter removal, and the total duration of catheterization has not exceeded 5 days for an umbilical artery catheter or 14 days for an umbilical vein catheter. 

Background

Although the umbilical stump becomes heavily colonized soon after birth, umbilical vessel catheterization often is used for vascular access in newborn infants. Umbilical vessels can be cannulated easily and permit both collection of blood samples and measurement of hemodynamic status. The incidences of catheter colonization and BSI are similar for umbilical vein catheters and umbilical artery catheters. In several studies, an estimated 40%–55% of umbilical artery catheters were colonized and 5% resulted in CRBSI; umbilical vein catheters were associated with colonization in 22%–59% of cases [147, 148, 340] and with CRBSI in 3%– 8% of cases [148]. Although CRBSI rates are similar for umbilical catheters in the high position (i.e., above the diaphragm) compared with the low position (i.e., below the diaphragm and above the aortic bifurcation), catheters placed in the high position result in a lower incidence of vascular complications without an increase in adverse sequelae [148].

Risk factors for infection differ for umbilical artery and umbilical vein catheters. In one study, neonates with very low birth weight who also received antibiotics for >10 days were at increased risk for umbilical artery CRBSIs [148]. In comparison, those with higher birth weight and receipt of parenteral nutrition fluids were at increased risk for umbilical vein CRBSI. Duration of catheterization was not an independent risk factor for infection of either type of umbilical catheter. 

A recent randomized trial (n = 210) evaluated whether long-term umbilical venous catheterization (up to 28 days) would result in the same or fewer CRBSIs when compared with neonates who were randomized to short-term umbilical venous catheterization for 7–10 days followed by percutaneous central venous catheterization. CRBSI rate was higher (20%) among long term catheterized neonates when compared with short term catheterized neonates (13%).

The difference was not statistically significant (P = .17), although the study was underpowered.

The study was not powered to evaluate differences in venous thrombosis rates [341]. 

 

Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric

Patients  

Recommendations

In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of insertion to reduce the risk of infection [46, 47, 157, 158]. 

In children, the brachial site should not be used. The radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion [46]. 

A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion [47, 158, 159]. 

During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. 

Replace arterial catheters only when there is a clinical indication. 

Remove the arterial catheter as soon as it is no longer needed. 

Use disposable, rather than reusable, transducer assemblies when possible [160–164]. 

Do not routinely replace arterial catheters to prevent catheter-related infections [165, 166, 167, 168]. 

Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced [37, 161]. 

Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile [160, 169–171].

Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed flush system (i.e., continuous flush), rather than an open system (i.e., one that requires a syringe and stopcock), to maintain the patency of the pressure monitoring catheters [163, 172]. 

When the pressure monitoring system is accessed through a diaphragm, rather than a stopcock, scrub the diaphragm with an appropriate antiseptic before accessing the system [163].

Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit [163, 173, 174].

Sterilize reusable transducers according to the manufacturers’ instructions if the use of disposable transducers is not feasible [163, 173–176].

Background

Arterial catheters are usually inserted into the radial or femoral artery and permit continuous blood pressure monitoring and blood gas measurements. The risk of CRBSI for arterial catheters is lower than that associated with non-coated, uncuffed, non-tunneled short-term CVCs (1.7 versus 2.7 per 1,000 catheter days) [6]. However, risk of CRBSI rates are comparable between arterial catheters and coated, uncuffed, non-tunneled short term CVCs [6]. Unlike CVCs, use of full barrier precautions during arterial cannulation does not appear to reduce the risk of arterial CRBSI [158, 159]. Nonetheless, when arterial catheters are inserted using a protocol which includes maximum barrier precautions, a very low risk of CRBSI (0.41/1,000 catheter days) can be achieved [47]. Although a meta-analysis failed to discern a difference in rates of CRBSI among three sites of insertion (radial, femoral, and axillary) [342], colonization of catheters inserted in the femoral site occurs more often [158]. In addition, a prospective observational study of over 2,900 arterial catheters that were inserted using maximum barrier precautions demonstrated an almost 8-fold increase in the incidence of CRBSI when the femoral site was used compared with the radial site [343]. Furthermore, there is a greater risk of CRBSI caused by gram-negative bacteria when the femoral site is used [343]. The rates of catheter colonization and CRBSI appear similar between the radial and dorsalis pedis sites [157]. The risk of developing a CRBSI increases with the duration of catheterization [166, 344]; however, the routine changing of arterial catheters at scheduled times does not result in a diminution of the risk of CRBSI [165]. Catheters that need to be in place for >5 days should not be routinely changed if no evidence of infection is observed.

 

Replacement of Administration Sets 

Recommendations 

In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, [177] but at least every 7 days [178–181].

No recommendation can be made regarding the frequency for replacing intermittently used administration sets. 

No recommendation can be made regarding the frequency for replacing needles to access implantable ports. 

Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion [182–185]. 

Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed, per the manufacturer’s recommendation (FDA website Medwatch) [186].

No recommendation can be made regarding the length of time a needle used to access implanted ports can remain in place. 

Background

The optimal interval for routine replacement of IV administration sets has been examined in several well-controlled studies and meta-analyses. Data from these studies reveal that replacing administration sets no more frequently than 72–96 hours after initiation of use is safe and cost-effective [141, 177, 179–181]. More recent studies suggest that administration sets may be used safely for up to 7 days if used in conjunction with antiseptic catheters or if fluids that enhance microbial growth (e.g., parenteral nutrition or blood) have not been used [216, 345]. When a fluid that enhances microbial growth is infused (e.g., fat emulsions and blood products), more frequent changes of administration sets are indicated as these products have been identified as independent risk factors for CRBSI [182, 216, 346–350]. Little data exist regarding the length of time a needle used to access implanted ports can remain in place and the risk of CRBSI. While some centers have left them in place for several weeks without CRBSI, [351], this practice has not been adequately studied. 

 

Needleless Intravascular Catheter Systems 

Recommendations

Change the needleless components at least as frequently as the administration set. There is no benefit to changing these more frequently than every 72 hours. [39, 187–193]. 

Change needleless connectors no more frequently than every 72 hours or according to manufacturers’ Recommendations for the purpose of reducing infection rates [187, 189, 192, 193]. 

Ensure that all components of the system are compatible to minimize leaks and breaks in the system [194]. 

Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices [189, 192, 194–196].

Use a needleless system to access IV tubing. 

When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves [197–200]. 

Background

Stopcocks used for injection of medications, administration of IV infusions, and collection of blood samples represent a potential portal of entry for microorganisms into vascular access catheters and IV fluids. Whether such contamination is a substantial entry point of microorganisms that cause CRBSI has not been demonstrated. Nonetheless, stopcocks should be capped when not being used. In general, closed catheter access systems are associated with fewer CRBSIs than open systems and should be used preferentially [352]. 

“Piggyback” systems (secondary intermittent infusions delivered through a port on a primary infusion set) are used as an alternative to stopcocks. However, they also pose a risk for contamination of the intravascular fluid if the device entering the rubber membrane of an injection port is exposed to air or if it comes into direct contact with nonsterile tape used to fix the needle to the port. Modified piggyback systems have the potential to prevent contamination at these sites [353]. 

Attempts to reduce the incidence of sharps injuries and the resultant risk for transmission of bloodborne infections to healthcare personnel have led to the introduction and mandating of needleless infusion systems. There are several types of needleless connectors on the market. 

The first type of needleless system connectors consisted of a split septum connector, which

is accessed with a blunt cannula instead of a needle (external cannulae activated split septums). Because of the large amount of space in the connector to accommodate the cannula, when the cannula is removed it may result in the creation of negative pressure which may cause blood to be aspirated into the distal lumen, possibly increasing the risk of catheter occlusion or thrombosis. A luer-activated device, which incorporates a valve preventing the outflow of fluid through the connector, was designed to eliminate this problem. Some luer devices require a cap to be attached to the valve when not in use, which can be difficult to maintain aseptically, and therefore they may be prone to contamination.

Another type of second-generation needleless system addressed the occlusion issue by incorporating positive or neutral fluid displacement to either flush out aspirated blood or prevent its aspiration into infusion catheters. 

Use of needleless connectors or mechanical valves appear to be effective in reducing connector colonization in some [196, 354, 355], but not all studies [356] when compared with stopcocks and caps. In one study [354], the incidence of CRBSI was reduced when the needleless connector was compared with standard stopcocks. Appropriate disinfectants must be used to prevent transmission of microbes through connectors [357]. Some studies have shown that disinfection of the devices with chlorhexidine/alcohol solutions appears to be most effective in reducing colonization [195, 196]. In addition, the time spent applying the disinfectant may be important. One study found that swiping the luer-activated device with 70% alcohol for only 3 to 5 seconds did not adequately disinfect the septal surface [358]. However, a number of outbreak investigations have reported increases in CRBSIs associated with a switch from external cannulae activated split septum needleless devices to mechanical valve devices [197, 198, 200, 359]. The reasons for these associations are not known and it is also not known if this is a device-specific or class association, particularly as physical and mechanical properties of needleless connectors vary from device to device. In addition, one investigation found CRBSIs increased with the switch from a luer-activated negative displacement mechanical valve to a luer-activated positive fluid displacement mechanical valve [199]. However, in an observational study, a switch from a luer-activated negative displacement mechanical valve to a different luer-activated positive displacement mechanical valve as part of a bundled intervention resulted in a significant decrease in CRBSIs [201]. Potential explanations for outbreaks associated with these devices include difficulty encountered in adequate disinfection of the surface of the connector due to physical characteristics of the plastic housing diaphragm interface, fluid flow properties (laminar vs. turbulent), internal surface area, potential fluid dead space, inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices, and the presence of internal corrugations that could harbor organisms, particularly if the catheters are used to withdraw blood [199]. Some studies have shown that the increase in CRBSIs with the change to luer activated devices may be related to improper cleaning and infection control practices such as infrequently changing the devices [192, 194]. Additionally, silver-coated connector valves have been FDA approved; however, there are no published randomized trials with this device and no recommendation can be made regarding its use. Likewise, an antiseptic-barrier cap for needleless connectors has been studied in a laboratory setting and appears to be effective in preventing the entry of microorganisms [360] but has not yet been studied in a clinical trial. 

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